MTM Innovation Medication Therapy Management: Past and Future Megan Jolley Milne, PharmD, BCACP
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MTM Innovation
Medication Therapy Management: Past and Future
Megan Jolley Milne, PharmD, BCACP
Learning Objectives
• Describe the history of MTM to establish a foundation for where innovation can happen.
• Evaluate innovative strategies to improve MTM.
• Compare MTM opportunities in Medicare and Medicaid.
Timeline of MTM History
3
Medicare Modernization Act of 2003
• Part D created
• MTM is born
• Statute:
• MTM is designed to promote
• Enhanced enrollee understanding
• Increased enrollee adherence
• Detection of adverse drug events
• May be furnished by a pharmacist
Asheville Project
5
pre
pre
2005: What is MTM?
6
http://www.pharmacist.com/mtm J Am Pharm Assoc. 2005;45(5):566-72
2006: Part D Begins
7
2008
8
J Am Pharm Assoc. 2008;48:341–353
Part D Manual
9
Chapter 7 Part D Manual
10
MTM in Part D
Part D plans choose MTM features:
• Who?
• In-house or network
• What?
• # Medical conditions
• Which?
• Medical conditions ≥ 5/9
11
• How much?
• # Rx Claims
• Chronic
• When?
• Frequency of targeting
• Min. quarterly
MTM Eligibility
Rx Claims # Rx Dx
12
• Part D only• Must reach threshold
• 2015: $3,138• Divided by frequency of identification• Ex: quarterly ID = $785 in last quarter
• Plans can limit to chronic or specific classes
MTM Eligibility
Rx Claims # Rx Dx
13
• Plan sets minimum:≥2 or ≤8 Rx
• Issue• Nonadherence
MTM Eligibility
Rx Claims # Rx Dx
14
• 2 or 3 Chronic Diseases• Plan can limit this to a
specific list• At least 5 of Core list:
• Alzheimer’s• Arthritis (OA, RA)• Osteoporosis• CHF• DM
• Dyslipidemia• ESRD• HTN• Bipolar• Chronic Mental Health
• Depression• Schizophrenia• Chronic Lung Disorder• Asthma• COPD
2010 - Affordable Care Act
15
CMS Standardized Format
16
Medicare Part D 2014 Timeline
January 2014
CMS proposes sweeping changes for Part D
February 2014
CMS releases draft 2015 call letter that builds upon proposed changes in proposed rule
March 7, 2014
Comments for proposed rule and draft call letter due
March 10, 2014
CMS announces rescission of most of Part D proposed rule
April 7, 2014
CMS publishes final 2015 Call Letter
17
Used with permission from AMCP
Medicare Part D 2014-2015 Timeline
May 2014
CMS releases final rule for 2015 without most controversial provisions
January 2015
CMS releases final rule for 2016 without many of the controversial provisions from the proposed rule
February 2015
CMS releases draft 2016 call letter and does not include the controversial provisions
March 6, 2015
Comments due to CMS on the 2016 draft call letter
April 6, 2015
Final call letter release
18
Used with permission from AMCP
Enhanced MTM Model
• CMS opened the MTM innovation floodgates
• Plans can be paid for innovative MTM solutions
• Non-bid $
19
Enhanced MTM Model Timeline
Sep/Oct 2015
CMS announces Enhanced MTM Model
Nov 2015
CMS provides webinar outlining interoperability standards for HIT
Dec 2015
CMS provides webinar showing cases of team-based care coordination using HIT
Jan 7, 2016
Requests for Applications due
Jan 1, 2017
Enhanced Model begins
20
Used with permission from AMCP
Health IT & MTM
• HIT = Health Information Technology
• CMS’ Enhanced MTM Model should rely on HIT-Enabled Team-Based Care Coordination
• Teams:
• Interdisciplinary care teams
• Within health plan: disease and case management RNs
• Community: prescribers and pharmacies
21
Enhanced MTM Model Timeline
Sep/Oct 2015
CMS announces Enhanced MTM Model
Nov 2015
CMS provides webinar outlining interoperability standards for HIT
Dec 2015
CMS provides webinar showing cases of team-based care coordination using HIT
Jan 7, 2016
Requests for Applications due
Jan 1, 2017
Enhanced Model begins
22
Used with permission from AMCP
Health IT & MTM
• Referrals back and forth
• Information interoperable between EHR, Rx databases
• Find source of “truth” in MTM
23
Case #1: Prospective MTM
• Part D MTM is currently retrospective
• Innovation: identify prospectively
• New members to a plan
• Star Ratings for noncompliance
• Case #1: Medicare Advantage Dual-eligible Special Needs Plan (D-SNP)
24
Star Ratings
Purpose
• Creating a referral process between the telephonic health risk assessment by nurses and the MTMP allows for:
• Seamless care for the member with fewer telephone calls from the health plan
• Coordination of care between MTMP and healthcare services/case management
• Decreased medical and pharmacy costs
• Rein-in medication costs before expenses incurred
Lessons Learned
• Need data
• Pharmacy claims from prior insurer
• Communication is key
• Extra patients identified
• Testing, testing, testing
• Ensure criteria match up
26
True or False?
• Medicare Part D plans must reimburse retail pharmacists to perform MTM comprehensive medication reviews (CMRs) for patients in their pharmacy.
27
MTM PaymentPa
rt D
Admin Budget
Overhead
MTM
In-House Pharmacist
Third-Party MTM
PharmacyRx Budget Rx
28
Provider Legislation Initiative
29
MTM PaymentPa
rt D
Admin Budget
Overhead
MTM
In-House Pharmacist
Third-Party MTM
PharmacyRx Budget Rx
30
Part B
Medicaid States with MTM*
31
Blue = state with MTM legislation*Not a comprehensive list
Case #2: Medicaid MTM
• MTM helps Medicare members
• Why not Medicaid?
• Targeted Medicaid Aged, Blind, and Disabled (ABD) members
• Leverage existing expertise in another line of business
32
Expansion of MTMP into Medicaid ABD
• What number of members would we like to target?
• What percentage of members?
• What cutoffs would we like to use?
• Opt-in or opt-out?
• Who will manage it?
• When to implement? Targeted go-live date?
• What data to share?
Steps in Implementation of MTMP
• Determine algorithm of precise criteria for targeting
• # medications, # conditions, specific conditions, % of members? Opt-in or opt-out?
• How will targeting be completed: inside or outside MTM database?
• Level of output: just member? Just physician?
• Determine information needed in MTM database
• Pharmacy claims
• Medical claims (ICD-9/10)
• Lab data
• Death dates
• Long term care status
• HCC risk scores
• Frequency of data exchange
35
HIT Implementation of MTMP
Star Ratings
HIT Implementation of MTMP
• Negotiate a contract with MTM Vendor database based on needs
• Create a BRD outlining where data will come from and who be responsible for each set of data
• PBM: Rx claims
• Health Plan IT:
• Demographics, eligibility
• ICD-9/10 medical claims from member database
Timing: 3-4 months for implementation
HIT Implementation of MTMP
• Create a project request for IT support
• Wait for approval, allocation of resources
• Guide IT in appropriate implementation
• Validate data in MTM Database, IT testing
• Deployment of formal files
• Training
• Go Live
Timing: 4-6 months for implementation
Inputs and Outputs
• Care coordination: what does each team need to know?
• Nurses: MTM MD and patient documents
Export PDF to case management software
Interoperability: field-to-field transfer
• CMR date, pharmacist’s name, drug therapy problems
• Pharmacists: level of case management care
Export list of patient’s care level, nurse’s name
Interoperability: case management issues, dates
38
MTMP Integration within Medicaid
• MTM pharmacist-created progress notes are loaded into case management database and visible within member summary database for nursing staff
– Personal Medication List
– Medication Action Plan
– MTM Summary for Physician with action items
• Medicaid MTMP Pharmacists goal: provide care for members along with rest of Interdisciplinary Care Team
Need More Information?
Megan Jolley Milne, PharmD, [email protected]
Resources:
Academy of Managed Care Pharmacy
http://www.amcp.org/MTMResources/• • •
American Pharmacists Association MTM Central
www.pharmacist.com/mtm
www.pharmacistsprovidecare.com• • •
Center for Medicare and Medicaid Services
http://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/MTM.html
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