Changes to MTM Requirement Needed

FEBRUARY 01, 2009
Julie Khani and Douglas Hoey

Ms. Khani and Mr. Sewell are copresidents of the Coalition for Community Pharmacy Action.

As policymakers begin to debate the key issues within health care reform, the Coalition for Community Pharmacy Action (CCPA) is urging Congress to strengthen the existing medication therapy management (MTM) requirement in Medicare Part D. The coalition is advocating for changes to the MTM benefit in order to improve patient health as well as reduce overall Medicare expenditures.

Julie Khani
Vice president
of federal
programs at

Charles Sewell
Senior vice
of government
affairs at

The Medicare Modernization Act of 2003 (MMA) was signed to provide a comprehensive federal prescription drug benefit to >40 million seniors and individuals with disabilities who qualified under Medicare to help them afford the cost of their medicines. It also was intended to provide seniors and individuals more choices in health care, better benefits, and savings.

For instance, seniors could choose a stand-alone drug plan or have their drug benefit incorporated into broader medical coverage. These provisions were to modernize Medicare and give individuals more control over the costs of their health care and give them access to coverage that is affordable, flexible, and portable.

Since MMA was established in 2006, beneficiaries have had wider access to prescription drugs, and recent reports reveal that satisfaction with Part D among seniors has been high. An important aspect of the legislation is the recognition of the value of MTM for beneficiaries who receive benefits under the program.

The MMA requires Medicare health plans to make MTM programs available to targeted beneficiaries. Patients must have multiple disease states, take multiple Part D?covered medications, and be likely to reach a designated amount in prescription drug spending. In 2008, the set spending amount was $4000.

Under the MMA, these programs are to be developed in cooperation with pharmacists and physicians, and care may be provided by pharmacists. The requirements, however, are vague and lack uniform standards. As a result, services to Medicare beneficiaries vary widely.

For example, one Part D plan might provide MTM services for a beneficiary with 3 chronic conditions and 5 prescriptions, whereas another Part D plan might provide MTM services for a beneficiary with 2 chronic conditions and 3 prescriptions. This lack of standardization is unfair to Medicare beneficiaries and limits the potential of MTM programs to improve care and maximize savings to the Medicare program. If the current requirements are not standardized to ensure appropriate utilization, beneficiaries will not reap the full benefits of the Medicare Part D program.

CCPA is advocating for several changes to the existing MTM requirement in Medicare Part D. MTM programs should be available to any Medicare Part D beneficiary with a condition that is likely to increase federal health care spending, regardless of whether the patient meets the annual cost threshold. Furthermore, CCPA believes that there should be strong pharmacy access requirements to ensure wide availability of MTM programs through community pharmacies.

The Coalition for Community Pharmacy Action (CCPA) is an alliance between the National Association of Chain Drug Stores (NACDS) and the National Community Pharmacists Association (NCPA), which together represent more than 55,000 community pharmacies. CCPA leverages the support, effort, and infrastructure of NACDS and NCPA while engaging community pharmacy to participate and advocate on issues affecting the industry.

An important first step in the expansion of MTM would be coverage of an annual medication review for targeted Medicare Part D beneficiaries. This review would increase the likelihood of Medicare beneficiaries taking their prescription drugs appropriately, improving patient health and reducing higher-cost medical services.

The majority of Medicare Part D prescriptions are filled by the members of the National Association of Chain Drug Stores and the National Community Pharmacists Association. Working together through CCPA, we strive to improve the Medicare Part D program. Expanding MTM programs in Medicare will improve the health and well-being of Medicare beneficiaries, improve health outcomes, and reduce health care costs. The coalition is committed to advocating for these important changes, advancing the role of pharmacy as part of the health care system.