The legislation addresses the shortcomings of the current MTM qualification system, but it has some shortcomings of its own.
Bipartisan legislation recently introduced into the US Senate recognizes the positive impact a pharmacist can have on the outcome of a patient's medication therapy regimen.
If it becomes law, the Medication Therapy Management Empowerment Act of 2015 (MTMEA) (S. 776) will increase the number of Medicare beneficiaries that qualify for pharmacist-provided medication therapy management (MTM) services.
MTMEA is directed specifically at addressing the number of chronic conditions a Medicare Part D patient needs to have in order to qualify for MTM services. According to the 2015 Medication Therapy Management Program Guidance and Submission Instructions from the US Centers for Medicare and Medicaid Services (CMS), patients must have multiple chronic diseases, with 3 chronic diseases being the maximum number a Part D plan sponsor may require for targeted enrollment. Medicare Part D sponsors cannot require more than 3 chronic conditions in order for a member to be eligible for their MTM programs.
Changes under the MTMEA would give Medicare Part D beneficiaries with only 1 of 4 specific chronic conditions potential access to MTM program services. These qualifying conditions include diabetes, cardiovascular disease, chronic obstructive pulmonary disease (COPD), and high cholesterol.
In addition to being diagnosed with 3 or more chronic conditions, MTM-qualifying patients must also meet 2 other criteria. These requirements include taking multiple Part D drugs, with 8 being the maximum number a Part D plan sponsor can require for enrollment, as well as being likely to incur annual costs for covered Part D drugs greater than or equal to the specified 2015 MTM cost threshold of $3138.
Unfortunately, the introduction of S. 776 only addresses the number of chronic conditions a Medicare recipient needs in order to be eligible to receive MTM benefits. The eligibility requirements regarding the number of Part D medications a patient must be taking and the annual cost for covered drugs both remain unchanged.
Under these new guidelines, it is possible that a senior newly diagnosed with cardiovascular disease and high cholesterol who is discharged from the hospital after a near-fatal heart attack may still not qualify for Medicare Part D-sponsored MTM services. It is possible that the patient would be sent home on a dangerous blood-thinning medication, 2 or more blood pressure medications, a medication to control heart rhythm, and perhaps a medication to decrease cholesterol. The total number of medications may be 6 at most, but more likely 5, which is well below the number required to qualify for a Medicare Part D MTM program.
Additionally, it is possible a pharmacist may be working with the prescribing physician in order to help the patient receive the most appropriate generic medications while also keeping their co-pays down to the first tier generic price. With thoughtful prescribing, it is not inconceivable that a patient may meet the 8 prescription minimum requirement but still fall below the annual MTM cost threshold, and therefore not qualify for program services.
The American Pharmacists Association has outlined a plan describing how pharmacists may provide MTM services. Subjectively, pharmacists know how well patients respond to a comprehensive medication review (CMR) during an MTM visit. Speaking with a patient for 30 to 45 minutes while discussing their medication regimen, barriers to adherence, and general health literacy far exceeds the results from a 3- to 5-minute medication consult at the pharmacy counter.
Objectively, a recent CMS report indicated that Medicare patients with chronic conditions who received annual CMR as an MTM service maintained an improvement in their treatment regimen and adherence to therapy compared with those who did not receive the same MTM services.
Additionally, the Congressional Budget Office determined that a 1% increase in prescription drug usage (adherence) among Medicare Part D patients would save up to $1.7 billion per year in total health care costs.
Pharmacist-sponsored MTM programs are effective at increasing medication adherence and improving overall medication therapy regimens, and providing these services would save health care dollars. This legislation should be taken to the next level by decreasing the number of Medicare Part D medications that a patient needs to take in order to qualify for services and eliminating the drug cost threshold.
2015 Medication Therapy Management Program Guidance and Submission Instructions
Medication therapy management in pharmacy practice: Core elements of an MTM service model (version 2.0)
CMS Medication Therapy Management
Medication Therapy Management in a Chronically Ill Population
Offsetting Effects of Prescription Drug Use on Medicare’s Spending for Medical Services