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United States : Participants selected for Part D Enhanced Medication Therapy Management Model.

Today, the Centers for Medicare & Medicaid Services (CMS) Center for Medicare and Medicaid Innovation (Innovation Center) is announcing the participants in the Part D Enhanced Medication Therapy Management (MTM) model. This Enhanced MTM model offers an opportunity and financial incentives for basic stand-alone Part D Prescription Drug Plans (PDPs) in selected regions to offer innovative MTM programs in lieu of the standard CMS MTM model, aimed at improving the quality of care while also reducing costs. As part of the better care, smarter spending, healthier people approach to improving health delivery, CMS will test changes to the Part D program that aim to achieve better alignment of PDP sponsor and government financial interests, while also creating incentives for robust investment and innovation in MTM targeting and interventions. The objectives for this model are for stand-alone PDP sponsors to identify and implement innovative strategies to optimize medication use, improve care coordination, and strengthen system linkages.

The Enhanced MTM model test will begin January 1, 2017 with a five-year performance period. CMS will test the model across 5 Part D regions: Region 7 (Virginia), Region 11 (Florida), Region 21 (Louisiana), Region 25 (Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota, Wyoming), and Region 28 (Arizona). Regions were evaluated based on variation in market competition, the range of geographic, population, and market characteristics, and the range of Parts A and B spending variance. This set of regions was selected so as to allow for a sufficiently powered model test with comparison regions and to (in aggregate) be broadly representative of national market characteristics.

Six Part D sponsors that operate a total of 22 Plan Benefit Packages and provide benefits to an estimated 1.6 million beneficiaries in eligible Part D Regions will participate in the first year of the model. Upon approval from CMS, the selected basic stand-alone PDPs in these regions can vary the intensity and types of MTM interventions they provide based on beneficiary risk level and seek out a range of strategies to individualize beneficiary and prescriber outreach and engagement. The selected PDPs can accomplish these goals by leveraging the core competencies of their own organizations, their network pharmacy providers, and prescribers to accurately identify and effectively intervene with beneficiaries whose issues with medication management have caused, or are likely to cause, adverse outcomes and/or significant non-drug program utilization and costs.

The Enhanced MTM Model is authorized under section 1115A of the Social Security Act (added by section 3021 of the Affordable Care Act) (42 U.S.C. 1315a), which authorizes the Center for Medicare and Medicaid Innovation to test innovative health care payment and service delivery models that have the potential to lower Medicare, Medicaid, and Childrens Health Insurance Program (CHIP) expenditures while maintaining or enhancing the quality of beneficiaries care. CMS will test this model in the Medicare program through a limited waiver of certain Part D requirements, including current CMS MTM program requirements, for participants in the test regions during the performance period.

The Medicare Modernization Act (MMA), which created the Part D program, required that every Part D plan offer an MTM program as a quality improvement feature. MTM generally refers to activities intended to optimize therapeutic outcomes by ensuring that patients are taking their medications safely and as prescribed, addressing any barriers to their doing so, and bringing any medication issues to the attention of the treating physician.

MTM programs can generate cost savings and result in improved outcomes for patients in a variety of ways. Evidence has shown MTM can improve medication adherence, which is associated with medical cost savings even when accounting for changes in drug expenditures. MTM can also help to ensure that medications are taken properly and adverse drug events are avoided, particularly when new or high-risk medications are initiated, resulting in improved care for beneficiaries and significant savings from reduced hospitalizations and emergency department use. Improved accuracy of medication administration can both improve outcomes and reduce waste, especially for high-cost drugs where therapeutic goals may not be achieved and expensive regimens may have to be repeated if medications are not taken correctly. MTM programs can also improve the appropriateness of prescribing, ensuring that beneficiaries are receiving evidence-based therapies appropriate for their condition, potentially reducing complications and unnecessary medical costs in order to improve beneficiary outcomes. Finally, MTM can help to identify and eliminate duplicative therapies, as well as identify opportunities to switch to similar, lower-cost medications, both of which can reduce prescription drug costs.

Evidence suggests that the MTM services currently offered by Part D plans fall short of their potential to improve quality and reduce unnecessary medical expenditures, most likely due to misaligned financial incentives and regulatory constraints. Competitive market dynamics and Part D program requirements and metrics may incentivize investment in these activities only at a level necessary to meet the minimum compliance standards. Currently, Part D statutory and regulatory MTM provisions require uniform service offerings to enrollees who meet the plans program criteria, based on numbers of medications and chronic conditions and expected annual prescription drug costs. The result is that Part D MTM programs may not include the level or resources nor the type of activities that could have the greatest positive effect on beneficiary outcomes.

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Publication:Mena Report
Date:Oct 4, 2016
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