Contributor: Preparing for Massive MTM Program Expansion—Pharmacy-Led Medical Cost Savings to Fund CMS Changes

Anticipated medication therapy management (MTM) program changes from CMS will greatly increase the number of eligible Medicare beneficiaries who qualify for enrollment into the program—creating a large administrative burden for plans in terms of resources and funding. These new qualification parameters are expected to come into effect in the 2025 measurement year.

CMS expects its new MTM criteria will increase the number of eligible members from 4.5 million (9%) to 11 million (23%) and acknowledges the proposed changes will lead to additional plan costs of around $336 million annually.

To rise to these challenges, Medicare Advantage prescription drug (MAPD) plans and prescription drug plans (PDPs) will need to increase the budgeted spend required to scale up the MTM program accordingly. Consequently, plans will need to be strategic about the way they engage with members around their medications and determine how to best fund an expanded MTM program.

With a focus on pharmacy-led medical cost reduction, plans can maximize the identification and resolution of drug therapy problems (DTPs) to empower pharmacists in the quality and efficiency of comprehensive medication reviews (CMRs). This drives positive health outcomes and quantifiable medical cost savings, which can help fund (in whole or in part) the anticipated program expansion cost.

What’s in store for MAPD plans and PDPs with MTM program changes?

As of 2023, plans are able to set MTM eligibility parameters to include those members who have up to 3 common chronic conditions, are taking up to 8 Part D drugs, and meet the annual spending threshold of $4935.

However, the updated guidelines are set to significantly broaden the number of people who must be considered for MTM services, which include CMRs and other medication management services from a qualified pharmacist, to avoid DTPs.

With the new program criteria, CMS plans to lower the number of qualifying drugs from 8 to 5 and lower the cost threshold to just $1004 to bring it more in line with the average annual cost of 5 generic drugs in 2020. Plans will also need to evaluate members against a list of 10 common conditions and ensure these newly eligible members receive a CMR that includes an “interactive consultation” performed in real time, whether via synchronous telehealth or in person.

Four strategies to prepare for expanded MTM activities

To rise to the challenge of an expanded MTM program, the key will be finding ways to deliver MTM services with more efficiency and in ways that quickly generate savings. Expanding the reach of existing resources and preserving others provides capacity for future medication management needs. If done correctly, extending the reach of MTM resources and generating new forms of value should render MTM self-sustaining while contributing to higher Star Ratings, which come with their own attractive financial and marketing rewards.

Plans that wish to succeed with MTM should start to evaluate their technical infrastructure, staff training and member engagement strategies to ensure they have the right tools in place to effectively scale their efforts.

1. Support pharmacy workflows with technology to maximize cost reduction

Clinician-to-member relationships are at the heart of success with any member engagement initiative, including MTM. Empowered by access to abundant data about the member’s health conditions, prescriptions, and behavior patterns, outreach staff are able to elevate the quality and efficiency of the CMR.

A platform that leverages both medical and pharmacy claims on a frequent basis (daily or weekly) helps the health plan identify the broadest possible set of DTPs within the population of MTM-eligible members, to guide the pharmacist in the most clinically effective CMR. By combining medical claims data alongside pharmacy data, the plan can identify DTPs based on primary adherence, where ICD-10 diagnosis codes do not have correlating pharmacy claims. The availability of this data in real-time allows a pharmacist to access a broader set of DTPs during the CMR, to further drive improved health outcomes and medical cost reduction.

Real-time analytics available through the platform during a CMR also support the pharmacist in capturing additional information that can drive a highly efficient engagement. For example, the availability of J-codes (also found within medical claims) can indicate the use of high-cost specialty drugs, and the opportunity for transition to a lower-cost alternative drug or administration site—other opportunities for patient and plan savings.

Real-time analytics available through the platform during a CMR also support the pharmacist in capturing additional information that can drive a highly efficient engagement. For example, the availability of J-codes (also found within medical claims) can indicate the use of high-cost specialty drugs, and the opportunity for transition to a lower-cost alternative drug or administration site—other opportunities for patient and plan savings.

2. Assess current infrastructure and explore options for scalability

To meet expectations, MAPD plans and PDPs will need a technology platform that can conduct the advanced analytics necessary to stratify populations by risk, track outreach and engagement, and return actionable insights into program performance—all at a scale they have never had to deal with before.

Plans should carefully review their existing tools with an eye toward scalability and flexibility, especially around use by health plan and network pharmacy clinicians. For example, leaders may wish to consider MTM partners that offer Software-as-a-Service options that can support incremental expansion and fluctuations in capacity that may happen throughout the year.

3. Identify current and future member eligibility

Health plans must be able to identify members eligible for MTM proactively under the new guidelines. Even more helpful is the ability to predict when members are likely to become eligible in the near future, in order to help the plan prepare for enrollment into MTM services.

If and when CMS finalizes the new MTM rules, tools and partners that allow a health plan to accurately identify the number of potential newly eligible members can also help the plan forecast expected growth of MTM program costs.

4. Monitor program for ongoing effectiveness and cost reduction opportunities

The goal of MTM is to slash downstream spending by reducing avoidable utilization and supporting better outcomes for members. But since plans can’t manage what they can’t measure, they need to be able to see, in near real time, how well their efforts are working toward achieving this goal.

Leaders should consider adopting tools that provide access to customizable, detailed dashboards for deep insights into identification of new issues, member outreach patterns, successful completion of MTM activity, and claims-based evidence of cost savings from DTP resolutions and other interventions.

Access to these insights enables plans to understand where to focus their efforts to maximize cost savings that can be folded back into the MTM program or used elsewhere to fund other critical member services.

By taking a structured, data-driven approach to optimizing, executing, and monitoring the new MTM landscape, MAPD plans and PDPs can meet the proposed program criteria changes, achieve cost savings that can help fund program expansion, support higher overall Star Ratings, and continue to provide high-quality, equitable service for members with multiple medications and conditions.