CMS warns that MTM will take time to set up

Don't expect Medicare beneficiaries to qualify for medication therapy management (MTM) until the second or third quarter of 2006. And data on the actual health outcomes of the 2006 program will not be available until late 2007 or 2008. That timeline came from officials at the Centers for Medicare & Medicaid Services, who spoke at an American Health Quality Association (AHQA) meeting in Arlington, Va., last month.

CMS officials also confirmed that the agency will not require MTM under the new Medicare prescription benefit to be a face-to-face service. They indicated the currently approved drug plans are employing a variety of methods to meet the MTM requirement, not just using pharmacists.

"The only stipulations outlined in the regulation, in section 101, are just that plans must offer a medication therapy management program. And in order to be eligible, you must meet these criteria. But otherwise, we have not been proscriptive on which interventions should be offered," said Vikki Oates, MAS, acting director of the CMS Division of Clinical & Economic Performance, Medicare Drug Benefit Group.

The CMS officials made it plain that MTM is still a work in progress, but they did give a few more details of what it will look like next year, since the agency has analyzed some of the things the plans have agreed to do. And at this moment MTM looks like a very mixed bag.

The interventions by which drug plans will fulfill the MTM requirement include beneficiary letters, medication review, refill reminders, counseling, educational services, and R.Ph. and nurse outreach, said Sunil K. Sinha, M.D., MBA, also of the Division of Clinical & Economic Performance. Some of the drug plans will also target providers to help them with the MTM effort, he said, including efforts such as patient profiles, guidelines, and letters.

And although it is not a requirement, Sinha said some plans have specified outcomes they will look for, including drug-drug interactions, over- and underutilization of drugs, polypharmacy, patient satisfaction, disease-related health costs, changes in medication regimens, and medication adherence and persistence.

For the requirement that a beneficiary must have multiple chronic diseases to receive MTM, the CMS analysis of the new plans found that the number of conditions the plans are requiring ranges from two to five, but a majority will require only two chronic conditions.

And to meet the regulation that to be eligible for MTM a beneficiary must be likely to incur $4,000 in annual costs in covered Part D drugs, the plans are analyzing those costs through a variety of methods, with the majority calculating them based on monthly or quarterly costs, according to Sinha.

The drug plans will be reporting, on a half-year basis, the number of beneficiaries who meet the criteria for enrollment, the number participating, the number who disenroll for any reason, the number who decline to participate, and the number of drug dollars spent per MTM beneficiary per month. CMS will evaluate the data to ascertain the percentage of beneficiaries targeted for MTM in order to identify the optimum identification criteria, said Sinha.

For the vision of MTM going forward, Sinha indicated, CMS anticipates there will be collaboration with stakeholders to establish criteria for minimum quality standards, standards of care for interventions, and validation of new measures.

Sinha and other CMS officials spoke at the meeting of AHQA, the association that represents the Quality Improvement Organizations (QIOs), which Medicare has long contracted with in the individual states for work such as spreading best practices in health care and reducing medical errors. The new prescription benefit law now requires the QIOs to provide assistance and monitor quality in the programs.

The CMS officials said at this point it is the drug plans' role, on a voluntary basis, to work with the QIOs to improve health care and quality outcomes. They added that although the involvement of pharmacists in the efforts of QIOs and the drug plans is downstream, R.Ph.s may do well to get to know people in their state QIOs, so the work will move quickly when it begins.

The Author is a writer based in Maryland.