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Pharmacists at Center of Drug Adherence Pilot

Medicare Is Finally Offering More Flexibility for MTM Programs
Stephen Barlas

The Medicare program is finally providing Part D outpatient drug plans with some flexibility for medication therapy management (MTM) programs. The Centers for Medicare and Medicaid Services (CMS) announced an MTM pilot program starting in 2017 that offers Part D prescription drug plans (PDPs) potential improvements and incentives to upgrade their MTM plans,1 which even the CMS admits have failed to live up to expectations.

If there is a key watchword in this pilot program, it is “pharmacist.” The CMS hopes that PDPs will make greater and better use of pharmacists and that physicians and pharmacists will form a more unified nexus in caring for Part D patients. However, the CMS will not change its policy prohibiting pharmacists from billing for MTM services. The hope is that the PDPs will use their incentive payments from Medicare to reimburse pharmacists, although the CMS has introduced what the American Pharmacists Association (APhA) views as an antipharmacist element in the pilot.

The Academy of Managed Care Pharmacy (AMCP) has been among the groups pushing for more MTM flexibility. Mary Jo Carden, AMCP Vice President of Government and Pharmacy Affairs, says PDPs will have just a short time to assess whether the “enhanced” MTM pilot program, which will be available only in certain geographic areas, suits them well enough to apply for inclusion. The program is scheduled to start in the 2017 plan year. “They have to feel comfortable enough about how they will be judged, and they have to do that in less than a year,” she says. “Plans will have more flexibility as to whether they must perform a comprehensive medical review, for example. And plans will have flexibility to provide some products that could help with medication adherence, such as special compliance packaging and mnemonic devices.”

However, questions remain about whether the new payment streams to the PDPs will be ample enough to encourage aggressive new MTM efforts and to compensate for the additional costs to the plans.

Current requirements for MTM targeting allow a Part D plan to set a minimum number of drugs as high as eight, meaning someone would have to be taking eight drugs to qualify. Plans can set that bar much lower if they want, but spending has to exceed $3,138 annually. A member with three or more chronic diseases, out of a list of nine, is eligible. In other words, a plan cannot require members to have four or more chronic diseases. Members who meet all three criteria receive an annual comprehensive medical review and then quarterly targeted medical reviews.

Those three targeting “floors” go out the window in the enhanced pilot program. PDPs can target whomever they want as long as the CMS approves their applications. Only PDPs rated three stars or above will automatically be eligible. Services beyond those previously allowed can be provided. And perhaps most important, the CMS will offer two new payments to participating PDPs: an incentive payment and a performance payment.

The per member/per month incentive payment—which will differ from plan to plan, based on the scope and intensity of MTM services offered—is meant to provide the PDP with additional funds that it could use, for example, to pay in-house or retail pharmacists for providing MTM services. However, the plans will be required to “earn back” those payments in the form of savings.

The performance payment will be based on the PDP meeting quality and cost targets, similar to the structure of the accountable care organization program. For the years 2017 and 2018, those payments will be based on a PDP reducing Medicare Part A and B costs for its members by 2%. That reduction will have to be for the entire PDP membership, not just the members enrolled in the enhanced MTM program. The performance bonus would be a $2 per member increase in the government subsidy to the plan premium, leading to lower beneficiary premiums. Starting in 2019, the CMS hopes to have specific quality standards in place.

One thing that seems a bit curious about the proposed program is the CMS’s intention to waive a provision in the current MTM legal grounding that says an “MTM may be furnished by a pharmacist,” when an intervention not typically provided by a pharmacist is necessary to “resolve all barriers to optimized drug therapy or for financial need.” That language imposes no requirement on anyone. So the APhA argues that removing the language appears to conflict with statements throughout the announcement that specifically mention pharmacists and emphasize the need to utilize pharmacists and strengthen the coordination between them and the entire health care team, including the patient.

The success of the pilot program will depend on the CMS resolving that question about pharmacist participation and other critical issues, such as reporting of data from the PDPs, the 2019-and-beyond quality standards, and the sufficiency of incentive payments. The plans will ultimately determine how much of those incentives get passed along to retail and managed care pharmacists, who will probably have to do yeoman’s work to make this MTM pilot program a success.

Author bio: 
Mr. Barlas is a freelance writer in Washington, D.C., who covers issues inside the Beltway. Send ideas for topics and your comments to
  • Centers for Medicare and Medicaid Services. Part D Enhanced Medication Therapy Management Model. September 282015;Available at: Accessed October 28, 2015