Usage of MTM, CMR Is Very Low In Part D, Avalere Study Finds

Reprinted from MEDICARE ADVANTAGE NEWS, biweekly news and business strategies about Medicare Advantage plans, product design, marketing, enrollment, market expansions, CMS audits, and countless federal initiatives in MA and Medicaid managed care.

By James Gutman, Managing Editor

August 28, 2014 Volume 20 Issue 16

Despite persistent and varied efforts by CMS to foster their spread, less than half of Medicare Part D enrollees eligible for medication therapy management programs receive them, and only 11% of all Part D enrollees were part of MTM programs in 2012, according to a new study of CMS data from that year by consulting firm Avalere Health LLC. Moreover, Avalere found that just 1% of Part D enrollees in 2012 received the comprehensive medication review (CMR) that all Part D plans must offer to MTM enrollees (see chart, p. 4).

The percentages, though, are markedly different in Medicare Advantage drug plans (MA-PDs) versus stand-alone Prescription Drug Plans (PDPs). MA-PD members, said Avalere, were nearly three times more likely than were PDP enrollees to get a CMR — and were nearly four times as likely to receive an intervention such as “outreach to a prescriber” or a change in therapy as a result of the CMR.

There seem to be specific reasons for those differences, Avalere Executive Vice President Matthew Eyles tells MAN. For one thing, he explains, it is harder to demonstrate a return on investment for MTM in PDPs, which carry low beneficiary premiums and are responsible just for pharmaceutical benefits, than in “integrated plans” liable for both medical and drug benefits in Medicare. Eyles adds that some drug utilization review is helpful in either kind of plan, but PDPs can accomplish this at the “point of prescription” without having to absorb all the costs of a full MTM program. He notes that the leading PDPs now offer monthly premiums as low as about $15, thus leaving little extra money for MTM initiatives.

Lack of Stars Bonuses for PDPs Cited

Asked whether the lack of CMS star-rating quality bonuses for PDPs as opposed to for MA-PDs could be a factor in less MTM enthusiasm on the part of PDPs, he acknowledges that some of the categories measured in determining eligibility for stars bonuses are affected by MTM. But he also points out that CMS does not have the statutory authority to award stars bonuses to PDPs and would have to make the difficult argument that its demonstration authority grants such powers if it wants to change this unilaterally.

Furthermore, none of the MA-PD versus PDP factors explain why there is such low take-up of MTM programs by beneficiaries even when they are offered. While CMS estimated in a 2010 Fact Sheet that 25% of Part D beneficiaries are eligible for MTM, Avalere found that among the 10 largest carriers participating in Part D, MTM enrollment rates of members ranged from a low of 4.6% to a high of 17.5%. And the share of MTM enrollees receiving a CMR was as low as 2.4% in one plan although as high as 73.8% in another, the consulting firm’s data show.

Eyles says “there’s not a lot of deep insight” on why beneficiaries are not signing up for MTM to the extent that CMS had hoped and expected. While it may seem on the surface like a “value add” that beneficiaries would want, “there may be something in the messaging” and in how plans are communicating with members about MTM that is slowing the adoption, he suggests. The term “MTM,” for example, he says, doesn’t mean much to members, and there is no evidence that the number or quality of MTM programs enters into beneficiary decisions on which Medicare plan to join. He has no theory on why the rate of CMR adoption is so low.

On MTM itself, however, part of the explanation for low usage may lie in the parameters CMS allows Part D plans to use in limiting eligibility. Now, for instance, Part D plans do not have to offer MTM to members unless they incur annual drug costs of at least $3,144, have at least three chronic diseases and take at least eight Part D-covered medications. CMS proposed lowering all those thresholds in a section of its draft MA and Part D rule in January, but withdrew these changes in a May 7 memo that followed opposition to the intended MTM expansion from both parties in Congress (MAN 5/22/14, p. 1).

Part of this opposition stemmed from the Academy of Managed Care Pharmacy (AMCP), which continued to express doubts about the MTM expansion in an Aug. 8 letter to members. “AMCP…does not believe that the Part D program’s current infrastructure, which is little more than a regulatory unfunded mandate, provides a solid foundation for a practice model that truly provides the level of services necessary to improve outcomes,” CEO Edith Rosato wrote. Her letter contends that a CMS study itself suggests that the current Part D MTM program “does not effectively reduce overall costs, improve health outcomes or reduce hospitalizations.”

The letter cited reservations expressed by the Medicare Payment Advisory Commission (MedPAC) about the proposed MTM expansion on grounds of cost and effectiveness (MAN 3/13/14, p. 1). Rosato added that “MTM works when targeted to individuals who require and could benefit from the services,” but that the proposed mandatory expansion “would further stretch limited resources.” Managed care pharmacists, she asserted, have invested lots of time, effort and expense in identifying eligible beneficiaries under the current MTM requirements, “yet continue to have difficulty getting these beneficiaries to enroll in the program.”

Eyles points out that CMS must expand MTM in order to comply with provisions in federal laws. And the agency has proposed the expansion in part because it recognizes existing MTM programs weren’t having the desired effects that would result from more widespread use, he contends. With this in mind, Eyles expresses doubt that CMS will go along with the AMCP concept of more targeted MTM programs.

So what will happen? In Eyles’ view, the agency will continue to monitor MTM usage and might propose some sort of expansion in the preliminary 2016 Part D Call Letter next February. “The issue will not go away,” he predicts.

View the Avalere study by visiting the Aug. 28 From the Editor entry at MAN's subscriber-only Web page: www.aishealth.com/newsletters/medicareadvantagenews.