CMS Advance Call Letter, Impact on MTM Program Submission

CMS recently released the 2018 Advance Call Letter for Medicare Part D Programs (https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/Advance2018.pdf).  Submissions for the Medication Therapy Management (MTM) program are due May 1, 2017.  The MTM program is the perfect place to gain experience with and understand the status of new quality metrics.  Including in some form (either as part of your program identification or design), the quality metrics entering Display or STAR status benefits a Medicare Advantage Program by:

  • Improving the value (ROI) of MTM interactions
  • Provides the Plan with advanced understanding of the status of a population
  • Prepares the plan to address the quality metric at a population level

Here are a few quality metric highlights that the folks at CSS believe fit well into an MTM program, and might be used to guide MTM program submission over the next few months.

Opioids

Over and inappropriate use of opioids is a critical problem for most Medicare Advantage plans.  Taken as a whole the cost of opioid use outstrips most chronic and even specialty drugs.  Moreover, opioid use is driving an ever increasing volume of emergent and inpatient care.

  • CMS continues to refine its opioid overutilization policy and expects sponsors to reduce opioid over-utilization in the Part D program. They are soliciting comments and suggestions about the following new proposals to reduce the unsafe opioid over-utilization:
    • Changes to the retrospective Over-utilization Monitoring System opioid over-utilization methodology
    • Additional guidance about prospective formulary-level cumulative morphine equivalent dose (MED) point of sale (POS) edits
    • CMS is also seeking feedback on a more significant future revision to target beneficiaries with more than 3 prescribers regardless of the number of opioid dispensing pharmacies.
  • The Use of Opioids from Multiple Providers and/or at High Dose in Persons without Cancer is evaluated using 3 separate measures in accordance with PQA guidance.  These measures were included in the 2016 Patient Safety Reports and will be added as 2019 Display measures (using 2017 data):
    • Measure 1: Use of Opioids at High Dosage in Persons without Cancer (OHD): The proportion (XX out of 1,000) of individuals from the denominator receiving prescriptions for opioids with a daily dosage greater than 120 mg morphine milligram equivalents (MME) for 90 consecutive days or longer.
    • Measure 2: Use of Opioids from Multiple Providers in Persons without Cancer (OMP): The proportion (XX out of 1,000) of individuals from the denominator receiving prescriptions for opioids from four (4) or more prescribers AND four (4) or more pharmacies.
    • Measure 3: Use of Opioids at High Dosage and from Multiple Providers in Persons without Cancer (OHDMP): The proportion (XX out of 1,000) of individuals from the denominator receiving prescriptions for opioids with a daily dosage greater than 120 mg morphine milligram equivalents (MME) for 90 consecutive days or longer, AND who received opioid prescriptions from four (4) or more prescribers AND four (4) or more pharmacies.

Interactions, Inappropriate Combinations and Inappropriate Medications

CMS continues to refine it’s focus on inappropriate medication use

  • CMS is analyzing the PQA’s Chronic Use of Benzodiazepine Sedative -Hypnotic (BSH) measure.  After initial review, they do not propose adding the measure to Display or STAR sets, but will continue to monitor BSH rates.
  • The updated PQA Drug-Drug Interaction (DDI) measure is currently being evaluated in Display measure Status.
  • The High Risk Medication (HRM) has been returned to Display measure status for 2017.  CMS expects to return HRM to STAR measure status with modification.  Expected changes to this measure include removing thioridazine, trimethobenzamide and chloral hydrate from the list of HRMs, and requiring an average dose calculation for doxepine, reserpine and digoxin.
  • PQA is exploring a new measure for the Part D program – Concurrent Use of Opioids and Benzodiazepines 

Comprehensive Medication Review

CMS believes that the Comprehensive Medication Review (CMR) is a key component of the MTM program.  As such it will continue to receive due scrutiny.

  • CMS is proposing a change to the display of the CMR rate.  Currently, the CMR rate is displayed with one decimal.  CMS is proposing rounding this measure to the nearest integer using standard rounding rules.  Clustering to determine STAR cut points would be conducted after rounding.  CMR calculation specifications will remain the same.
  • CMS piloted a new MTM program audit protocol in 2016 evaluating Part D sponsors’ MTM programs. Findings identified during pilots of the new MTM audit protocols are not currently applied to Star Ratings.  After the pilot phase, CMS will review and apply any relevant MTM program audit findings for data integrity reviews for the MTM CMR Completion Rate measure that could demonstrate systemic failures by sponsors that resulted in biased MTM data.
  • CMS created a Categorical Adjustment Index (CAI) that can be applied to Star measures to adjust for the disparity of performance in the Low Income Subsidy/Dual-eligible (LIS/DE) populations.  CMS has proposed applying this adjustment index to the CMR rate.  The adjustment index is currently applied to the Medication Adherence for Hypertension (RAS antagonists) measure.

Care Coordination and Transitions of Care

Most Medicare programs provide care coordination and transition management services.  The literature regarding early readmissions is relatively conclusive that the inappropriate use of medications (e.g. return to the use of legacy medications,  inability to obtain post discharge medications, etc) are significant factors contributing to the early readmission.   Moreover, medication reconciliation post transition is critical to preventing early readmissions.

  • CMS is proposing to move the Medication Reconciliation Post- Discharge Part C measure from a Display Measure to a STAR Measure in 2018 STAR Ratings with a weighting of 1.  Then, in 2019 applying a weighting of 3 to this measure to reflect its role in assisting to improve a beneficiary’s overall health status.
  • CMS has proposed triple-weighting of the Care Coordination and Medication Reconciliation Post-Discharge measures.  The believe that these measures are good proxies for demonstrating “well-integrated, person-centered care that creates a positive experience for members”. 
  • The proposed Part C Transition of Care measure has a component regarding the performance of medication reconciliation within 30 days of inpatient discharge.  CMS is suggesting that data for this measure would be a Display measure in 2020 (using 2018 data)

Chronic Disease

  • The measure Statin Therapy for Patient’s with Cardiovascular Disease is now a Display measure.  CMS is proposing that this measure become a STAR measure in 2019.
  • The measure Statin Use in Patients with Diabetes (SUPD) will continue to be a Display measure for 2018 (using 2016 data).  This measure will be moved to STAR measure status in 2019 (using 2017 data).
  • Medication Management for People with Asthma is still under analysis and will not be added as a Display or STAR measure in 2018.

Mental Health

  • CMS is proposing to remove the Part D Chronic Use of Atypical Antipsychotics by Elderly Beneficiaries in Nursing Home Display measure and replacing it with the PQA Antipsychotic Use in Persons with Dementia (APD) measure.  The APD measure is defined as the percentage of Medicare Part D beneficiaries 65 years or older with dementia who received prescription fills for antipsychotics without evidence of a psychotic disorder or related condition. Reporing on this measure is already in process through the Patient Safety Awareness website.  CMS is proposing that this continue but with improving the stratification calculations beginning with 2017 reports. This will be applied to the 2017 program year data for the 2019 display measures.  CMS also proposes to display APD rate and the rates for two population breakouts as follows- the overall APD rate and the rates for two population breakouts – Community-only residents (never a nursing home resident) and Long-Term nursing home residents (greater than 100 cumulative days in a nursing home). CMS will assess adding the APD measure to the Star Ratings in the future
  • CMS is evaluating the measure Depression Screening and Follow-Up for Adolescents and Adults.  The measure assesses the percentage of patients age 12 and older who were screened for depression using a standardized assessment tool, such as the PHQ-9, and if positive, received appropriate follow-up care within 30 days of the positive screen. This measure would potentially be a Display measure in 2020 (using 2018 data). CMS is seeking feedback on the measure, the best range of standardized assessment tools to be used in primary care settings for screening, and the measure’s reliance on electronic clinical data systems.
     

    As always I am happy to discuss any of these thoughts in greater detail. Feel free to reach out by phone or e-mail.

    Jim Notaro

    716.541.0273 x101

    jnotaro@csshealth.com