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November 20, 2015

Prescription drug plans (PDPs) serving the five Part D regions eligible to participate in the Part D Enhanced Medication Therapy Management Model Test ( have a lot to consider as they prepare for the January submission deadline. The Centers for Medicare and Medicare Services (CMS) Center for Medicare and Medicaid Innovation (CMMI) has – by design – left much to the imagination in terms of the program’s structure, member eligibility criteria, and engagement strategies.

When designing a program for the demonstration model, there are some fundamental questions that need to be addressed: How will you determine the parameters within medication-related risks to identify your targeted beneficiaries? How will your MTM services be delivered and what will they include? Will you manage the program internally, or will you subcontract all or part of your program elsewhere? How will you monitor and report on your program’s performance?

And, most importantly: How will it all work together to reduce cost of care for your plan to earn the financial incentives offered by CMS?

This may seem like a daunting project in such a short time frame; but Clinical Support Services, Inc. (CSS) has the MTM knowledge, experience and resources to help guide and assist plans in developing and managing model programs in the following ways:

  • Identifying Targeted Populations
    Traditionally, CMS has required a “brute force” approach for identifying MTM eligible members (i.e. high cost, lots of drugs, lots of disease). This was a good “first draft” approach for identifying the members who would benefit from MTM, however CMS has recognized that it produced a sufficient number of false positive identification (members who used a lot of medication but were well managed) and failed to identify a significant number of members who were of lower complexity but would benefit from MTM services). Consequently, CMS has provided little direction in terms of the parameters for defining eligibility criteria. Opening the doors for plans to analyze their pharmacy claims data in novel ways to identify members with medication use risks which predispose them to hospitalizations and other iatrogenic illness.
  • MTM Program Design
    The Enhanced PDP model challenges plans to develop an MTM program that departs from its current standard Part D requirements. CMS has recognized that if plans can refine their identification routines to “thin slice” their members by problem type, they should also be able to design programs better matched in texture and intensity to the scope of problems found in identification. Plans can alter the typical comprehensive medication review (CMR) and targeted medication review (TMR) standards, or test completely new engagement and medication review strategies.   An Enhanced PDP MTM program design will likely be a compendium of MTM programs.
  • MTM Delivery
    To paraphrase Shakespeare – To face or not to face, that is the question. Up until now there has been a running controversy regarding MTM delivery – Is a face-to-face MTM interaction better than a telephonic interaction? Currently, there is little objective evidence that supports the use of one method over another. Health plans have typically opted for a telephonic option delivered by a small group of tightly managed clinicians to deliver MTM services. This allowed the plan to better control the regulatory requirements regarding the provision of comprehensive medication reviews (CMRs).   However, now that CMR rates are a STAR measure plans will need to rethink this “one size fits all” approach to MTM delivery. MTM will have to “meet the member where they live” delivering MTM in a manner that is most preferred by the member (vs. the plan). CMS recognizes this in their Enhanced PDP model and encourages plans to be delivery model agnostic.
  • Interoperability
    As the delivery of MTM services becomes more and more delivery model agnostic, there will need to be better standards regarding system to system communication of MTM cases. Plans cannot expect that MTM providers continue to utilize multiple MTM documentation systems. Optimally, MTM providers would be able to document MTM cases in their preferred system and transmit a case summary in a community standard format. The currently accepted clinical standard for documenting clinical concepts is the Systemized Nomenclature of Medicine – Clinical Terms (SNOMED CT) Codes. The Pharmacy Information Technology Collaborative has developed a framework for documenting MTM cases using SNOMED codes ( . Utilization of a common coding / documentation structure across MTM providers reduces providers’ barrier to providing MTM services and plans’ overhead in “accounting” for MTM delivery.
  • Outcomes Reporting
    Of course the entire rational behind the Enhanced PDP program flexibility is that it will produce better outcomes. While certainly CMS is interested in process (CMR rates) and proxy (HbA1c levels) measures, in the end CMS is most concerned about correlating MTM services with reductions in non-planned care (i.e. urgent care, emergency care and hospitalizations). In preparing their PDP applications plans may want to consider

    • Data Integration
      CMS has indicated that it will provide plans with the “medical claims data” required to assess MTM’s effect on non-planned care. In fact, this is not a new offer – the CMS Innovation Center has made this data available to other initiatives, and this administration’s CMS has been significantly more transparent with Medicare claims data than any other CMS. Consequently, it’s not unlikely that CMS will, in fact, fulfill it’s promise and plans will need to incorporate into their responses how to assess the total cost of care (and other related) effects of MTM.
    • Quality Measures Selection
      As CMS is allowing flexibility in MTM program identification, design and delivery plans will have to search beyond the current set of STAR and Display measures to assess the process and proxy aspects of their programs. The National Quality Form (NQF) and Pharmacy Quality Alliance (PQA) certainly are the thought leaders in this area and provide a great “head start” for plans. Likely, to measure the full breadth of an innovative MTM program plans will have to adapt existing NQF and PQA measures, and possibly need to design measures which have not currently been submitted for endorsement.
  • Flexibility
    Your Enhanced MTM proposal will likely not be “carved in stone”. CMS is encouraging participating plans to test different MTM strategies to reduce the cost of care, meaning your program should be capable of changing directions quickly for trial and error testing. Likely, CMS will be looking for plans to operate innovate program components in PDSA cycles – eliminating program components that don’t work and substituting with new innovation.

The Part D Enhanced MTM Model provides PDPs with a novel opportunity to innovate in the MTM space. Moreover, with CMS’s plans to incent PDPs with premium subsidies and shared savings the potential of the Enhanced MTM model may be significant. Many PDPs may be concerned that the reward may not be worth the investment, and this would be a valid concern as many aspects of the Enhanced MTM model have yet to be fully articulated. However, right now it’s a bit like a poker game where everybody is checking on the raise – it costs very little to prepare your initial proposal as stay in the game and see what the “flop” brings.

I would be 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

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