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For those of us with a passion for medication management we are all encouraged to see the dissemination of medication management into Medicaid programs.  The Tennessee Senate and House, for example, are deliberating the adoption of legislation requiring all Medicaid managed care providers who participate in TennCare (the Tennessee Medicaid program) to incorporate a medication management program into their offering.

Certainly, the dissemination of medication management into Medicaid is a result of the “foothold” MTM has achieved in Medicare Part D.  It was the Medicare program that moved community based medication management from it’s academic roots to a scalable program which provides a documented degree of value.  In its 2010 Medicare call letter, the Bush administration, specified the parameters of a Medicare based medication management program – Medication Therapy Management (MTM).  This call letter proscribed the methods to be used to identify eligible members, offer medication management services, deliver and document the medication management interaction.

The Medicare based medication management process has become so institutionalized that we use the acronym MTM, like Kleenex, to describe all forms of medication management.  This is both good and bad.  Good in that it recognizes that robust medication management requires a well specified process.  Bad in that it contributes to the notion that all robust medication management must follow the Medicare Part D MTM process.  However, Medicaid programs serve a population unlike Medicare programs.  Consequently, for Medicaid programs to generate a value for a Medicaid plan their design should respect the Medicaid population and their specific medication use concerns.  Below are a few thoughts regarding the uniqueness of Medicaid medication management programs.


All medication management programs should have a well articulated program design. Program design allows, program managers to focus medication management interventions of appropriate intensity (e.g. physician consult notes, patient consults, patient coaching) toward achieving program goals (e.g. reducing legacy therapy, decreasing regimen cost, increasing medication adherence).  Without program design a plan is simply counting on the “midas touch” of the medication management clinician to create value.

The program design for Medicare MTM was initially constructed to achieve the value propositions of the Medicare program.  Specifically, reduce costs, improve adherence, improve the use of renin mediating agents in diabetes, and minimize the use of high risk medication.  Over the course of the past 7 years we have seen CMS refine these value propositions.  The use of renin agents and minimization of high risk medications have been dropped and the use of dyslipidemia therapy in diabetics has been added.

As Medicare and Medicaid cater to different populations, one might expect the value propositions to be different.  In turn, the program design for a Medicaid program should differ from Medicare programs.  Certainly, cost reduction is a value proposition that would be common to both programs.  However, while Medicare quality is demonstrated in achieving STAR measures, Medicaid programs focus more on HEDIS metrics.  The metrics used by Medicaid programs to demonstrate quality vary from state to state.  In addition, typically Medicaid programs serve younger, more disenfranchised populations and medication use may be more impacted by social determinants of care.

Attempting to “shoe horn” a Medicare Part D program design into a Medicaid medication management program can be a recipe for sub-optimizing the achievement of program goals.


Program identification is the process of identifying a subset of members from the general population who might benefit from medication management.  Traditionally, the Medicare Part D program has assumed that the members who will benefit most from medication management are those members with the most complex and expensive medication regimens.  However, experience with the Medicare program has demonstrated that this is not always the case.  In fact, CMMI’s enhanced medication management model allows plans to vary from the traditional program identification rubric in order to focus on members where medication management will provide best value.

Medicaid programs are not required to follow CMS guidelines for member identification in their medication management programs.  Consequently, they should not feel restricted by these traditional requirements in identifying members for a medication management program.  In fact, Medicaid programs can (and should) get quite creative in creating their medication management program identification criteria.  Unlike Medicare programs, Medicaid programs can be razor focused in selecting members for medication management.  Some examples might include:

  • HIV members with low HIV medication MPRs
  • Patients utilizing more than two behavioral health medications
  • Patients using break-through inhalers without the concomitant use of controller medication

…or some combination of all of these


Member engagement is the process of engaging the member to rectify a medication therapy gap (an instance where the patient’s medication regimen appears to deviate from clinical evidence).  In some cases it is most appropriate to engage the patient directly (e.g. adherence gaps).  In other cases it may be more effective to engage a patient through their prescriber (e.g. use of legacy medication).  Regardless, when we engage members or prescribers we should engage with their preferred mode.  There is no reason to engage a patient face-to-face if the interaction can be completed telephonically equally as well and the patient is comfortable with this mode of engagement.  Finally, engaging members using a particular mode simply for ideological reasons (e.g. using face to face because that is the clinicians preferred mode) may increase program costs, decrease program value and impart no additional benefit to the member.

The Medicare Part D program design assumes a patient – MTM clinician intervention will provide more program value that a prescriber – MTM clinician intervention.  Moreover, the Medicare program institutionalizes this philosophy with its CMR STAR rate.  Consequently, Medicare Part D plans are required to engage in a race for high CMR rates.

Medicaid programs are not saddled with this type of member engagement requirement and should take full advantage of this flexibility.  Medicaid programs can specifically match the type and mode of member engagement to the therapy gap to be resolved and the member’s preferences.

If you are designing a Medicaid medication management program these are a few areas where you may want to consider deviating from the traditional Medicare Part D MTM program design.

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