To date, medication therapy management (MTM) services have largely been delivered by plans in a “check the box only” mode to satisfy rather low-expectation CMS Part D requirements. That expectation is beginning to shift as CMS moves from emphasizing outcomes over process quality measures and as new MTM models are being evaluated.
Cut Points and Calculations
Several years ago, plans faced their first “aha” moment when CMS published the first Star Rating MTM Comprehensive Medication Review (CMR) completion Star rating cut points. Prior to that time, the measures were being reviewed but were considered as “display only” and therefore not a part of the overall Star rating calculation. These first official cut points indicated that, at least when it came to delivering a completed CMR to a member, some plans had figured out how to reach a large majority of their qualified members, but most had not.
To achieve a 5-Star rating on this metric, a plan had to document CMR contact with over 75% of eligible members. This was a high goal for many plans hovering around 20% up until that point, and many plans and vendors woke up to a huge shock on the morning those cut points were published.
Reaching for the Stars vs Getting Engaged
Since that time, MTM vendors and those conducting MTM in-house have faced heightened pressure to meet the challenge of improving their delivery of completed CMRs. This is especially challenging given the varying nature of plan delivery types and the vastly different member demographics for whom they provide services. In some ways, assigning value to MTM has become about achieving a completed CMR to cross a CMS Star rating threshold rather than the truly valuable clinical impact that an engagement with a member about their medication therapy can and should have.
Outcomes Equal Increased Weight
Currently, the single-weighted CMR completion rate is the only Star rating directly correlated with MTM by name. However, year over year CMS continues to migrate its Star rating improvement strategy from process to outcome measurement. With that evolution, individual measure weights increase in impact severity as outcomes measures are more heavily “weighted” than less complex and health impactful process measures.
As plans wade through this ever-changing regulatory environment, it bears noting that, beginning in measurement year 2018 and realized in 2020, an increasing percentage of measures included in the Star ratings will be directly or indirectly impacted by MTM or medication-related activities.
As provider incentives move inexorably toward risk- and value-based reimbursement, larger provider groups are implementing standardized, clinically validated treatment pathways that often include a pharmaceutical intervention.
And while historically, the most well-known medication-related measures have been commonly thought of as the cluster of medication adherence measures, newer measures encompass a broader range of medication issues such as:
medication reconciliation
post-discharge, statin therapy for cardiovascular disease
opioid overutilization
asthma
Medication Measures Are Triple Weighted
As with Star rating adherence measures, most medication-based measures are triple weighted and, therefore, have a proportionally higher impact on the overall Star rating. Other existing Star Rating Part C measures such as blood sugar control for patients with diabetes or blood pressure control are heavily impacted by the appropriate use of medications.
Existing MTM processes offer a logical avenue to improve Star ratings while at the same time ride out the period as CMS shifts its attention further to the qualitative impact of MTM. However, health plans will face ongoing challenges with ensuring that the staff that is providing the MTM service, whether it is comprehensive review or an interim targeted medication review, is up to date on the newest therapies and treatment approaches.
Future Challenges
Plans will need to ensure not only that they are reaching the most members possible but that they are making the most of that opportunity. Many plans are looking to target specific populations and diseases such as diabetes and cardiovascular disease. They are also facing challenges with members suffering from socioeconomic or mental health disadvantages. Pharmacists need to possess a whole host of skills in order to overcome these clinical, social, and economic hurdles when they go to provide care.
In general, it’s unlikely that a plan will risk getting caught flat-footed like that day when those 2016 cut points were published; and plans are now monitoring the CMR rates closely whether or not they are providing that service in–house or via a vendor.
Opportunities for Pharmaceutical Manufacturers
In the years ahead, strategic partnerships that offer refreshed clinical skills, new ways of reaching and retaining member attention, and combined Part C and D medication oversight programs will be key to plans and their partners achieving and maintaining their Star rating and clinical goals.
— Lisa Erwin, RPh, CGP, Senior Clinical Strategist, Aventria Health Group