What are Medication Therapy Management Programs (MTMPs), which issues impede their implementation, and how can they boost care quality?

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he first article in this series published in the November/December 2005 issue of ECPN (and available at www.extendedcarenews.com/article/4965), discussed the Medicare Modernization Act (MMA) of 2003, its overall implications for long-term care facilities, and specific elements of the benefit itself. As year two approaches, stakeholders are seeing an evolution in plan design and the number of plans available as well as—in light of the November election results—rumblings about alterations to the legislation.
       One of the areas addressed slightly in the last article was the MMA provision for Medication Therapy Management Programs (MTMPs). With the burden of initial implementation of the Part D benefit on Prescription Drug Plans (PDPs), Medicare Advantage plans (MAPDs), and providers, the Centers for Medicare & Medicaid Services has taken a light hand in the quality and speed with which plans offer these required programs. But stakeholders should see an acceleration of activity around MTMPs (and more specificity in services provided under the various programs) in 2007, followed by some hard accountability from CMS on plans to demonstrate that their MTMP services produce quality medication therapy outcomes in 2008. That said, let us take a closer look at the issue.

The MTMP Mandate

       In its original legislative language, the MMA outlines a quality improvement (QI) infrastructure to assure not only that beneficiaries receive the medication benefits they are entitled to but that plans provide for services to assure that these medications are used correctly and that their usage and outcomes are studied to determine the best approaches to pharmaceutical care for geriatric persons and other beneficiaries covered under Part D. CMS mandates for plans to have a CMS-approved MTMP and for services to be provided to “target beneficiaries.” The actual CMS language states that plan entities must provide an MTMP that:
• Ensures optimum therapeutic outcomes
• Reduces the risk of adverse events, including adverse drug interactions
• Includes practicing pharmacists and physicians
• Is a complete program, with policies and procedures, described services, payment schedules, etc.
• Targets specific beneficiaries who:
       o suffer from multiple disease states;
       o take multiple Part D-covered drugs;
       o and are expected to incur annual drug expense in excess of $4,000.
       Each plan can decide what constitutes “multiple” for conditions and medications, and most have decided to apply these target benchmarks across their entire coverage population. An important caveat to note is that while CMS does not allow plans to have different formularies for different beneficiary populations, it does allow and encourages plans to have specialized MTMPs that reflect the needs of different beneficiary populations.

The Goals of MTMPs

       The guidance CMS has given to plans is general and revolves around urging plans to build MTMPs that have elements designed to promote:
• Enhanced enrollee understanding (through beneficiary education, counseling, and other means that promote the appropriate use of medications) and reduced risk of potential adverse drug events (ADEs) in association with the use of medications
• Increased enrollee adherence to prescription medication regimens
• Detection of ADEs and patterns of over-use and under-use of prescription drugs
• Services [which] include but are not limited to:
o performing health status assessment;
o formulating prescription drug treatment plans;
o managing high-cost specialty medications;
o evaluating and monitoring patient response to drug therapy;
o providing education and training;
o coordinating medication therapy with other care management services;
o and participating in state-permitted collaborative management of drug therapy.
       While looking at these design elements, one can see that some may be better suited to an ambulatory geriatric population rather than a nursing home population that has enjoyed the benefit of required drug regiment review (DRR) by consultant pharmacists. Let us take a closer look at how MTMPs may be designed differently in these settings.

MTMPs: One Size Does Not Fit All

       The previous article in this series stated that CMS does not consider assisted living facilities as “institutional.” Therefore, there is a different set of benefit standards and liabilities for assisted living patients, and they are the same as for beneficiaries who are living at large. In what we would call the “ambulatory” elder population, pharmacist medication management services are rare. In the past, payers have provided them on a managed care basis. Generally, these medication interventions have not been face to face, and they have not been specifically tailored for geriatric patients.
       Nonetheless, there are features of existing MTMPs that have been applied to Part D beneficiaries. With some work, these existing programs may evolve to address issues of ambulatory and assisted living patients. In general, MTMP services to this population could focus broadly on adherence and persistence; identification, resolution, and prevention of medication-related problems; and health status assessments, screenings, and wellness services. Thus, the approach to ambulatory and assisted living populations could be built around ensuring that medications are used as ordered, prescriptions are actually filled, drug interaction and possible ADEs are identified, and the overall bar is raised in proactively dealing with prevention issues and quality of life for those with chronic disease.
       Nursing home patients present a totally different view of MTMP services. These, of course, are frail elderly patients with multiple disease states and multiple medication uses. They are prone to exacerbated medication-related problems, and of course their response to medication is very different from young and “young-old” patients. The fact that consultant pharmacists routinely assess these patients adds another wrinkle to how we should construct MTMPs to add value to pharmaceutical care in nursing homes. The intense regulatory environment in long-term care also complicates the task of implementing MTMPs within the nursing home environment.
       To deal with these issues, the American Society of Consultant Pharmacists (ASCP), whose members are experts in providing pharmaceutical care and other services to nursing home patients (and seniors, regardless of where they reside), has empanelled the Medication Therapy Management Task Force to address MTMPs—first in nursing homes and then in other settings as well. To date, the task force and the Board of Directors have adopted an ASCP policy statement on Medication Therapy Management (MTM) in nursing homes. They are working on an operational plan for MTMP stakeholders to use to construct meaningful programs in nursing homes. The tenets of the existing policy are:
       1. ASCP advocates, as indicated in regulatory provisions for MTMPs, for Part D sponsors to provide flexibility in the MTM services offered to residents of long-term care facilities, and for these services to reflect the unique differences in these residents and settings.
       2. The MTM program should primarily focus on optimizing therapeutic outcomes and reducing ADEs for the beneficiary; it should secondarily focus on reduction of drug costs when warranted.
       3. Pharmacists who provide MTM services to long-term care facility residents should have expertise in geriatric drug therapy.
       4. Medicare Part D sponsors who provide MTM services to long-term care facility residents and providers of federally mandated DRR should coordinate these services to ensure they are not duplicative.
       5. MTM recommendations received by the administrator, prescriber, pharmacy provider, or caregiver/resident are best reconciled by the facility’s consultant pharmacist.
       6. MTM services provided by Medicare Part D sponsors to long-term care facility residents must be coordinated through the facility’s administrator.

Issues and Barriers to MTMPs

       In addition to the discussion on how to construct MTMPs that appropriately address the needs of differing beneficiary populations, there are other issues that need to be considered with regard to MTMPs and services. For-profit plan entities may view MTMPs as an additional way to control costs, and they may focus their plans on inappropriate use of step therapy, prior authorization, or other utilization-control measures rather than focusing on the clinical outcomes of MTMPs (as mandated by CMS).
       While CMS mandates these programs, there is little guidance or oversight at this point—and, so far, little accountability of the programs. Plans may view the requirements for MTMPs as unfunded mandates (ie, internal costs that the plans must incur that affect their profitability). If some examples of addressing medication management increase plan costs (eg, a need for a more expensive agent for a specific type of patient or identification of disease states that are not being treated), there may be little or no enthusiasm or incentive on the part of the plans to implement these services. Plans that are responsible for both medical and medication costs may see the value of appropriate medication management to reduce overall healthcare costs (ie, that a dollar spent on MTMP services will reap multiple rewards in medical cost savings and cost avoidance). Many feel that the MMA Part D structure should be changed so that the clinical and economic goals of all plans are more closely aligned, providing incentive to all providers to foster the most appropriate MTMPs possible.
       Issues remain around the “who” of MTM. Which professionals are authorized to provide these services, what should their level of competency and/or credentials be, and how (and how much) should they be compensated for providing these types of services?

Conclusion

       The MTMP provisions of MMA are a quantum leap toward bringing quality pharmaceutical care and medication management services to our nation’s elderly, regardless of where they reside. The programs are in their infancy, and the focus has been on overall implementation of the operational aspects of Part D rather than on MTM. This situation will change, and sharp attention will be paid to these programs over the next two years. The multidisciplinary team in all practice settings will be challenged to adapt to MTMP interventions. We all need to understand the intent of these programs, embrace the opportunity to improve our patients’ medication outcomes, and work to integrate MTMPs into our everyday practices.