The U.S. Centers for Medicare and Medicaid Services (CMS) requires Medicare Part D sponsors to have Medication Therapy Management Programs (MTMP) to ensure that qualified beneficiaries use safe and appropriate medications for their medical conditions. Under CMS guidelines, beneficiaries who qualify for MTMP include patients with multiple chronic diseases, those taking various Part D drugs, and beneficiaries incurring an annual drug cost that exceeds a predetermined amount.
One required part of MTMPs is a comprehensive medication review (CMR). CMS defines a CMR as “an interactive, person-to-person, or telehealth medication review and consultation of a beneficiary’s medications … by a pharmacist or qualified provider.” CMRs are required annually and “intended to aid in assessing medication therapy and optimizing patient outcomes.”
CMS first began considering CMR completion rate as an official Star Ratings measure in 2016 and announced the Star Rating cut points, which are listed in Table 1.
|Medicare Advantage Prescription Drug Plan (MA-PD)
|≥33% to <51%
|≥51% to <59%
|≥59% to <75%
|Prescription Drug Plan (PDP)
|≥17% to <31%
|≥31% to <39%
|≥39% to <53%
Once the CMR completion rate display measure took effect, one Part D Health Plan* collaborated with Abarca to re-engineer its MTM Program, which previously was performing at two stars. To assist this plan, Abarca launched an innovative approach that combined technology, analytics capabilities, and a clinical team of epidemiologists, nurses, and pharmacists to develop a comprehensive MTM solution aimed at improving the CMR Completion Rate, the patient and prescriber experience, and quality of the program.
From the start, this program was unique in that it was seamlessly integrated into Abarca’s proprietary PBM platform. This enabled analytics, prescriber outreach, and quality assurance programs to be carefully synchronized to deliver targeted interventions around MTM outreach and adherence in a standardized and reproducible manner. It also allowed Abarca to respond quickly to client requests and regulatory requirements.
The initiative included the following components:
- An integrated MTM module which connected medical conditions, clinical notes, and drug utilization data in one platform;
- An intuitive business intelligence dashboard to facilitate the analysis of data in real-time to drive meaningful interventions around adherence and MTM outreach;
- A prescriber outreach initiative for those beneficiaries that had not been able to be contacted and had not opted out of the program; and
- A collaborative quality improvement process to optimize and standardize the MTM experience for beneficiaries.
Abarca’s approach to improving the CMR quality and completion rate focused on three major components:
- Review of medications, including prescription and over-the-counter (OTC) medications, herbal therapies, and dietary supplements. This interview was conducted with the beneficiary;
- Interactive intervention and consultation with MTMP beneficiaries and, where appropriate, with prescribers; and
- Improving engagement and condition awareness with beneficiaries by providing them with written take-away recommendations, monitoring, education, or self-managed care.
During this assessment, the pharmacist or qualified personnel identified medication-related problems and provided a summary of their findings with recommendations to the beneficiary and prescribing physician(s).
In less than two years, the new MTM Program allowed Abarca and the Part D Health Plan to improve the CMR display measure from three stars to five stars. The Plan reached CMR completion rates of 84% and 88% for both plans in 2016. These results contributed to helping the plan achieve an overall 5-star rating from CMS for Part-D.
Abarca learned many lessons along the way and has used that knowledge to improve the program and CMR completion rates. The following are the top five noteworthy lessons learned:
- Integrated MTM platforms connecting medical, clinical notes, and drug utilization data allow for a better clinical user experience. This also enables better reporting capabilities, which improves the allocation of clinical resources.
- Prescriber outreach has improved MTM CMR completion rates and member’s satisfaction with the MTM program.
- Improved analytics can significantly improve MTM program efficiency and effectiveness.
- Continuous quality assurance training of the MTM clinical teams improves outcomes.
- Coordination of care among plan, prescriber, and PBM outcomes.
This quality improvement initiative and program may be used as a model of care for other clinical interventions related to URAC, HEDIS, stars, and quality measures.