PHILADELPHIA — Starting next year, Medicare Part D will feature a new wrinkle in the drug insurance program: medication therapy management.
A medication therapy management (MTM) program was mandated for 2007 by the Centers for Medicare and Medicaid Services (CMS) for selected Medicare beneficiaries who are participating in Part D coverage. MTM programs are targeted to beneficiaries who have multiple chronic diseases, use multiple medications in Part D, and have anticipated Part D costs for 2007 of more than $4,000, Mary Dorholt said at a conference sponsored by the American Society on Aging. The program, as it's currently structured, will apply to about 3% of Medicare beneficiaries who enroll in Part D, said Ms. Dorholt, vice president for Medicare client support at Medco Health Solutions Inc. in Maple Grove, Minn., a Part D sponsor.
The minimum criteria for beneficiaries to qualify for a MTM program include having at least five chronic conditions, with at least two from this list: hypertension, elevated serum cholesterol, heart failure, diabetes, and chronic obstructive pulmonary disease. Beneficiaries also need a history of claims for at least six different medications that are covered under Part D. But the CMS policy also states that Part D sponsors can lower their eligibility standards so that more beneficiaries qualify for their MTM program.
Medco has developed a profile of the anticipated profile of chronic diseases that will occur in beneficiaries who qualify for their MTM program. The most common illness is hypertension, which is anticipated to affect about 90% of qualifying beneficiaries, Ms. Dorholt said.
Although the CMS requires Part D sponsors to offer a MTM program next year “to ensure that covered Part D drugs are appropriately used to optimize therapeutic outcomes” and to reduce the risk of adverse drug effects, the specifics of each program have been left to each Part D sponsor. The program Medco created is designed to educate beneficiaries on the importance of compliance, to identify and help eliminate barriers and risks from drug therapy, to review important health and safety issues, and to find opportunities for lower costs by more use of generic drugs and providing medications through the mail.
The essence of the program is to “talk to patients and help them understand why they are taking their drugs and how to take them correctly,” said Ms. Dorholt.
Although individual beneficiaries will not pay for the MTM programs, they are required to enroll. A challenge for Medco and other part D sponsors will be to educate beneficiaries that the service is free and to encourage their enrollment, Ms. Dorholt said.
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