PHILADELPHIA — Starting this month, 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. The MTM requirement is designed “to ensure that covered Part D drugs are appropriately used to optimize therapeutic outcomes” and to reduce the risk of adverse drug effects.
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 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, or chronic obstructive pulmonary disease. Beneficiaries also must have a history of claims for at least six different medications covered under Part D. But the CMS policy also states that Part D sponsors can lower their eligibility standards so more beneficiaries qualify for their MTM program.
Medco has developed a profile of the anticipated 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.
The specifics of each program have been left to each Part D sponsor. The program that Medco created is designed to educate beneficiaries about the importance of compliance, identify and help eliminate barriers and risks from drug therapy, review important health and safety issues, and find opportunities for reduced costs by increasing the use of generic drugs and providing medications through the mail.
The essence of the MTM program is to “talk to patients and help them understand why they are taking their drugs and how to take them correctly,” Ms. Dorholt said.
Individual beneficiaries will not pay for the medication therapy management programs, but 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, she said.