Currently, pharmacists are eligible to receive some compensation for Medication Therapy Management (MTM) through Medicare Part D. CMS designed these programs (MTMP) to ensure optimal therapeutic outcomes for targeted beneficiaries through improved medication use and reduce the risk of adverse events. MTM programs are administered by Prescription Drug Plans (PDPs) and are required to be developed in cooperation with licensed and practicing pharmacists and physicians. However, numerous policy constraints limit patient participation in these programs even with the 2010 CMS enhancements.

    • Medicare Part D restricts patient eligibility: Currently, only senior age, disabled, and low-income patients are eligible for prescription benefits and MTM services via Part D. However, disease management and all other patient care services occur at any age within our U.S. health system as both a preventive measure for progression or exacerbation of chronic disease, and as a treatment measure.
    • Patients must be a Medicare Part D participant: For those patients meeting the Medicare Part D eligibility criteria, monthly premiums payable directly by participants are required. In the current IHS system for example, where 100% of health care expenses for eligible patients are covered, the patient-perceived benefit of paying monthly premiums possibly reduces participation in MTM services.
    • Eligibility for MTM services varies among the PDPs: Patients who suffer from co-morbid chronic diseases like diabetes, hypertension, dyslipidemia, must take multiple Medicare Part D-covered prescription medications, and must incur at least $3,000 in Medicare Part D drug expenses annually in order to qualify for MTM services. CMS allows the PDP to define certain eligibility parameters: number of medications a patient must be taking, number of chronic conditions the patient must have, and specific diseases covered. The PDP also defines whether all drugs are covered, only disease-specific drugs are included, or only specific drug classes are included. Because of specific targeting criteria, patients who may need MTM services but do not meet the plan’s criteria will not be able to participate. MTM compensates pharmacists for a subset of cognitive services they can provide in only some of our sickest patients.
    • Enrollment has been historically low: In 2006, approximately 10% of Medicare Part D-enrolled participants met the criteria for MTM services. More recent program years show a slight increases to 12%.
    • MTM under Part D does not incentivize the health system to focus on prevention: The growing incidence of various complex disease states such as cardiovascular diseases, heart failure and hypertension are affecting patients at earlier stages of their lives. These younger patients require pharmacists to spend significant amounts of time and resources managing their health care needs, but without a compensatory mechanism for the pharmacist’s cognitive services. This delay of care seems to go against current medical practice and withholds value-added, preventive, cost-effective, and patient-centered services until the customer has progressed to a more critical state of health.
    • Part D Sponsors can determine which discipline of provider to deliver their MTM services: Although pharmacists are specifically named by CMS for MTM delivery, and currently provide 99.9% of services, other qualified providers such as nurses, physicians, and other Non-Physician Practitioners represent health care alternatives for utilization in MTM programs.

Click here to download the 2011 Advanced Pharmacy Practice Report to the USSG.


2011 Advanced Pharmacy Practice Report to the USSG


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