Changes to Medication Therapy Management drive significant costs and can impact Star Ratings

During the past month, all of you #StarRatings leaders have been busy reading, analyzing, and discussing the provisions included in the CMS Proposed Rule 2024. We're right there with you, and you may recall our previous article that touched on the major provisions directly impacting Stars and QBP last month. But those direct-impact provisions are only one out of the 12 major provisions in the rule, many of which can have pretty significant impacts to your ratings as well. Four of the remaining provisions are related to Part D, and represent significant cost increases for the industry in the long run, as well as impacts to both the design and budget for improvement programs. In this article, we are honing in on the biggest proposed cost driver, changes to the Part D Medication Therapy Management program, and potential implications for your Star Ratings.

MTM Overview

Medication Therapy Management (MTM) ensures that beneficiaries can have access to a one-on-one interaction with a pharmacist or other licensed health care provider to holistically address their medication treatment profile and complete a comprehensive medication review, among other things. Since 2006, CMS has required all Part D sponsors to incorporate a medication therapy management program into their plan’s benefit structure with the intention to:

1. optimize therapeutic outcomes,
2. decrease adverse medication interaction effects,
3. avoid unnecessary costs, and
4. help coordinate additional resources if needed.

Every year, sponsors must submit a description of their MTM program to CMS for review and approval as part of the bid development requirements for the upcoming contract year.

Throughout the years, CMS has continuously updated the program through changes to eligibility criteria, MTM services, reporting requirements, and beneficiary communication. These proposed changes have generated concerns about the potential impact on plan administrative costs, beneficiary premiums, and the quality of existing MTM programs. Currently, most plans require beneficiaries to fulfill the following criteria in order to be eligible for enrollment in their MTM Program:

1. Have three (3) or more chronic conditions,
2. Take eight (8) or more Part D drugs, and
3. Meet the cost threshold ($4,935 for CY2023).

MTM and the Star Ratings

CMS added the Medication Therapy Management (MTM) Program Completion Rate for Comprehensive Medication Review (CMR) as a Part D Star Ratings process measure, at a weight of 1x, beginning in CY2016. This measure requires that beneficiaries 18 + years of age who are enrolled in the MTM program for at least 60 days during the reporting period receive a CMR at any time while they are enrolled in it. Moreover, the data for this measure is subject to an annual audit. Health plans that do not score at least 95%, or are not compliant, on their data validation, will receive a “CMS identified issues with this plan’s data” instead of a rate and could see their individual measure reduced to 1-Star performance. Since its inclusion in Star Ratings, industry performance and the 5-Star thresholds for MAPD contracts have steadily increased (Figure 1).

While we are on this topic, it is worth noting there are some changes proposed for CMR that could impact performance going forward and Part D sponsors need to consider in their preparation efforts:

1. Codify longstanding guidance that a CMR can be completed by a beneficiary’s prescriber, caregiver, or any other authorized individual if the beneficiary has a cognitive impairment.
2. CMR must be completed during a real-time interaction, whether is in-person, via telehealth, via phone, or other emerging technologies.

What CMS is proposing...and why.

According to CMS, since the establishment of the MTM program Part D sponsors have had significant flexibility in determining the number of and specific chronic conditions, and the number of Part D medications that will make beneficiaries eligible to enroll in the MTM Program. At the start of the program, the expectation was that 25% of the Part D population would be eligible to receive MTM services but by CY2020, a mere 8% were considered eligible. Why? A couple of reasons.

First, availability and use of lower-cost generics has increased substantially since the start of the program, while the cost threshold for participation in MTM has continued to increase (Figure 2). This has led to what CMS deemed "grossly misaligned" trend that has "inappropriately reduced MTM eligibility year-over-year."

Second, CMS points out a “near universal convergence among Part D sponsors to the most restrictive targeting criteria currently permitted under the regulation”.

As this scenario unfolded CMS has become more prescriptive with the MTM Program every year, and with these changes in the Proposed Rule 2024 we can see a definitive intention to complete its standardization. Here’s what could become part of the regulation in the near future:

• Part D sponsors to target all 10 chronic conditions (Figure 3);
• Lower the qualifying amount of Part D drugs to enroll in MTM from 8 to 5 medications;
• Include all Part D maintenance drugs;
• Lower the cost threshold from $4,935 (as calculated for CY2023) to the average annual cost of 5 generic drugs at $1,004 (based on CY2020 PDE data).

With the proposed changes, CMS expects an increase in Part D population enrollment in the MTM Program from 4.5 million (9%) to 11 million (23%) beneficiaries, which is closer to its original target, at an approximate total cost for the industry of?$336 million per year over the next decade.

So what does this mean for you, Stars Warrior?

1. MTM program changes, together with the other three Part D provisions (LIS eligibility, LI NET Program, and the changes to approved Part D formularies) of the Proposed Rule 2024 translate into a substantial cost for the industry for both plans and the Medicare Trust Fund over the coming decade. These changes aimed at expanding access and supporting lower costs could be considered the “transactional cost” of reducing health disparity among Part D beneficiaries (see article cover image).
2. As a Stars leader one of the first questions you need to ask yourself is: what does a 14% increase in MTM enrollment mean for my health plan, for my Part D MTM/CMR measure, and for my Star ratings? According to the CMS Fact Sheet Summary of 2018 MTM Programs, more than 90% of Part D sponsors use outside personnel (PBM, MTM Vendor, etc.) to provide MTM services to their beneficiaries. Whether you use internal staff or an external vendor for MTM services, it will be critical to understand what their capacity to maintain or improve performance looks like in a scenario where the measure denominator is suddenly increased.
3. An increased measure denominator means more data to manage. As mentioned before, the MTM/CMR measure data is subject to audit by CMS and in case of a data validation failure, the rating can be reduced to 1 Star. Even though this is a process measure with a weight of 1x, receiving 1 star can potentially affect the Part D Improvement measure in a negative way and thus the Part D and Overall Star Ratings performance of your contract. In light of CMS' additional proposal to limit QI measure hold harmless provision only to 5-star plans, any drop in performance on single-weighted measures like MTM can have huge implications for 4-star plans on the "rounding bubble."
4. Additional beneficiaries participating in the MTM program means additional opportunities to improve member experience through enhanced access to care and ensuring that beneficiaries can get their needed prescription drugs. It can also provide an opportunity to improve medication adherence rates by educating beneficiaries about the correct use of their medications, and identify cost-related situations where additional resources, like a potential LIS eligibility or supplemental benefits to close SDOH gaps, can be coordinated. But those additional interactions are a double-edged sword. Increased member outreach to newly-eligible enrollees risks increasing member abrasion. So preparation will be key to your success by ensuring coordinated and streamlined outreach across plan staff and vendors, and across campaigns for members in several measures, to produce the best experience and outcomes for your members.

Best next steps to prepare your organization for potential changes

Unfortunately, we don't have a crystal ball that can tell us whether or not?these changes are going to happen, but we certainly know there are things you can do in the meantime:

• Understand the proposed changes and what needs to be done ahead of time to prepare;
• Inform your Executive Leadership Team. Let them know you will need their support to secure the necessary resources to address these changes should they ultimately be codified;
• Talk to your Pharmacy Team and/or PBM, MTM vendor, etc. about these changes. Make sure they are aware of the implications, check for capacity with internal and external resources alike, and start working on a strategy to receive the new MTM enrollees with open arms;
• Understand the plan benefit that will be submitted in the June bid for the next calendar year. Participate in those conversations and make sure the product will make it easy for beneficiaries to receive the care they need with the best quality possible;
• Work with your analytics team to estimate potential new MTM enrollees based on the proposed changes specifications and how that can impact measures like the Part D MTM/CMR completion rate;
• Inform your Customer Service Team. Let them know about the importance of their future interactions with beneficiaries and that they need to be ready to answer any questions regarding Part D benefits, MTM Program, etc. while providing a great member experience; and
• If you have concerns or questions make sure your health plan submits comments to CMS by the February 13, 2023 deadline.

We hope this information is useful to you and that it helps create awareness. If you have additional questions about this or any of the Proposed Rule 2024 provisions please do not hesitate to contact us at Rex Wallace Consulting, LLC . We are always glad to help!