Assessing Medicare Beneficiary Eligibility for Medication Therapy Management Programs Using PINNACLE, a National Cardiovascular Data Registry

Medication therapy management (MTM) is a mandated component of the 2003 Medicare Modernization Act for Part D prescription drug plans and Medicare Advantage plans, whereby the pharmacist or other qualified provider identifies, resolves, and prevents medication-related problems to optimize the therapeutic outcomes for individual patients.1 MTM programs typically involve a comprehensive review of all medications, both prescription and nonprescription (including natural and herbal products), that a patient is currently taking. In addition, an evaluation of the patient's medication-taking behavior is conducted, as well as an assessment of the patient's understanding, concerns, and expectations regarding his or her current medication regimen and health.1 MTM differs greatly from traditional counseling offered by community pharmacists that occurs as part of the drug dispensing process. As part of non-MTM medication dispensing, pharmacists review the drug and identify its indications, directions for use, storage requirements, side effects, long-term toxicity, drug interactions, food interactions, and medication adherence factors. Depending on the number of medications, and whether the patient accepts or denies counseling by a pharmacist at the point of prescription pickup, this service may take approximately 5 to 10 minutes. By contrast, MTM may take 30 to 60 minutes and is a service that is independent of, but can occur in conjunction with, the provision of a medication product.2 MTM promotes collaboration with other healthcare providers, which is especially important as patients undergo transitions in care environments.2 The pharmacist reviews the complete medication profile to explore ways to optimize the patient's medication therapy. Strategies to optimize medication therapy may include interventions to resolve medication interactions, inappropriate dosing or formulation (eg, tablet vs patch), therapeutic duplication, and ways to improve adherence.2 These strategies are then discussed with the patient's prescriber for his or her consideration. On prescriber approval, the pharmacist will inform the patient of any medication changes and will then educate the patient on the appropriate medication self-management.2 MTM programs and services have been shown to improve drug therapy goal attainment and medication adherence, as well as to reduce medication errors while reducing overall costs in patients with cardiovascular (CV) disease; however, MTM has been greatly underutilized for chronic diseases, including CV conditions.2–7 Beginning in 2010, Medicare Part D plans were required to implement covered MTM programs that target beneficiaries who have multiple chronic diseases, take multiple medications, and had an anticipated annual drug spending of $4000 in 2009 and $3000 beginning in 2010.8 Health insurance plans cannot require patients to have more than 3 chronic diseases to meet MTM eligibility, and the plans must target at least 4 of 7 core chronic diseases, including hypertension, heart failure, type 2 diabetes, dyslipidemia, respiratory disease, bone disease–arthritis, or mental health.8 KEY POINTS ▸ Medication therapy management (MTM) for chronic diseases was mandated by the 2003 Medicare Modernization Act but is greatly underutilized. ▸ To participate in an MTM, patients must have ≥3 chronic diseases and meet a set amount of drug spending. ▸ MTM has been shown to improve drug medication adherence, reduce medication errors, and lower overall costs in patients with CV disease. ▸ This is the first non–claims data study to estimate patient MTM eligibility among Medicare beneficiaries with multiple cardiovascular (CV) conditions ▸ Data used for this analysis came from the Medicare PINNACLE Registry, which collects information from outpatient cardiology practices in the United States to help improve care quality. ▸ Overall, 7.9% to 64% of patients with ≥3 chronic CV conditions are estimated to meet the $3000 minimum annual drug spending required for MTM program eligibility. ▸ Payers indicate that the most common barrier to implementing MTM programs is patient lack of willingness to participate in such programs. ▸ Providers should educate patients on the benefits of MTM programs and encourage their participation. National surveys of payers offering MTM programs conducted by the American Pharmacists Association (APhA) indicate that payers believe that the most common challenge to implementing MTM programs is that patients are not interested in these programs or they decline to participate in them, as was indicated by 47% of respondents in a 2010 survey conducted by the APhA.9 The purpose of this present study was to identify the proportion of patients who are eligible for, and who could potentially benefit from, participating in MTM, based on Medicare beneficiaries who were enrolled in a large nationally representative outpatient cardiac registry.