What is Enhanced MTM?

Chapter 10: What is Enhanced MTM?

On January 1, 2017¹, CMS launched a pilot program to test changes to the traditional MTM model. Enhanced MTM implements program changes like increased payment incentives and regulatory flexibility patient enrollment requirements. The stated outcomes of the program are to reduce the net expenditure of Medicare Part D and to increase therapeutic outcomes. The Enhanced MTM attempts to accomplish these outcomes by allowing healthplans to identify and implement innovative changes and strategies that improve care coordination, reduce improper medication use, reduce adverse drug events, and other plan-specific outcomes measures.

Which Plans Participate in Enhanced MTM?

The following Part D sponsors are participating in the Part D Enhanced MTM Model:^1,2,3

• Blue Cross and Blue Shield Northern Plains Alliance
• Blue Cross and Blue Shield of Florida
• CVS Health (SilverScript/CVS Insurance Company)
• Humana
• UnitedHealthcare (UnitedHealth Group)
• WellCare Prescription Insurance

The six Part D Sponsors have 22 active plans in the enhanced MTM program. To participate in the enhanced MTM program, Part D sponsors were required to offer Enhanced MTM within all participating regions where they administered plans eligible to participate in Enhanced MTM.

Of the 34 Medicare Part D Prescription Drug Plan (PDP) regions, five were included in the Enhanced MTM program:^1,3

• Region 7 (Virginia)
• Region 11 (Florida)
• Region 21 (Louisiana)
• Region 25 (Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota, Wyoming)
• Region 28 (Arizona)

How Do Enhanced MTM Programs Differ From Traditional MTM?

Enhanced MTM has two broad differences when compared to traditional MTM:²

1. Design flexibility: Part D Sponsors are free to alter eligibility criteria for MTM services and to vary the services provided. Compared to the CMS requirements for traditional MTM offerings (one yearly CMR and quarterly TMRs), plans are free to alter their service offerings considerably.
2. Payment incentives: Enhanced MTM provides administrative funding to Part D sponsors in the form of prospective per enrollee payment. If sponsors reduce Medicare spending in the identified population, they are eligible to receive additional incentive payments.

A report released in October 2019 examines outcomes of the first 20 months of the Enhanced MTM program. The report found that in practice most of the plans fit their new MTM programs into the following four models:³

• Drug therapy problem (DTP) programs, which targeted drug-related patient safety issues, non-adherence (or likelihood of future non-adherence) to specific drugs for new or existing users, high drug utilization, or opioid utilization;
• Chronic disease programs, which targeted beneficiaries managing specific chronic diseases or multiple chronic diseases;
• High spend programs, which targeted beneficiaries with high medical and/or drug expenditures; and
• Transitions of care programs, which targeted beneficiaries with a recent inpatient discharge.

Limitations of Traditional MTM Programs Addressed by Enhanced MTM

CMS has implemented the Enhanced MTM program to address several perceived limitations of traditional MTM programs.³

Traditional MTM programs have limited data reporting requirements, which may incentivize utilization without encouraging positive outcomes. Traditional MTM programs only require the reporting of MTM eligibility and provision of service data for enrollees. The Enhanced MTM model requires plans to submit monthly eligibility data and quarterly encounter data. Plans have leveraged SNOMED Clinical Terms to report encounter data. Encounter data allows for performance-based payments, and high-quality data submission is incentivized.

Within the Traditional MTM framework, Part D sponsors do not have incentives to incur medical costs that are met by Medicare Part A and Medicare Part B. Under the Enhanced MTM program, CMS grants incentives to reduce system-wide healthcare costs based on whether Part D plans accomplish a net reduction of two percent for beneficiaries enrolled in Medicare Part A and Part B Plans. Plans that accomplish this reduction receive two dollars per member per month as a subsidy from CMS to the Part D premium.

Another limitation of traditional MTM programs is that plan sponsors are required to implement MTM services without funds to offset the cost of doing so. Without additional administrative funds, plans are not incentivized to provide MTM services that extend above the minimum CMS requirements. Enhanced MTM provides a prospective supplemental payment to offset the administrative costs of providing MTM services. This additional incentive is separate from the sponsor’s annual plan bid. CMS bases the administrative payment on the services that the plan sponsor intends to provide. Payments ranged from two to eleven dollars per beneficiary per month.

Traditional MTM programs are limited in their flexibility for the plan sponsor to design MTM services specific to their treatment population. The Enhanced MTM model does not require a yearly CMR or quarterly TMRs. Sponsors are also free to utilize claims data from Medicare Part A, and Medicare Part B claims to target and implement their Enhanced MTM program. The intended consequence of allowing greater flexibility for plans to tailor their MTM services is so that plans may tailor their offerings to meet the health needs of their specific population of patients.

Patient Characteristics

The findings of the first 20 months of the Enhanced MTM model have shown promising results.^2,3 Plan sponsors have identified 1.6 million beneficiaries as eligible to receive their Enhanced MTM services. Within this population of patients, 7.9% of them met the required criteria to receive Traditional MTM services in 2016. In 2017, 71.7% of patients were eligible to receive Enhanced MTM services based on expanded criteria from plan sponsors. The percentage of patients eligible for services varied considerably by plan and ranged from 54.7% to 87.7%.

Key Findings

The first evaluation report summarized three key findings during the first 20 months of the Enhanced MTM program.^2,3

1. Innovative targeting results in an expanded pool of eligible beneficiaries and allows for Enhanced MTM services to be tailored to beneficiaries’ risk characteristics

Sponsors implemented targeted identification through predictive analytics and risk stratification. Predictive analytics can identify patients with a high future likelihood of drug-related problems, high spending, and hospital admissions. After identification, patients were risk-stratified to determine which services should be offered and at what intensity. Predictive analytics and risk stratification strategies largely replaced the Traditional MTM parameters of the number of chronic conditions, number of medications, and drug spending. The expanded targeting criteria are the primary reasons for the substantial increase in patients eligible to receive MTM services when comparing Traditional MTM to Enhanced MTM.

Many plans have implemented lighter-touch services, like refill reminders, newsletters, “ask a pharmacist” phone lines, vaccination reminders, and expanded transition of care services.

1. Flexibility of the Enhanced MTM Model along with evolving sponsor experience drives variation in data reporting

Most plan sponsors had no prior experience with SNOMED CT, which meant that additional time and training were required to implement new data reporting practices. Additionally, the inherent variability in how SNOMED CT maps specific clinical content has resulted in differences in how sponsors document and report data.

1. Enhanced MTM Model implementation is progressing as planned, with some engagement-related challenges that are being actively addressed by sponsors

Sponsors have invested resources into new systems and processes to take advantage of the opportunities afforded by Enhanced MTM. Some examples include new partnerships, new data-sharing systems, and new processes for data reporting. All sponsors have continued to utilize call centers for outreach to beneficiaries, but have noted that reluctance to respond to phone outreach is a challenge. Sponsors have also reported difficulty with the fidelity of contact information.

Some sponsors added new community pharmacy networks to leverage the expertise of community retail pharmacists, but some challenges include the thinness of staffing models and inconsistent documentation between pharmacies.