Medicare MCOs have edge in managing medications

February 1, 2006

One less-noticed aspect of the Medicare prescription drug program aims to control spending on medicines by paying special attention to high-use patients, something that may give Medicare managed care plans an advantage. The Medicare Modernization Act (MMA) requires prescription drug plans (PDPs) and Medicare Advantage drug plans (MA-PDs) to establish Medication Therapy Management Programs (MTMPs) for seniors with multiple chronic diseases who spend more than $4,000 a year on medicines. The goal is to ensure appropriate prescribing, boost compliance with drug regimens and reduce adverse events for those patients who take several medications.

WASHINGTON, D.C.-One less-noticed aspect of the Medicare prescription drug program aims to control spending on medicines by paying special attention to high-use patients, something that may give Medicare managed care plans an advantage. The Medicare Modernization Act (MMA) requires prescription drug plans (PDPs) and Medicare Advantage drug plans (MA-PDs) to establish Medication Therapy Management Programs (MTMPs) for seniors with multiple chronic diseases who spend more than $4,000 a year on medicines. The goal is to ensure appropriate prescribing, boost compliance with drug regimens and reduce adverse events for those patients who take several medications.

This policy poses challenges for most PDPs, but may provide a competitive advantage for MA-PDs to deliver quality care. Effective MTMP initiatives are likely to boost drug spending as a way to keep patients out of hospitals and doctors' offices. This represents a cost-effective way to provide better care for MA plans that cover both medical services and prescription drugs. But stand-alone PDPs have little to gain from this trade-off.

UPFRONT INVESTMENT

Many PDPs are expected to turn to retail pharmacists or other specialists to provide counseling to patients on appropriate medication use. Plans also may use nurses and other in-house staff to carry out MTMP services. The program may be a boon to all if it succeeds in improving compliance with prescribed medicines and in reducing side effects, and pharmacists support the requirement as a way to gain reimbursement from drug plans.

CMS has provided little guidance on how drug plans should meet the MTMP requirement but promises to do so. The agency will be looking for ways to measure if these programs have an impact on pharmacy compliance and drug safety problems, as well as health outcomes.