Medicare Medication Therapy Management Research Articles

Medicare medication therapy Management: Beneficiary characteristics and utilization patterns in a national CMS Medicare fee-for-service sample (2013 to 2016)

BackgroundThe Medicare Medication Therapy Management (MTM) program has been available to eligible Medicare Part D beneficiaries since 2006, but research regarding program utilization and characterization is limited. ObjectiveTo describe enrollee and MTM program characteristics in a national sample of Medicare fee-for-service (FFS) beneficiaries (2013 to 2016). MethodsUsing a 5% random sample of Medicare FFS beneficiaries, we conducted a descriptive time series analysis to examine annual MTM enrollment and describe the type of MTM criteria at enrollment (Center for Medicare and Medicaid Services [CMS] vs. expanded). We investigated the offer of Comprehensive Medication Review (CMR) along with CMR receipt status, and delivery characteristics, as well as frequencies of Target Medication Reviews (TMRs). ResultBeneficiaries who met CMS enrollment criteria, compared to those eligible under expanded criteria, were significantly older, more likely to be of white race, more likely to be female, and had a significantly higher number of comorbidities. Of those meeting CMS criteria, the proportion receiving TMR increased from 95% in 2013% to 98.1% in 2016, and over 97% were offered a CMR. Although the proportion of beneficiaries offered a CMR was stable over the study period, the proportion who received a CMR increased from 17% in 2013% to 35.4% in 2016. Telephone CMR delivery was the most common method used (87.8% to 89.1% of CMRs over the study period). Over 95% of the CMRs were delivered by a pharmacist. ConclusionDuring the years 2013 to 2016, enrollment in the MTM program increased, as did the proportion of enrollees receiving TMRs and CMRs. However, uptake remained low and the main factors driving participation remain unclear. Significant differences in demographic characteristics between beneficiaries enrolled under the CMS MTM enrollment criteria and the expanded criteria suggest the need to further investigate the optimal provision of such programs.

Effects of comprehensive medication review on opioid overuse among medicare beneficiaries.

This study examined the effects of the comprehensive medication review of Medicare medication therapy management programs on opioid overuse among Medicare beneficiaries. This retrospective study analyzed Medicare data from 2016 to 2017. The intervention group included Medicare beneficiaries who newly received comprehensive medication review in 2017; the control group referred to patients who met the general eligible criteria for the medication therapy management program but did not enroll in 2016 or 2017. Propensity score matching was performed to increase characteristic compatibility between the intervention and control groups. Three measures of opioid overuse were analyzed: use of opioids at a high dosage, use of opioids from multiple providers, and concurrent use of opioids and benzodiazepines. The effects of comprehensive medication review on opioid overuse were analyzed with a multivariate logistic regression with an interaction term between the receipt of comprehensive medication review and the year 2017. The proportion of concurrent use of opioids and benzodiazepines declined at a greater rate among the recipients (2.21%) than non-recipients (1.55%) of the comprehensive medication review. In the adjusted analysis, the odds ratio of no concurrent use of opioids and benzodiazepines was 5% higher (1.05; 95% confidence interval = 1.02-1.09) among recipients than non-recipients. These significant findings were not found for the other two measures of opioid overuse. Comprehensive medication review is associated with reduced concurrent use of opioids and benzodiazepines among Medicare beneficiaries. Such service should be incorporated into the current approaches for addressing the opioid epidemic.

Racial and ethnic disparities in the enrolment of medicare medication therapy management programs.

Racial/ethnic disparities have been found in prior literature examining enrolment in Medicare medication therapy management programs. However, those studies were based on various eligibility scenarios because enrolment data were unavailable. This study tested for potential disparities in enrolment using actual MTM enrolment data. Medicare Parts A&B claims, Medication Therapy Management Data Files, and the Area Health Resources File from 2013 to 2014 and 2016 to 2017 were analysed in this retrospective analysis. An adjusted logistic regression compared odds of enrolment between racial/ethnic minorities and non-Hispanic Whites (Whites) in the total sample and subpopulations with diabetes, hypertension, or hyperlipidaemia. Trends in disparities were analysed by including interaction terms in regressions between dummy variables for race/ethnic minority groups and period 2016-2017. Disparities in MTM enrolment were detected between Blacks and Whites with diabetes in 2013-2014 (Odds Ratio = 0.78, 95% Confidence Interval = 0.75-0.81). This disparity improved from 2013-2014 to 2016-2017 for Blacks (Odds Ratio=1.08, 95% Confidence Interval = 1.04-1.11) but persisted in 2016-2017 (Odds Ratio = 0.84, 95% Confidence Interval = 0.81-0.87). A disparity was identified between Blacks and Whites with hypertension in 2013-2014 (Odds Ratio = 0.92, 95% Confidence Interval = 0.89-0.95) but not in 2016-2017. Enrolment for all groups, however, declined between periods. For example, in the total sample, the odds of enrolment declined from 2013-2014 to 2016-2017 by 22% (Odds Ratio=0.78, 95% Confidence Interval=0.75-0.81). Racial disparities in MTM enrolment were found between Blacks and Whites among Medicare beneficiaries with diabetes in both periods and among individuals with hypertension in 2013-2014. As overall enrolment fell between periods, concerns about program enrolment remain.

Social determinants predict whether Medicare beneficiaries are offered a Comprehensive Medication Review.

Medication reviews through Medicare's Medication Therapy Management (MTM) program may improve patient outcomes and lower health system costs, but these effects could be limited by a program design that does not address social determinants of health. To analyze the effects of social determinants of health on the odds of an eligible Medicare beneficiary not being offered Comprehensive Medication Review (CMR). Using the full 100% sample of the 2016 Part D Medication Therapy Management Data File linked to Medicare Master Beneficiary Summary File, a retrospective, cross-sectional analysis was conducted to determine which social and demographic variables are most strongly associated with being eligible for a CMR but not being offered one. Descriptive statistics were generated using SAS studio 3.8. Variables associated with the highest odds of not receiving a CMR when eligible are residence in Louisiana OR 1.79 (95%CI 1.70-1.88), receiving the LIS OR 1.76 (1.73-1.79), dual eligibility for Medicare and Medicaid OR 1.25 (1.12-1.41), and Black race OR 1.19 (1.16-1.21). Social determinants of health, most strongly geography and low-income status, predict being eligible for but not being offered CMR. Race continues to be a factor in disparate access to MTM services.

Racial/ethnic disparities in the enrollment of Medication Therapy Management programs among Medicare beneficiaries with Alzheimer’s disease and related dementias

Objective Previous analysis of policy scenarios reported potential disparities in eligibility in the Medicare Medication Therapy Management (MTM) program. With recently released MTM data, this study aimed to determine if racial/ethnic disparities exist in MTM enrollment among Medicare beneficiaries with Alzheimer’s disease and related dementias (ADRD). Methods Medicare claims/records (from 2013–2014 and 2016–2017) linked to the Area Health Resources File were examined. Included individuals were patients with ADRD and diabetes, hypertension or hyperlipidemia. The proportions of MTM enrollment were compared between non-Hispanic White (White) patients and racial/ethnic minority groups in descriptive analysis. Racial/ethnic disparities were then examined using a logistic regression adjusting for patient and community characteristics. Disparities across study periods were compared by estimating a logistic regression model with interaction terms between dummy variables for each racial/ethnic minority group and 2016–2017. Results In unadjusted analyses, minorities had higher enrollment proportions than Whites. In 2016–2017, for example, enrollment percentages for Whites, Blacks, Hispanics, Asian/Pacific Islanders (Asians) and Others were respectively 14.44%, 16.71%, 19.83%, 16.66%, and 17.78%. In adjusted analyses, Blacks had lower enrollment odds than Whites within all cohorts. In the entire study sample in 2016–2017, for example, Blacks with ADRD had 9% lower odds of MTM enrollment (odds ratio 0.91, 95% confidence interval [CI] = 0.86–0.97) than Whites. These disparities decreased over time among the ADRD sample and all sub-groups. The interaction term between Blacks and 2016–2017, for instance, indicated that disparities were lowered by 11% (odds ratio 1.11, 95% CI = 1.05–1.16) across study periods among those with ADRD. Conclusions Blacks with ADRD, and diabetes, hypertension or hyperlipidemia have lower likelihood of MTM enrollment than Whites. Racial disparities were reduced over time but not eliminated.

Potentially Inappropriately Prescribed Medications Among Medicare Medication Therapy Management Eligible Patients with Chronic Kidney Disease: an Observational Analysis

BackgroundPotentially inappropriately prescribed medications (PIPMs) among patients with chronic kidney disease (CKD) may vary among clinical settings. Rates of PIPM are unknown among Medicare-enrolled Medication Therapy Management (MTM) eligible patients.ObjectivesDetermine prevalence of PIPM among patients with CKD and evaluate characteristics of patients and providers associated with PIPM.DesignAn observational cross-sectional investigation of a Medicare insurance plan for the year 2018.PatientsMedicare-enrolled MTM eligible patients with stage 3–5 CKD.Main MeasuresPIPM was identified utilizing a tertiary database. Logistic regression assessed relationship between patient characteristics and PIPM.Key ResultsInvestigation included 3624 CKD patients: 2856 (79%), 548 (15%), and 220 (6%) patients with stage 3, 4, and 5 CKD, respectively. Among patients with stage 3, stage 4, and stage 5 CKD, 618, 430, and 151 were with at least one PIPM, respectively. Logistic regression revealed patients with stage 4 or 5 CKD had 7–14 times the odds of having a PIPM in comparison to patients with stage 3 disease (p < 0.001). Regression also found PIPM was associated with increasing number of years qualified for MTM (odds ratio (OR) 1.46–1.74, p ≤ 0.005), female gender (OR 1.25, p = 0.008), and increasing polypharmacy (OR 1.30–1.57, p ≤ 0.01). Approximately 14% of all medications (2879/21093) were considered PIPM. Majority of PIPMs (62%) were prescribed by physician primary care providers (PCPs). Medications with the greatest percentage of PIPM were spironolactone, canagliflozin, sitagliptin, levetiracetam, alendronate, pregabalin, pravastatin, fenofibrate, metformin, gabapentin, famotidine, celecoxib, naproxen, meloxicam, rosuvastatin, diclofenac, and ibuprofen.ConclusionOver one-third of Medicare MTM eligible patients with CKD presented with at least one PIPM. Worsening renal function, length of MTM eligibility, female gender, and polypharmacy were associated with having PIPM. Majority of PIPMs were prescribed by PCPs. Clinical decision support tools may be considered to potentially reduce PIPM among Medicare MTM–enrolled patients with CKD.

PHS83 - Comparative Effectiveness of Mtm Eligibility Criteria Under ACA and Mma Across Racial and Ethnic Groups in Medicare

To examine the comparative effectiveness of the Medicare medication therapy management (MTM) eligibility criteria under Patient Protection and Affordable Care Act (ACA) and Medicare Modernization Act (MMA) in identifying patients with medication utilization issues (MUI) across racial/ethnic groups in Medicare. This study analyzed Medicare data (2012-2013) linked to Area Health Resource Files. MUI were defined based on medication utilization measures used in Medicare Part D Star Ratings. MTM eligibility criteria under ACA, and MTM eligibility thresholds in 2009, 2013, and proposed 2015 MTM eligibility criteria under MMA were analyzed. Multinomial logistic regression was used to analyze the comparative effectiveness of ACA and MMA MTM eligibility criteria across racial/ethnic groups. The study controlled for patient characteristics at both individual and community/county levels. Main/sensitivity analyses were conducted to cover the ranges of eligibility thresholds and combinations. Higher likelihood of and lower racial/ethnic disparities in MTM eligibility were found under ACA than MMA. For example, in the main analysis for 2013, 74.50% more patients met MTM eligibility criteria under ACA than MMA (P<0.0001). Disparities between non-Hispanic Blacks (Blacks) and Hispanics versus non-Hispanic Whites (Whites) were 2.47% and 1.79%, respectively, lower under ACA than MMA (P<0.05 for both). Adjusted relative risk ratio (RRR) for Blacks versus Whites was 0.69 (95% Confidence Interval (CI)=0.67-0.70), indicating that the ACA MTM eligibility criteria were 31% more effective compared to those under MMA among Blacks vs. Whites. The same RRR was 0.79 (95% CI=0.76-0.81) for Hispanics/Whites. Similar patterns were found in all unadjusted/adjusted sensitivity analyses. The ACA MTM eligibility criteria were more effective than those under MMA and were also more comparatively effective among racial/ethnic minorities than Whites. Although the future of ACA is uncertain, ACA-based MTM eligibility criteria provide an alternative to MMA-based MTM eligibility criteria in improving effectiveness of MTM eligibility.

Disparity Implications of Proposed 2015 Medicare Eligibility Criteria for Medication Therapy Management Services.

Previous studies found that racial and ethnic minorities may be less likely than non-Hispanic Whites (Whites) to meet existing Medicare medication therapy management (MTM) eligibility criteria. To address these issues, the Centers for Medicare & Medicaid Services (CMS) proposed alternative Medicare MTM eligibility criteria for 2015. Due to opposition to other Part D reforms proposed simultaneously by various stakeholders, CMS rescinded all proposed reforms. This study was conducted to determine whether non-Hispanic Blacks (Blacks) and Hispanics have lower likelihood of meeting the proposed 2015 Medicare MTM eligibility criteria. This retrospective observational analysis used Medical Expenditure Panel Survey data (2010-2011). The final study sample was comprised of 2,721 Whites (weighted to 37,185,896), 917 Blacks (weighted to 4,665,644), and 538 Hispanics (weighted to 3,532,882). Chi-square tests were used to examine racial and ethnic disparities in meeting proposed 2015 MTM eligibility criteria and each component of proposed 2015 MTM eligibility criteria. In multivariate analysis, a logistic regression model was used to control for population socio-demographic and health-related characteristics. Compared to Whites with a proportion of MTM eligibility of 58.82%, the eligible proportion was 57.09% (P=0.20) for Blacks, and 48.97% (P<0.0001) for Hispanics, respectively. According to multivariate logistic regression, odds ratios of meeting MTM eligibility for Blacks and Hispanics compared to Whites were 0.74 (95% Confidence Internal [CI] = 0.62-0.88) and 0.53 (95% CI=0.43-0.67), respectively. The proposed 2015 MTM eligibility criteria would not eliminate racial and ethnic disparities in MTM eligibility. Alternative MTM eligibility criteria should be devised.

Potential effects of racial and ethnic disparities in meeting Medicare medication therapy management eligibility criteria.

Medication therapy management (MTM) has the potential to play an instrumental role in reducing racial and ethnic disparities in health care. However, previous research has found that Blacks and Hispanics are less likely to be eligible for MTM. The purpose of the current study was to examine the potential effects of MTM eligibility criteria on racial and ethnic disparities in health outcomes. The current study is a retrospective cross-sectional analysis of the Medicare Current Beneficiary Survey Cost and Use files for the years 2007 and 2008. A difference-in-differences model was used to compare disparities in outcomes between ineligible and eligible beneficiaries according to MTM eligibility criteria in 2010. This was achieved by including in regression models interaction terms between dummy variables for Blacks/Hispanics and MTM eligibility criteria. Interaction terms were interpreted on both multiplicative and additive terms. Various regression models were used depending on the types of variables. Whites were more likely to report self-perceived good health status than Blacks and Hispanics among both MTM-eligible and MTM-ineligible populations. Disparities were greater among MTM-ineligible than MTM-eligible populations (e.g., on additive term, difference in odds=1.94 and P<0.01 for Whites and Blacks; difference in odds=2.86 and P<0.01 for Whites and Hispanics). A few other measures also exhibited significant patterns. MTM eligibility criteria may exacerbate racial and ethnic disparities in health status and some measures of health services utilizations and costs and medication utilization. Future research should examine strategies to remediate the effects of MTM eligibility criteria on disparities.

Historical trend of racial and ethnic disparities in meeting Medicare medication therapy management eligibility in non-Medicare population

Prior research examining racial and ethnic disparities in meeting Medicare medication therapy management (MTM) eligibility criteria among the non-Medicare population suggests minorities have lower likelihood of being eligible than non-Hispanic Whites (Whites). However, such research has not examined trends in disparities and whether these disparities may be expected to decrease over time based on historical data. To examine trends in MTM eligibility disparities among the non-Medicare population from 1996-1997 to 2009-2010. This retrospective observational analysis used Medical Expenditure Panel Survey data from the two study periods. The MTM eligibility criteria used by health insurance plans in 2008 and 2010 were analyzed. Trends in disparities were examined by including interaction terms between dummy variables for 2009-2010 and non-Hispanic Blacks (Blacks)/Hispanics in a logistic regression. Interaction effects were estimated on both the multiplicative and additive terms. Main and sensitivity analyses were conducted to represent the ranges of the Medicare MTM eligibility thresholds used by health insurance plans. According to the main analysis, Blacks and Hispanics were less likely to be eligible than Whites for both sets of eligibility criteria in 1996-1997 and in 2009-2010. Trend analysis for both sets of criteria found that on the multiplicative term, there were generally no significant changes in disparities between Whites and Blacks/Hispanics from 1996-1997 to 2009-2010. Interaction on the additive term found evidence that disparities between Whites and Blacks/Hispanics may have increased from 1996-1997 to 2009-2010 (e.g., in the main analysis between Whites and Hispanics for 2010 eligibility criteria: difference in odds=-0.03, 95% CI: [-0.03]-[-0.02]). Racial and ethnic minorities in the non-Medicare population experience persistent and often increasing disparities in meeting MTM eligibility criteria. Drug benefit plans should take caution when using elements of Medicare MTM eligibility criteria.

Disparity implications of the Medicare medication therapy management eligibility criteria: a literature review

The emphasis on eliminating racial and ethnic disparities in healthcare has received national attention, with various policy initiatives addressing this problem and proposing solutions. However, in the current economic era requiring tight monetary constraints, emphasis is increasingly being placed on economic efficiency, which often conflicts with the equality doctrine upon which many policies have been framed. The authors’ review aims to highlight the disparity implications of one such policy provision – the predominantly utilization-based eligibility criteria for medication therapy management services under Medicare Part D – by identifying studies that have documented racial and ethnic disparities in health status and the use of and spending on prescription medications. Future design and evaluation of various regulations and legislations employing utilization-based eligibility criteria must use caution in order to strike an equity–efficiency balance.

Pharmacy Students' Knowledge of the Medicare Drug Benefit and Intention to Provide Medicare Medication Therapy Management Services

To examine PharmD students' knowledge about Medicare Part D and their attitudes toward and intention to provide Medicare medication therapy management services (MTMS). Fourth-professional year students were given a self-administered survey instrument that assessed: (1) knowledge about Medicare Part D; (2) attitudes, perceived behavioral control, subjective norms, and intention to provide Medicare MTMS; and (3) demographic and experience information. Ninety-five students responded for a response rate of 94%. Students showed good basic knowledge about Medicare Part D, with a mean score of 94%. Almost 60% of students agreed that they intended to provide Medicare MTMS, but agreement dropped to 37% when they were asked if they were willing to take initiative to provide MTMS. The lack of willingness to take initiative to provide Medicare MTMS suggests that colleges and schools of pharmacy must strengthen efforts to encourage students to take on the role of service provider.

Characteristics of older adults who meet the annual prescription drug expenditure threshold for medicare medication therapy management programs.

The Medicare Modernization Act of 2003 requires drug plan sponsors to provide medication therapy management programs (MTMPs) to beneficiaries with (1) drug expenditures above $4,000, (2) multiple comorbidities, and (3) multiple prescription drugs. The Medical Expenditure Panel Survey (MEPS) is a national probability survey conducted annually by the Agency for Healthcare Research and Quality and the National Center for Health Statistics to provide nationally representative estimates of health care use, expenditures, sources of payments, and insurance coverage for the U.S. civilian noninstitutionalized population. MEPS comprises 3 components, including the household component (HC) in which households and individuals within households are sampled. The medical provider component (MPC) supplements the HC by contacting providers (hospitals, outpatient offices, home health agencies, and pharmacies) reported in the HC, and the insurance component collects data on health insurance plans and is separate from the HC. The purpose of this study was to estimate from MEPS data for 2002-2003 (1) the proportion of older adults who may have met the $4,000 expenditure component of the MTMP criteria and (2) the patient-specific risk factors associated with meeting the $4,000 expenditure threshold. This study is a cross-sectional analysis of MEPS respondents aged 65 years or older. Data came from both the MEPS-HC and the supplemental MEPS-MPC for 2002 and 2003. Specific data files were pooled and included the Full Year Consolidated files, Prescribed Medicines files, and the Medical Conditions files for both the 2002 and the 2003 MEPS-HC. Variables extracted from the MEPS data files included demographics, socioeconomic status, functional limitations, health status, presence and number of chronic conditions, body mass index, medical and prescription drug insurance, and health care utilization measures. The expenditure threshold of $4,000 was adjusted to $3,810 in 2003 U.S. dollars. Survey-weighted logistic regression identified factors associated with meeting the expenditure threshold. Unbiased population point estimates were obtained by adjusting for survey nonresponse, poststratification, and oversampling of blacks and Hispanics using MEPS person-level weights. In all analyses, standard errors were adjusted for nonindependence of observations due to complex multistage sampling by specifying the strata and primary sampling units for each respondent. Based on a sample of 8,035 noninstitutionalized persons aged 65 years or older in the United States, representing a population of 36.5 million older adults, MEPS data estimate that approximately 3.3 million (9.2%) incurred annual drug expenditures greater than $3,810, accounting for 35% of $55.3 billion in drug expenditures among all older adults. Older adults meeting the $3,810 prescription expenditure threshold reported an average 10.8 (SE=0.2) unique medications, 82.2 (SE=1.8) prescriptions, and 5.2 (SE=0.1) chronic conditions. Prescription expenditures accounted for 33.9% of total health care expenditures compared with 15.8% for persons who did not meet the $3,810 criterion and an average 19.5% for all persons aged 65 years or older (n=8,035). Factors that predicted meeting the expenditure threshold included age in 10-year increments (odds ratio [OR]=0.81; 95% confidence interval [CI], 0.68-0.97), requiring help with activities of daily living (OR=1.53; 95% CI, 1.19-1.97), having functional limitations (OR=1.67; 95% CI, 1.30-2.14), having TRICARE (military health care services) benefits (OR=0.54; 95% CI, 0.33-0.86), and being on Medicaid (OR=1.36; 95% CI, 1.02-1.81). Other factors that were also predictive of meeting the expenditure threshold included mental health disorders, ulcers, diabetes, dyslipidemia, cardiac disease, chronic obstructive pulmonary disorder, and the number of chronic conditions. MEPS survey respondents aged 65 years or older with drug expenditures exceeding the MTMP threshold of $4,000 per year obtain substantially more drugs and have a higher disease burden than those with lower drug expenditures. Characteristics other than drug use, such as having functional limitations or requiring help with activities of daily living, can be used to identify potential MTMP candidates.

Prediction of pharmacist intention to provide Medicare medication therapy management services using the theory of planned behavior

Background Medicare Part D is a voluntary prescription drug benefit for Medicare beneficiaries. As part of the coverage, medication therapy management services (MTMS) are mandated for beneficiaries with chronic diseases who take multiple medications covered under part D and who are likely to incur annual costs that exceed a specified level. Objective To predict the behavioral intention of pharmacists to provide Medicare medication therapy management services (MTMS) using the theory of planned behavior (TPB) and to determine the relationship between pharmacists' characteristics and intention to provide MTMS. Methods The population for this cross-sectional descriptive study consisted of all community pharmacists in Iowa. Data collection occurred through a self-administered anonymous mail survey. Two surveys each were mailed to 500 pharmacies selected through a stratified random sample, 1 survey for the pharmacy manager and 1 survey for a staff pharmacist if applicable. Descriptive statistics and scale reliability were calculated for each of the 4 TPB scales (attitude, subjective norm, perceived behavioral control, and intention). Linear regression was used to predict intent as a function of the other 3 TPB factors, demographic factors, experience, and type of pharmacy. Results Out of 212 surveys received, 203 had usable data. The usable response rate ranged from 21% to 41%. Pharmacists' intent to provide MTMS was generally positive but varied in strength with a mean score of 22.47 (±4.00) and a range of 7-30. Pharmacists mostly agreed that they had appropriate training to provide MTMS but lacked time and support. The linear regression analysis found the constructs of attitude, subjective norm, and perceived behavioral control to be significant predictors of intent ( P < .05). Pharmacists with stronger intent to provide MTMS were those who felt they had more control over providing MTMS, felt their peers approved of the provision of MTMS, and had a positive attitude about providing MTMS. Type of pharmacy and pharmacist demographic variables were not significant predictors of intent to provide MTMS. Conclusion Pharmacists showed generally positive intent to provide MTMS. Perceived behavioral control, subjective norm, and attitude were significant predictors of intent ( P < .05). Strategies to help pharmacists provide MTMS should focus on finding time and support to provide MTMS rather than individual educational needs.