Medication Therapy Management Eligibility Research Articles

Effects of Medicare comprehensive medication review on racial/ethnic disparities in nonadherence to statin medications among patients with Alzheimer\u2019s Disease: an observational analysis

BackgroundAlzheimer’s Disease (AD) is the mostcommon cause of dementia, a neurological disorder characterized by memory loss and judgment impairment. Hyperlipidemia, a commonly co-occurring condition, should be treated to prevent associated complications. Medication adherence may be difficult for individuals with AD due to the complexity of AD management. Comprehensive Medication Reviews (CMRs), a required component of Medicare Part D Medication Therapy Management (MTM), have been shown to improve medication adherence. However, many MTM programs do not target AD. Additionally, racial/ethnic disparities in MTM eligibility have been revealed. Thus, this study examined the effects of CMR receipt on reducing racial/ethnic disparities in the likelihood of nonadherence to hyperlipidemia medications (statins) among the AD population.MethodsThis retrospective study used 2015-2017 Medicare data linked to the Area Health Resources Files. The likelihood of nonadherence to statin medications across racial/ethnic groups was compared between propensity-score-matched CMR recipients and non-recipients in a ratio of 1 to 3. A difference-in-differences method was utilized to determine racial/ethnic disparity patterns using a logistic regression by including interaction terms between dummy variables for CMR receipt and each racial/ethnic minority group (non-Hispanic Whites, or Whites, as reference).ResultsThe study included 623,400 Medicare beneficiaries. Blacks and Hispanics had higher statin nonadherence than Whites: Compared to Whites, Blacks’ nonadherence rate was 4.53% higher among CMR recipients and 7.35% higher among non-recipients; Hispanics’ nonadherence rate was 2.69% higher among CMR recipients and 7.38% higher among non-recipients. Differences in racial/ethnic disparities between CMR recipients and non-recipients were significant for each minority group (p < 0.05) except Others. The difference between Whites and Hispanics in the odds of statin nonadherence was 11% lower among CMR recipients compared to non-recipients (OR = 0.89; 95% Confidence Interval = 0.85-0.94 for the interaction term between dummy variables for CMR and Hispanics). Interaction terms between dummy variables for CMR and other racial/ethnic minorities were not significant. ConclusionsReceiving a CMR was associated with a disparity reduction in nonadherence to statin medications between Hispanics and Whites among patients with AD. Strategies need to be explored to increase the number of MTM programs that target AD and promote CMR completion.

Development of measurable criteria to identify and prioritize patients for inclusion in comprehensive medication management programs within primary care settings.

BACKGROUND: Pharmacists optimize medication use and ensure the safe and effective delivery of pharmacotherapy to patients using comprehensive medication management (CMM). Identifying and prioritizing individual patients who will most likely benefit from CMM can be challenging. Health systems have far more candidates for CMM than there are clinical pharmacists to provide this service. Furthermore, current evidence lacks widely accepted standards or automated mechanisms for identifying patients who would likely benefit from a pharmacist consultation. Existing tools to prioritize patients for pharmacist review often require manual chart review by a pharmacist or other clinicians or data collection by patient survey. OBJECTIVES: To (1) create new medication risk markers for identifying and prioritizing patients within a population and (2) identify patients who met these new markers, assess their clinical characteristics, and compare them with criteria that are widely used for medication therapy management (MTM). METHODS: Along with published literature, a panel of subject matter experts informed the development of 3 medication risk markers. To assess the prevalence of markers developed, we used Multum, a medication database, for medication-level characteristics, and for patient-level characteristics, we used QuintilesIMS, an administrative claims database derived from health plans across the United States, with data for 1,541,873 eligible individuals from 2014-2015. We compared the health care costs, utilization, and medication gap among patients identified through MTM criteria (both broad and narrow, as these are provided as ranges) and our new medication management score markers. RESULTS: We developed 3 claims-derivable markers: (1) instances when a patient filled a medication with high complexity that could affect adherence, (2) instances where a patient filled a medication defined as costly within a therapeutic category that could affect access, and (3) instances when a patient filled a medication defined as risky that could increase incidence of adverse drug events. In the QuintilesIMS database, individuals with 2 new medication risk markers plus at least 3 conditions and more than $3,017 in medication costs when compared with individuals meeting narrow MTM eligibility criteria (≥ 8 medications, ≥ 3 conditions, and > $3,017 medication costs) had increased costs ($36,000 vs $26,100 total; $24,800 vs 21,400 medical; $11,300 vs $4,800 pharmacy); acute care utilization (0.328 vs 0.256 inpatient admissions and 0.627 vs 0.579 emergency department visits); and 1 or more gaps in medication adherence(41.5% vs 34.7%). CONCLUSIONS: We identified novel markers of medication use risk that can be determined using insurance claims and can be useful to identify patients for CMM programs and prioritize patients who would benefit from clinical pharmacist intervention. These markers were associated with higher costs, acute care utilization, and gaps in medication use compared with the overall population and within certain subgroups. Providing CMM to these patients may improve health system performance in relevant quality measures. Evaluation of CMM services delivered by a pharmacist using these markers requires further investigation. DISCLOSURES: No outside funding supported this study. All authors are Johns Hopkins employees. The Johns Hopkins University receives royalties for nonacademic use of software based on the Johns Hopkins Adjusted Clinical Group (ACG) methodology. Chang, Kitchen, Weiner, and Kharrazi receive a portion of their salary support from this revenue. The authors have no conflicts of interests relevant to this study.

Effect of Cost-Related Medication Non-adherence Among Older Adults With Medication Therapy Management.

Background: Medication therapy management (MTM) was established by the Center for Medicare and Medicaid Services (CMS) with the aim to improve medication adherence. However, the national prevalence of cost-related medication non-adherence (CRN) is still unknown and there is a literature gap in the association between MTM services and CRN.Methods: A cross-sectional study was conducted. A nationally representative study sample from Medicare Current Beneficiary Surveys (MCBS) was used. Survey sampling weights were applied for national estimates of CRN. Weighted multivariable logistic regressions controlling for covariates were conducted to investigate the effect of the MTM on the CRN.Results: The study identified 1,549 MTM-eligible beneficiaries. The prevalence of CRN was higher in MTM-eligible individuals than in non-MTM eligible individuals (24.14 vs. 13.44%; P < 0.001). According to the results of multivariable logistic regressions, we found that MTM eligibility was significantly associated with a higher prevalence of CRN (OR: 1.59; 95% CI: 1.28–1.96). Additionally, some other variables such as health status, with or without low-income subsidy are also associated with CRN.Conclusions: Our findings suggest that the prevalence of CRN in MTM-eligible beneficiaries was higher than in non-MTM eligible beneficiaries. Further studies with the longitudinal design are warranted to clarify the relationship between MTM and CRN. Alternative strategies to improve CRN should be considered in future Medicare Part D Enhanced MTM Models.

Economic assessment of changes to an existing medication therapy management program of a large regional health plan.

BACKGROUND: Although medication therapy management (MTM) has specific eligibility criteria and is mandated for specific Medicare Part D enrollees, some health plans have expanded MTM eligibility beyond the minimum criteria to include other Medicare Part D enrollees, Medicaid, and commercial health plan patients. Differences exist in the mode of delivery, location of services, type of personnel involved in managing the service, and the subsequent outcomes. The type and intensity of MTM services delivered have evolved with time to more streamlined and robust interventions, necessitating ongoing evaluation of the effect on clinical and economic outcomes. OBJECTIVE: To assess the effect of changes to an existing MTM program on cost of care, utilization, and medication adherence. METHODS: UPMC Health Plan made changes to an existing MTM program by expanding eligibility (customized by the type of health plan), intervention types, pharmacist involvement, and patient followup contacts. After matching our intervention cohort (identified January 2017-June 2018) with the pre-2016 MTM historical controls (patients identified January 2014-June 2015 who would have been eligible if we used the intervention cohort eligibility criteria), we estimated that the effect of the program changes with a difference-in-difference model (preintervention [2014-2016] and postintervention [2017-2019]). Outcomes of interest included cost (total cost of care including medical, pharmacy, and unplanned care [i.e., unscheduled health care use such as emergency department visits] in 2017 U.S. dollars); utilization; medication adherence (proportion of days covered); and return on investment (ROI). Target population included continuously enrolled patients aged ≥ 21 years in the commercial, Medicare, and Medicaid health plans. RESULTS: Total propensity score-matched members was 10,747, 55% of which were in the historic control group. The average (SD) ages after matching the groups were similar (historical control group: 57.08 years [14.23], intervention group: 56.79 years [14.21]) and the majority was female (57%). Comorbidities identified most for patients included hypertension (77%), dyslipidemia (70%), and diabetes (52%). Forty-one percent were in the commercial, 37% in the Medicaid, and 23% in the Medicare health plans. Proportion of care activities undertaken in the intervention period compared with the control period were significantly different: "sent letter to physician" (67% vs. 87%), "sent letter to member" (15% vs. 0%), "pharmacist phone call to physician" (15% vs. 0.1%), and "pharmacist phone call to member" (13% vs. 7%). There were statistically significant reductions in unplanned care across all health plans especially in the Medicare population, in total cost of care, and increases in medication adherence in 4 therapeutic classes: anticoagulants (OR = 1.25, P = 0.005), cardiac medications (OR = 1.20, P < 0.001), statins (OR = 1.21, P < 0.001), and antidepressants (OR = 1.15, P < 0.001). There was a positive ROI of $18.50 per dollar spent, which equated to a cumulative net savings of $11 million over 24 months. CONCLUSIONS: In a large health plan, expanding MTM eligibility, intensifying patient follow-up contact and pharmacist involvement, and improving provider awareness had favorable clinical and economic benefits. DISCLOSURES: There was no funding for this project except employees' time. All authors are employees of UPMC and have no conflicts of interest to report.

Understanding the Socioeconomic and Geographical Characteristics of Beneficiaries Receiving a Comprehensive Medication Review.

Medicare Part D sponsors are required to offer medication therapy management (MTM) programs to eligible beneficiaries. Recent studies have demonstrated that there have been racial/ethnic disparities in MTM eligibility criteria. For example, compared with non-Hispanic White beneficiaries, Hispanic and non-Hispanic Black beneficiaries are less likely to be eligible for MTM. However, there is limited evidence for socioeconomic and geographical characteristics of those who are eligible and receive MTM services. To describe the demographic, socioeconomic, and geographic characteristics of Medicare beneficiaries who received MTM services. As part of a previous study, a national survey evaluated a convenience sample of perspectives of Medicare beneficiaries on the MTM standardized format. The survey was distributed through Medicare Part D plans to beneficiaries receiving MTM services from 2017-2018. As part of the survey, respondents could provide their ZIP codes. Geographical variables, such as the National Center for Health Statistics (NCHS) urban-rural classification scheme and economic research service (ERS) county typology codes, were then applied to respondents' ZIP codes, allowing for the classification of counties or census tracts by urbanization and economic dependence measures. Descriptive statistics are reported for demographic, geographical, and socioeconomic information. Of the 300 (of 434) respondents who provided their ZIP codes, 51.3% were aged 65-74 years; 50% were male; and 66.7% had at least a college education. There were 82.7% who self-identified as White, while only 8% self-identified as Hispanic or Black/African American. The majority of respondents (58.4%) lived in large metropolitan areas as defined by the NCHS urban-rural classification scheme. Respondents' counties were characterized by economic dependence with 14.0% of respondents living in federal/state government-dependent counties and 12.7% living in recreation-dependent counties. The majority of respondents who provided their ZIP codes identified themselves as White and lived in large metropolitan areas. Respondents who identified themselves as Hispanic or Black/African American were not well represented. This study provides geographical and socioeconomic characteristics of Medicare beneficiaries who received MTM services and highlights racial/ethnic differences. Further work is needed to confirm geographical and socioeconomic disparities among beneficiaries who received MTM services. No outside funding supported this study. Pellegrin is a member of the AMCP MTM Advisory Group. The other authors have nothing to disclose.

Relationship between patient characteristics and number of phone calls to complete a telehealth comprehensive medication review: A cross-sectional analysis

ObjectiveTo assess the relationship between patient characteristics and completion of telehealth comprehensive medication reviews (CMRs). DesignCross-sectional analysis of a national telehealth medication therapy management program. A negative binomial regression assessed the relationship between number of phone calls to complete a CMR and age, sex, number of medications, poverty level, geographic region, limited English proficiency (LEP), years eligible for CMR services, and if a caregiver completed the CMR. Setting and participantsPatients included in the analysis were Medicare enrolled, medication therapy management eligible, and completed a CMR in 2017. Patients excluded if they were younger than 65 years, they had incomplete data, they had participated in an employer-sponsored plan, or completed a CMR with their provider. Outcome measuresNumber of phone calls reflected number of outgoing phone calls needed to complete a CMR. ResultsAnalysis included 222,163 patients. Females needed 9% more calls to complete a CMR than males (incident rate ratio 1.09 [95% CI 1.08–1.10]). Adults older than 75 years compared with patients between age 65 and 74 years needed 7% fewer calls (0.93 [0.92–0.94]). Patients needing a caregiver to complete the CMR required 33% more calls than individuals who did not (1.33 [1.31–1.35]). Patients eligible for CMR services longer than 1 year required 12%-45% fewer calls to complete a CMR than recently eligible patients. A statistically significant interaction was detected between LEP and poverty quintile. ConclusionsThis study found that poverty level inversely affected the number of phone calls to complete a CMR between those considered LEP and English language-speakers. Female sex and caregiver presence were associated with number of phone calls needed to complete a CMR. Older age and length of CMR eligibility were inversely associated with the number of phone calls needed. Future research is warranted to evaluate whether targeted approaches may improve CMR completion rates.

Medication therapy management delivery by community pharmacists: Insights from a national sample of Medicare Part D beneficiaries

Introduction The Medicare Part D medication therapy management (MTM) program positions pharmacists to optimize beneficiaries' medications and improve care. Little is known regarding Part D MTM delivery by community pharmacists and other pharmacist provider types. Objectives To (1) characterize Medicare Part D MTM delivery by community pharmacists, (2) compare MTM delivery by community pharmacists to other pharmacists, and (3) generate hypotheses for future research. Methods A descriptive cross-sectional study using merged data from a 20% random sample of Medicare beneficiary enrollment data with a 100% sample of recently available 2014 Part D MTM files was conducted. Andersen's Behavioral Model was applied to describe MTM delivery across beneficiary characteristics. Descriptive and bivariate statistics were used to compare delivery of MTM between community and other pharmacist providers. Results Among beneficiaries sampled, community pharmacists provided comprehensive medication reviews (CMRs) to 22% (n=26,337) of beneficiaries receiving at least one CMR. Almost half (49.4%) were provided face-to-face. Across pharmacist cohorts, median days to CMR offer of post-MTM program enrollment were within the 60-day policy requirement. The community pharmacist cohort had fewer days from CMR offer to receipt (median 47 days). Community pharmacists provided more medication therapy problem (MTP) recommendations (mean [SD] of 1.8 [3.5]; p<0.001), but resolved less MTPs (0.2 [0.7]; p<0.001), and most commonly served beneficiaries that were in the south but less in the west/northeast. Additionally, community pharmacists served a smaller proportion of black beneficiaries, yet a larger proportion of Hispanic beneficiaries (p<0.001). Conclusion Community pharmacists provided approximately one in five CMRs for MTM eligible beneficiaries in 2014, with CMRs occurring more quickly, resulting in more MTP recommendations, but resolving less MTPs than those provided by non-community pharmacists. Future research should explore geographic/racial-ethnic disparities in beneficiaries served and strategies to increase negligible MTP resolution by community pharmacists.

Impact of Automated Targeted Medication Review Electronic Alerts to Reduce Potentially Inappropriate Medication Prescribing Among Medicare Enrolled Patients With Dementia.

Background:Finding ways to reduce prescribing of potentially inappropriate medications (PIMs) among patients with dementia is necessary. To evaluate an automated targeted medication review (TMR) service to reduce PIM prescribing among patients with dementia. This was a retrospective observational analysis of patients in a Medication Therapy Management (MTM) program for year 2017. Patients included if Medicare enrolled, MTM eligible, had dementia, and with PIM prescribing. Descriptive statistics described reduced PIM prescribing. Odds ratios (ORs) assessed prescriber relationship with PIM prescribing. Regression evaluated relationship between patient characteristics and discontinued PIMs. A total of 33 696 TMRs were triggered for 17 933 patients. Four months later, 11 608 TMRs led to a discontinued PIM among 8002 patients. Medications with the largest discontinuations were antihistamines (56%), muscle relaxants (53%), antiemetics (53%), and typical antipsychotics (40%). Physician primary care providers (PCPs) were more likely than nonphysician PCPs (OR = 4.54; 95% CI = 4.15-4.97; P < 0.001), psychiatrists (OR = 1.64; 95%CI = 1.44-1.86; P < 0.001), and neurologists (OR = 4.48; 95% CI = 4.07-4.93; P < 0.001) to prescribe medications to treat dementia and PIMs. Regression showed that younger age, female gender, higher poverty level, and a greater number of pharmacies, medications, and prescribers were associated with discontinued PIMs. Conclusions and Relevance: TMRs were effective in reducing PIM prescribing. Younger patients, individuals living in higher poverty levels, and patients with multiple prescribers or pharmacies may benefit most from this service. TMRs in primary care offices may reduce PIM prescribing.

Patterns and predictors of older adult Medicare Part D beneficiaries' receipt of medication therapy management.

Medicare Part D medication therapy management (MTM) includes an annual comprehensive medication review (CMR) as a strategy to mitigate suboptimal medication use in older adults. To describe the characteristics of Medicare beneficiaries who were eligible, offered, and received a CMR in 2013 and 2014 and identify potential disparities. This nationally representative cross-sectional study used a 20% random sample of Medicare Part A, B, and D data linked with Part D MTM files. A total of 5,487,343 and 5,822,188 continuously enrolled beneficiaries were included in 2013 and 2014, respectively. CMR use was examined among a subset of 620,164 and 669,254 of these beneficiaries enrolled in the MTM program in 2013 and 2014. Main measures were MTM eligibility, CMR offer, and CMR receipt. The Andersen Behavioral Model of Health Services Use informed covariates selected. In 2013 and 2014, 505,658 (82%) and 649,201 (97%) MTM eligible beneficiaries were offered a CMR, respectively. Among those, CMR receipt increased from 81,089 (16%) in 2013 to 119,181 (18%) in 2014. The mean age of CMR recipients was 75 years (±7) and the majority were women, White, and without low-income status. In 2014, lower odds of CMR receipt were associated with increasing age (adjusted odds ratio (OR)=0.99 (95% confidence interval (CI)=0.994-0.995), male sex (OR=0.93, 95% CI=0.926-0.951), being any non-White race/ethnicity except Black, dual-Medicaid status (OR=0.64, 95% CI=0.626-0.650), having a hospitalization (OR=0.87, 95% CI=0.839-0.893) or emergency department visit (OR=0.67, 95% CI=0.658-0.686), and number of comorbidities (OR=0.90, 95% CI=0.896-0.905). CMR offers and completion rates have increased, but disparities in CMR receipt by age, sex, race, and dual-Medicaid status were evident. Changes to MTM targeting criteria and CMR offer strategies may be warranted to address disparities.

Hydrocodone Reclassification and Opioid Prescribing in Surgically-Treated Breast Cancer Patients

Medicare Part D medication therapy management (MTM) includes an annual comprehensive medication review (CMR) as a strategy to mitigate suboptimal medication use in older adults.To describe the characteristics of Medicare beneficiaries who were eligible, offered, and received a CMR in 2013 and 2014 and identify potential disparities.This nationally representative cross-sectional study used a 20% random sample of Medicare Part A, B, and D data linked with Part D MTM files. A total of 5,487,343 and 5,822,188 continuously enrolled beneficiaries were included in 2013 and 2014, respectively. CMR use was examined among a subset of 620,164 and 669,254 of these beneficiaries enrolled in the MTM program in 2013 and 2014. Main measures were MTM eligibility, CMR offer, and CMR receipt. The Andersen Behavioral Model of Health Services Use informed covariates selected.In 2013 and 2014, 505,658 (82%) and 649,201 (97%) MTM eligible beneficiaries were offered a CMR, respectively. Among those, CMR receipt increased from 81,089 (16%) in 2013 to 119,181 (18%) in 2014. The mean age of CMR recipients was 75 years (±7) and the majority were women, White, and without low-income status. In 2014, lower odds of CMR receipt were associated with increasing age (adjusted odds ratio (OR) = 0.99 (95% confidence interval (CI) = 0.994–0.995), male sex (OR = 0.93, 95% CI = 0.926–0.951), being any non-White race/ethnicity except Black, dual-Medicaid status (OR = 0.64, 95% CI = 0.626–0.650), having a hospitalization (OR = 0.87, 95% CI = 0.839–0.893) or emergency department visit (OR = 0.67, 95% CI = 0.658–0.686), and number of comorbidities (OR = 0.90, 95% CI = 0.896–0.905).CMR offers and completion rates have increased, but disparities in CMR receipt by age, sex, race, and dual-Medicaid status were evident. Changes to MTM targeting criteria and CMR offer strategies may be warranted to address disparities.

Medication Therapy Management Delivery by Community Pharmacists: Insights from a National Sample of Medicare Part D Beneficiaries.

The Medicare Part D medication therapy management (MTM) program positions pharmacists to optimize beneficiaries' medications and improve care. Little is known regarding Part D MTM delivery by community pharmacists and other pharmacist provider types. To (1) characterize Medicare Part D MTM delivery by community pharmacists, (2) compare MTM delivery by community pharmacists to other pharmacists, and (3) generate hypotheses for future research. A descriptive cross-sectional study using merged data from a 20% random sample of Medicare beneficiary enrollment data with a 100% sample of recently available 2014 Part D MTM files was conducted. Andersen's Behavioral Model was applied to describe MTM delivery across beneficiary characteristics. Descriptive and bivariate statistics were used to compare delivery of MTM between community and other pharmacist providers. Among beneficiaries sampled, community pharmacists provided comprehensive medication reviews (CMRs) to 22% (n=26,337) of beneficiaries receiving at least one CMR. Almost half (49.4%) were provided face-to-face. Across pharmacist cohorts, median days to CMR offer of post-MTM program enrollment were within the 60-day policy requirement. The community pharmacist cohort had fewer days from CMR offer to receipt (median 47 days). Community pharmacists provided more medication therapy problem (MTP) recommendations (mean [SD] of 1.8 [3.5]; p<0.001), but resolved less MTPs (0.2 [0.7]; p<0.001), and most commonly served beneficiaries that were in the south but less in the west/northeast. Additionally, community pharmacists served a smaller proportion of black beneficiaries, yet a larger proportion of Hispanic beneficiaries (p<0.001). Community pharmacists provided approximately one in five CMRs for MTM eligible beneficiaries in 2014, with CMRs occurring more quickly, resulting in more MTP recommendations, but resolving less MTPs than those provided by non-community pharmacists. Future research should explore geographic/racial-ethnic disparities in beneficiaries served and strategies to increase negligible MTP resolution by community pharmacists.

Comparative Effectiveness of Medication Therapy Management Eligibility Criteria Across Racial/Ethnic Groups.

Previous research indicates that eligibility criteria for medication therapy management (MTM) services in Medicare prescription drug (Part D) plans, defined under the Medicare Modernization Act (MMA), are associated with racial/ethnic disparities and ineffective in identifying individuals with medication utilization issues. Our study's objective was to determine the comparative effectiveness of MTM eligibility criteria under MMA and in the Affordable Care Act (ACA) in identifying patients with medication utilization issues across racial/ethnic groups. ACA and MMA MTM eligibility criteria were compared on proportions of eligible individuals among patients with medication utilization issues. Multinomial logistic regression was conducted to control for patient/community characteristics. Need-based and demand-based analyses were used to determine disparities due to need and demand for healthcare. Main/sensitivity analyses were conducted for the range of eligibility thresholds. Medicare data (2012-2013) linked to Area Health Resources Files. A total of 964 610 patients 65 years or older. Medication safety/adherence measures, developed primarily by the Pharmacy Quality Alliance, were used to determine medication utilization issues. Higher proportions of patients were eligible based on ACA than MMA MTM eligibility criteria. For example, in 2013, proportions based on ACA and MMA MTM eligibility criteria would be 99.7% and 26.2%, respectively, in the main analysis (p < .001); in the demand-based main analysis, ACA criteria were associated with 13.6% and 9.8%, respectively, higher effectiveness than MMA criteria among non-Hispanic blacks and Hispanics than non-Hispanic whites. ACA MTM eligibility criteria are more effective than MMA criteria in identifying older patients needing MTM, particularly among minorities. J Am Geriatr Soc 67:581-587, 2019.

Predictive Value Positive of MTM Eligibility Criteria under MMA and ACA in Identifying Individuals with Medication Utilization Issues.

To compare the predictive value positives (PVP) of medication therapy management eligibility criteria under the Medicare Modernization Act (MMA) and Affordable Care Act (ACA) in identifying individuals with medication utilization issues (MUI). This is a retrospective analysis of Medicare database (2012-2013). MUI were determined based on medication utilization measures related to Medicare Part D Star Ratings. PVP or proportions of individuals with MUI were compared between individuals eligible for MTM under MMA and ACA. Need-based and demand-based logistic regression was used to adjust for patient characteristics. MTM eligibility thresholds in 2009 and 2013 and proposed 2015 MTM eligibility thresholds under MMA were examined. Main/sensitivity/disease-specific analyses were conducted to cover the range of eligibility thresholds and combinations. MMA has higher PVP in identifying patients with MUI than ACA. Proportions of individuals with MUI were higher based on MMA than ACA (e.g., 74.96% for 2009 MMA, 73.51% for 2013 MMA, and 62.46% for proposed 2015 MMA vs. 52.17% for ACA in main analysis; P<0.05). Adjusted findings were similar. For example, based on the demand-based model in the main analysis, the odds ratios were 2.474 (95% CI: 2.454-2.494) for 2013 MMA in comparison to ACA. These numbers indicate that the MMA MTM eligibility criteria for 2013 had 147.4% higher PVP in identifying patients with MUI than ACA. Similar patterns were found in most sensitivity and disease-specific analyses. MMA has higher PVP than ACA in identifying patients with MUI. This study may inform the government on future MTM policy.

Higher Predictive Value Positive for MMA Than ACA MTM Eligibility Criteria Among Racial and Ethnic Minorities: An Observational Study.

The objective of this study was to examine positive predictive value (PPV) of medication therapy management (MTM) eligibility criteria under Medicare Modernization Act (MMA) and Affordable Care Act (ACA) in identifying patients with medication utilization issues across racial and ethnic groups. The study analyzed Medicare data (2012-2013) for 2 213 594 beneficiaries. Medication utilization issues were determined based on medication utilization measures mostly developed by Pharmacy Quality Alliance. MMA was associated with higher PPV than ACA in identifying individuals with medication utilization issues among non-Hispanic blacks (blacks) and Hispanics than non-Hispanic whites (whites). For example, odds ratio for having medication utilization issues to whites when examining MMA in 2013 and ACA were 1.09 (95% confidence interval [CI] = 1.04-1.15) among blacks, and 1.17 (95% CI = 1.10-1.24) among Hispanics, in the main analysis. Therefore, MMA was associated with 9% and 17% higher PPV than ACA in identifying patients with medication utilization issues among blacks and Hispanics, respectively, than whites.

Racial and ethnic disparities in meeting MTM eligibility criteria among patients with asthma

ABSTRACTBackground: Asthma is one of the most frequently targeted chronic diseases in the medication therapy management (MTM) programs of the Medicare prescription drug (Part D) benefits. Although racial and ethnic disparities in meeting eligibility criteria for MTM services have been reported, little is known about whether there would be similar disparities among adults with asthma in the United States. Methods: Adult patients with asthma (age ≥ 18) from Medical Expenditure Panel Survey (2011–2012) were analyzed. Bivariate analyses were conducted to compare the proportions of patients who would meet Medicare MTM eligibility criteria between non-Hispanic Blacks (Blacks), Hispanics and non-Hispanic Whites (Whites). Survey-weighted logistic regression was performed to adjust for patient characteristics. Main and sensitivity analyses were conducted to cover the entire range of the eligibility thresholds used by Part D plans in 2011–2012. Results: The sample included 4,455 patients with asthma, including 2,294 Whites, 1,218 Blacks, and 943 Hispanics. Blacks and Hispanics had lower proportions of meeting MTM eligibility criteria than did Whites (P < 0.001). According to the main analysis, Blacks and Hispanics had 36% and 32% lower, respectively, likelihood of MTM eligibility than Whites (odds ratio [OR]: 0.64, 95% confidence interval [CI]: 0.45–0.90; OR: 0.68, 95% CI: 0.47–0.98, respectively). Similar results were obtained in sensitivity analyses. Conclusions: There are racial and ethnic disparities in meeting Medicare Part D MTM eligibility criteria among adult patients with asthma. Future studies should examine the implications of such disparities on health outcomes of patients with asthma and explore alternative MTM eligibility criteria.

Medication therapy management and adherence among US renal transplant recipients.

BackgroundMedication therapy management (MTM) services among patient populations with a range of disease states have improved adherence rates. However, no published studies have examined the impact of Medicare Part D MTM eligibility on renal transplant recipients’ (RTRs) immunosuppressant therapy (IST) adherence. This study’s purpose was therefore, to determine the effects of Medicare Part D MTM on IST adherence among adult RTRs at 12 months posttransplant.MethodsCross-sectional analyses were performed on Medicare Parts A, B, and D claims and transplant follow-up data reported in the United States Renal Data System. The sample included adult RTRs who were transplanted between 2006 and 2011, had graft survival for 12 months, were enrolled in Part D, and were prescribed tacrolimus. IST adherence was measured by medication possession ratio for tacrolimus. MTM eligibility was determined using criteria established by the Centers for Medicare and Medicaid Services. Descriptive statistics were calculated. Adherence was modeled using multiple logistic regression.ResultsIn all, 17,181 RTRs were included. The majority of the sample were male (59.1%), and 42% were MTM-eligible. Mean medication possession ratio was 0.91±0.17 (mean ± standard deviation), with 16.83% having a medication possession ratio of <0.80. MTM eligibility, sex, age, and number of prescription drugs were significantly associated with adherence in the full model (P<0.05). MTM-eligible RTRs were more likely to be adherent than those who were not MTM-eligible (odds ratio =1.13, 95% confidence interval 1.02–1.26, P=0.02).ConclusionThe findings provide evidence that access to MTM services increases IST adherence among RTRs.

Evaluation of Eligibility Criteria Used to Identify Patients for Medication Therapy Management Services: A Retrospective Cohort Study in a Medicare Advantage Part D Population.

General eligibility criteria used by the Centers for Medicare & Medicaid Services (CMS) to identify patients for medication therapy management (MTM) services include having multiple chronic conditions, taking multiple Part D drugs, and being likely to incur annual drug costs that exceed a predetermined threshold. The performance of these criteria in identifying patients in greatest need of MTM services is unknown. Although there are numerous possible versions of MTM identification algorithms that satisfy these criteria, there are limited data that evaluate the performance of MTM services using eligibility thresholds representative of those used by the majority of Part D sponsors. To (a) evaluate the performance of the 2013 CMS MTM eligibility criteria thresholds in identifying Medicare Advantage Prescription Drug (MAPD) plan patients with at least 2 drug therapy problems (DTPs) relative to alternative criteria threshold levels and (b) identify additional patient risk factors significantly associated with the number of DTPs for consideration as potential future MTM eligibility criteria. All patients in the Medicare Advantage Part D population who had pharmacy eligibility as of December 31, 2013, were included in this retrospective cohort study. Study outcomes included 7 different types of DTPs: use of high-risk medications in the elderly, gaps in medication therapy, medication nonadherence, drug-drug interactions, duplicate therapy, drug-disease interactions, and brand-to-generic conversion opportunities. DTPs were identified for each member based on 6 months of most recent pharmacy claims data and 14 months of most recent medical claims data. Risk factors examined in this study included patient demographics and prior health care utilization in the most recent 6 months. Descriptive statistics were used to summarize patient characteristics and to evaluate unadjusted relationships between the average number of DTPs identified per patient and each risk factor. Quartile values identified in the study population for number of diseases, number of drugs, and annual spend were used as potential new criteria thresholds, resulting in 27 new MTM criteria combinations. The performance of each eligibility criterion was evaluated using sensitivity, specificity, positive predictive values (PPVs), and negative predictive values (NPVs). Patients identified with at least 2 DTPs were defined as those who would benefit from MTM services and were used as the gold standard. As part of a sensitivity analysis, patients identified with at least 1 DTP were used as the gold standard. Lastly, a multivariable negative binomial regression model was used to evaluate the relationship between each risk factor and the number of identified DTPs per patient while controlling for the patients' number of drugs, number of chronic diseases, and annual drug spend. A total of 2,578,336 patients were included in the study. The sensitivity, specificity, PPV, and NPV of CMS MTM criteria for the 2013 plan year were 15.3%, 95.6%, 51.3%, and 78.8%, respectively. Sensitivity and PPV improved when the drug count threshold increased from 8 to 10, and when the annual drug cost decreased from $3,144 to $2,239 or less. Results were consistent when at least 1 DTP was used as the gold standard. The adjusted rate of DTPs was significantly greater among patients identified with higher drug and disease counts, annual drug spend, and prior ER or outpatient or hospital visits. Patients with higher median household incomes who were male, younger, or white had significantly lower rates of DTPs. The performance of MTM eligibility criteria can be improved by increasing the threshold values for drug count while decreasing the threshold value for annual drug spend. Furthermore, additional risk factors, such as a recent ER or hospital visit, may be considered as potential MTM eligibility criteria.

Potential Health Implications of Medication Therapy Management Eligibility Criteria in the Patient Protection and Affordable Care Act Across Racial and Ethnic Groups.

The Medicare Prescription Drug, Improvement, and Modernization Act requires Part D plans to establish programs to provide medication therapy management (MTM) services starting from 2006. MTM services have been found to improve patient outcomes from pharmacotherapy, reduce emergency room visits and hospitalizations, and reduce health care costs in a cost-effective fashion. However, previous research found that non-Hispanic blacks (blacks) and Hispanics may be less likely to be eligible for MTM services than non-Hispanic whites (whites) among the Medicare population, according to current Medicare MTM eligibility criteria. This finding is because Medicare MTM eligibility criteria are predominantly based on medication use and costs, and blacks and Hispanics tend to use fewer prescription medications and incur lower prescription medication costs. The Patient Protection and Affordable Care Act (PPACA) laid out a set of MTM eligibility criteria for eligible entities to target patients for MTM services: "(1) take 4 or more prescribed medications ...; (2) take any 'high risk' medications; (3) have 2 or more chronic diseases ... or (4) have undergone a transition of care, or other factors ... that are likely to create a high risk of medication-related problems." To (a) examine racial/ethnic disparities in meeting the eligibility criteria for MTM services in PPACA among the Medicare population and (b) determine whether there would be greater disparities in health and economic outcomes among MTM-ineligible than MTM-eligible groups. This was a retrospective cross-sectional analysis of the Medicare Current Beneficiaries Survey (2007-2008). To determine medication characteristics, the U.S. Food and Drug Administration's Electronic Orange Book was also used. Proportions of the population eligible for MTM services based on PPACA MTM eligibility criteria were compared across racial and ethnic groups using a chi-square test; a logistic regression model was used to adjust for population sociodemographic and health characteristics. Health and economic outcomes examined included health status (self-perceived good health status, number of chronic diseases, activities of daily living [ADLs], and instrumental activities of daily living [IADLs]), health services utilization and costs (physician visits, emergency room visits, and total health care costs), and medication use patterns (generic dispensing ratio). To determine difference in disparities across MTM eligibility categories, difference-in-differences regressions of various functional forms were employed, depending on the nature of the dependent variables. Interaction terms between the dummy variables for minority groups (e.g., blacks or Hispanics) and MTM eligibility were included to test whether disparity patterns varied between MTM-ineligible and MTM-eligible individuals. The sample consisted of 12,966 Medicare beneficiaries, of which 11,161 were white, 930 were black, and 875 were Hispanic. Of the study sample, 9,992 whites (86.4%), 825 blacks (86.3%), and 733 Hispanics (80.6%) were eligible for MTM. The difference between whites and Hispanics was significant (P less than 0.050), and the difference between whites and blacks was not significant (P greater than 0.050). In multivariate analyses, significant disparity in eligibility for MTM services was found only between Hispanics and whites (odds ratio [OR] = 0.59; 95% CI = 0.43-0.82) but not between blacks and whites (OR = 0.78; 95% CI = 0.55-1.09). Disparities were greater among the MTM-ineligible than the MTM-eligible populations in self-perceived health status, ADLs, and IADLs for both blacks and Hispanics compared with whites. When analyzing the number of chronic conditions, the number and costs of physician visits, and total health care costs, the authors of this study found lower racial and ethnic disparities among the ineligible population than the eligible population. Hispanics are significantly less likely than whites to qualify for MTM among the Medicare population, according to MTM eligibility criteria stipulated in the PPACA. PPACA MTM eligibility criteria may aggravate existing racial and ethnic disparities in health status but may remediate racial and ethnic disparities in health services utilization. Alternative MTM eligibility criteria other than PPACA MTM eligibility criteria may be needed to improve the efficiency and equity of access to Medicare Part D MTM programs.

Predictors of medication-related problems among medicaid patients participating in a pharmacist-provided telephonic medication therapy management program.

To identify predictors of medication-related problems (MRPs) among Medicaid patients participating in a telephonic medication therapy management (MTM) program. Retrospective analysis of data from patients enrolled in a previously published study. Two Medicaid administrative claims file databases (for health care utilization and prescription dispensing information) and one pharmacy organization file for MTM program information. Seven hundred twelve adult Medicaid patients who participated in a statewide pharmacist-provided telephone-based MTM program and who received an initial medication therapy review. The primary dependent variable was the number of MRPs detected during the initial medication therapy review. Secondary dependent variables were the detection of one or more MRPs related to indication, effectiveness, safety, and adherence. Predictor variables were selected a priori that, from the literature and our own practice experiences, were hypothesized as being potentially associated with MRPs: demographics, comorbidities, medication use, and health care utilization. Bivariate analyses were performed, and multivariable models were constructed. All predictor variables with significant associations (defined a priori as p<0.1) with the median number of MRPs detected were then entered into a three-block multiple linear regression model. The overall model was significant (p<0.001, R(2) =0.064). Significant predictors of any MRPs (p<0.05) were total number of medications, obesity, dyslipidemia, and one or more emergency department visits in the past 3months. For indication-related MRPs, the model was significant (p<0.001, R(2) =0.049), and predictors included female sex, obesity, dyslipidemia, and total number of medications (p<0.05). For effectiveness-related MRPs, the model was significant (p<0.001, R(2) =0.054), and predictors included bone disease and dyslipidemia (p<0.05). For safety-related MRPs, the model was significant (p<0.001, R(2) =0.046), and dyslipidemia was a predictor (p<0.05). No significant predictors of adherence-related MRPs were identified. This analysis supports the relative importance of number of medications as a predictor of MRPs in the Medicaid population and identifies other predictors. However, given the models' low R(2) values, these findings indicate that other unknown factors are clearly important and that criteria commonly used for determining MTM eligibility may be inadequate in identifying appropriate patients for MTM in a Medicaid population.

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.