Finding Equitable and Effective MTM Eligibility Criteria

The need to improve the Medicare eligibility criteria for medication therapy management (MTM) services in prescription drug (Part D) benefits has been highlighted recently when the Centers for Medicare and Medicaid Services (CMS) released their proposed 2015 rules for Part D plans. In this document, CMS credited our team’s series of findings on disparity implications of the current MTM eligibility criteria among the main reasons to change MTM eligibility. Combining medication review and treatment planning, MTM services were implemented by CMS in 2006 as a part of Part D based on the Medicare Modernization Act (MMA) and have been shown to significantly improve pharmacotherapy outcomes. MTM services are long overdue because drug-related morbidity/mortality is an age-old and costly public health problem, particularly among the elderly. However, as we have shown, Medicare MTM eligibility criteria are an institutionalized cause for disparities: the drug use/cost basis of MTM eligibility means that racial and ethnic minorities are less likely to qualif because, given the same health status, Blacks and Hispanics tend to use fewer drugs/incur lower drug costs than Whites. The recently proposed 2015 MTM eligibility criteria merely lower the drug use/cost thresholds within MMA statutory framework, and, thus, are unlikely to address these disparities. Moreover, MMA MTM eligibility criteria recently were found ineffective in capturing suboptimal-therapy problems such as drug nonadherence. The goal of this project is to address these issues by finding equitable and effective MTM eligibility criteria. “Effectiveness is essential for realizing MTM’s potential, and “equality of access” is the most widely- used definition of equity in policy documents. Specific Aim 1: To test whether using Star Ratings criteria, which we propose based on the medication safety/adherence measures in the CMS Part D Star Ratings system, can reduce racial and ethnic disparities in MTM eligibility. Specific Aim 2: To compare the effectiveness of the MTM eligibility criteria under the Patient Protection and Affordable Care Act (ACA) and MMA in identifying patients with medication utilization issues. We will compare them on sensitivity, specificity, predictive values (positive/negative), and the receiver operating characteristic curves. ACA MTM eligibility criteria are important to analyze, as recognized by CMS, because these criteria incorporate medication utilization issues within the MMA MTM eligibility framework. Specific Aim 3: To examine the comparative effectiveness of the MTM eligibility criteria under ACA and MMA in identifying medication utilization issues across racial and ethnic groups. We will also examine predictors for disparities and conduct disease-specific analyses. We will use 2013 Medicare Part D data linked to Parts A and B claims, the Master Beneficiary Summary File, and the Area Health Resource File. This project’s success is highly likely because our pilot data suggest that minorities may be as likely as Whites to meet the Star Ratings Criteria. The National Institute on Aging identifies disparities/medication utilization issues among Medicare beneficiaries as a funding priority.