Should eligibility for medication therapy management be based on drug adherence?

Area of Science:

• Health Services Research
• Pharmaceutical Policy
• Geriatric Medicine

Background:

• Medicare Part D plans offer Medication Therapy Management (MTM) services.
• Current eligibility criteria for MTM are restrictive, with less than 10% of enrollees receiving services.
• The effectiveness of current criteria in identifying at-risk beneficiaries is unknown.

Purpose of the Study:

• Evaluate medication underuse and non-adherence in Medicare beneficiaries with diabetes, heart failure, and COPD over three years.
• Determine if 2011 MTM eligibility criteria (≥$3,000 drug spending, ≥3 chronic conditions, ≥8 Part D medications) identify high-risk enrollees.
• Assess the sensitivity of MTM eligibility to changes in criteria.

Main Methods:

• A 5% random sample of Part D enrollees with targeted diseases from 2006-2008 was analyzed.
• Longitudinal patterns of exposure and adherence to key medications (ACE inhibitors/ARBs, beta-blockers, COPD controllers) were tracked.
• Medication patterns were compared between enrollees meeting and not meeting modal 2011 MTM eligibility criteria.

Main Results:

• Suboptimal use and adherence to evidence-based medications were prevalent across all studied disease cohorts.
• Enrollees with higher drug spending and multiple Part D medications showed better exposure and adherence rates.
• Current MTM criteria inadvertently target beneficiaries with higher medication utilization, excluding those with more problematic patterns.

Conclusions:

• Existing MTM eligibility criteria are not optimally designed to identify beneficiaries with suboptimal medication use or adherence.
• Policymakers should consider revising restrictive MTM eligibility criteria to better target patients with significant unmet needs.
• Adjusting criteria, such as lowering the required number of Part D medications, could substantially increase MTM eligibility.