Eligibility For And Enrollment In Medicare Part D Medication Therapy Management Programs Varies By Plan Sponsor

Area of Science:

• Health Services Research
• Pharmaceutical Policy
• Gerontology

Background:

• Medicare Part D plans are mandated to provide Medication Therapy Management (MTM) services.
• Beneficiaries eligible for MTM typically have multiple chronic conditions and high prescription drug costs.
• However, Medicare Part D plan sponsors have significant flexibility in establishing specific MTM eligibility criteria.

Purpose of the Study:

• To analyze enrollment rates in MTM services within Medicare Part D plans.
• To investigate the association between plan sponsor-defined eligibility criteria and MTM enrollment.
• To identify disparities in MTM access and their potential impact on patient outcomes and healthcare expenditures.

Main Methods:

• Analysis of newly available data from Medicare Part D stand-alone prescription drug plans and Medicare Advantage drug plans for the year 2012.
• Comparison of MTM enrollment rates across different plan sponsors.
• Statistical examination of the relationship between the restrictiveness of eligibility criteria (e.g., number of chronic conditions, drug utilization requirements) and enrollment percentages.

Main Results:

• Overall MTM enrollment averaged only 10% in 2012 across analyzed plans.
• Significant variation in enrollment rates was observed, ranging from less than 0.2% to over 57.0% among plan sponsors.
• More restrictive criteria, such as requiring three chronic conditions or specific drug classes, were associated with substantially lower enrollment rates compared to less restrictive criteria.

Conclusions:

• The wide variation in MTM enrollment is directly linked to the restrictiveness of eligibility criteria set by plan sponsors.
• These inequities in access represent missed opportunities for interventions that could improve medication adherence, therapeutic outcomes, and reduce healthcare costs.
• The Centers for Medicare and Medicaid Services' new Part D Enhanced Medication Therapy Management model aims to improve MTM impact through aligned incentives and innovation.