ACCP Calls for Significant Structural Reforms to Medicare Part D MTM

February 17, 2023

ACCP Calls for Significant Structural Reforms to Medicare Part D MTM
Advance Coverage of Team-Based Pharmacists’ Comprehensive Clinical Services to Get the Medications Right

Washington, DC -- ACCP is calling on the Centers for Medicare and Medicaid Services (CMS) to advance reforms to the Medicare Part D Medication Therapy Management (MTM) program to include coverage of medication optimization services provided by clinical pharmacists working as fully integrated members of the health care team.

Background to Medicare Medication Coverage

Following the implementation of the Part D benefit and the launch of the MTM program, pharmacists across all practice settings worked to deliver high quality patient care to beneficiaries within the Part D MTM structure and sought to make the program a success.

After almost two decades of experience, it is evident that the Part D MTM program as it is currently structured – delivered primarily through prescription drug plans and detached from the patient’s health care team and medical records – fails to support a patient-centric, comprehensive process of care necessary to realize the full potential of effective, team-based medication management in terms of improved outcomes and lower costs.

This concern is shared by the Medicare Payment Advisory Commission (MedPAC). In a March 2019 Report to the Congress, MedPAC stated, “we continue to be concerned that sponsors of stand-alone Prescription Drug Plans (PDPs) do not have financial incentives to engage in MTM or other activities that, for example, reduce unnecessary medical expenditures. Further, the effectiveness of the current MTM services in improving the quality of overall patient care is unclear.”¹

Like MedPAC, ACCP questions whether medication optimization for beneficiaries can be achieved through improvements to the current Part D MTM program. By design, Part D MTM is an administrative benefit delivered by the patient’s Part D plan sponsor, rather than a comprehensive medical benefit coordinated through the patient’s health care team. Part D MTM is largely delivered using drug claims data and is narrowly focused on issues such as duplications in therapy, gaps in adherence, use of certain classes of medications, and generic substitution. Experience has shown that physicians may be reluctant to accept recommendations from drug plans with which they have no direct relationship.

ACCP’s Recommendation

Medication misuse and the adverse drug events that ensue is estimated to account for at least $528.4 billion in unnecessary health care spending annually. Comprehensive Medication Management (CMM) has been shown to improve outcomes, increase patient satisfaction, alleviate physician “burnout,” and save money.  

CMM is a well-established standard of care in our nation’s leading private sector health systems, including Geisinger, Kaiser Permanente, Mayo Clinic, and Johns Hopkins.  Nationally, VA clinical pharmacy specialists (CPS) hold scopes of practices that confer medication prescriptive authority and the responsibility to modify, start, stop and/or continue medications as per guideline recommendations, collaborative practice agreements, and the CPS’ clinical judgment. CPS also perform associated physical assessments, order lab tests, and initiate consults for other services.

Integrating CMM provided by clinical pharmacists, in close collaboration with physicians, is a critically important step to help ensure that medication therapy is fully optimized, contributing to better care, lower costs, improved outcomes, and enhanced equity for the entire Medicare program. 

Click here to read ACCP’s comment letter in response to the 2024 Medicare Proposed Rule.