Few Medicare Beneficiaries Receive Comprehensive Medication Review Services

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A new analysis from Avalere Health finds that less than half of all Medicare prescription drug (Part D) enrollees eligible for medication therapy management (MTM) programs receive these services. Under Medicare rules, the Centers for Medicare & Medicaid Services (CMS) requires all Part D plans to provide MTM services to beneficiaries who meet certain criteria and have high drug utilization.
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MTM services involve providing high-utilizing beneficiaries with a complete review of their medication regimens by a clinical pharmacist in order to provide education, improve adherence, and detect adverse drug events or inappropriate medication use. Specifically, CMS estimates that 25 percent of beneficiaries are eligible for MTM (2010 Medicare Part D MTM Programs Fact Sheet). Yet, only 11 percent of all Part D enrollees were part of a MTM program in 2012.

“With only half of enrollees eligible for MTM programs receiving benefits, the Avalere analysis shows that these valuable services are under-used in Medicare,” said Dan Mendelson, CEO of Avalere Health. “As regulators consider reforms, they will need to balance access to services with the operational realities faced by health plans.”

In 2012, Part D beneficiaries who had at least two chronic conditions, take at least three medications, and have annual drug spending of more than $3,100 were eligible for MTM services. MTM programs are intended to optimize therapeutic outcomes through improved medication adherence and reduced risk of adverse events such as drug-drug interactions or clinically inappropriate therapies. In addition to offering eligible beneficiaries MTM services, Part D plans are required to offer all MTM enrollees a comprehensive medication review (CMR).

However, Avalere found significant variation in participation in MTM programs and implementation of CMRs across carriers. Specifically, among the top 10 carriers participating in Medicare Part D, MTM enrollment rates ranged from a low of 4.6 percent to a high of 17.5 percent, with between 2 and 74 percent of MTM enrollees receiving a CMR. Overall, only approximately 1 percent of all Medicare Part D enrollees received a CMR.

“Under the Affordable Care Act, plans have new incentives that are likely to expand MTM services and reduce variation among plans in future years,” said Caroline Pearson, vice president at Avalere Health.

While overall participation in MTM programs is low, enrollees in Medicare Advantage prescription drug plans (MA-PDs) were almost three times as likely as those in standalone prescription drug plans (PDPs) to receive a CMR. In addition, MA-PD enrollees were nearly four times as likely to receive an intervention-such as outreach to a prescriber or a change in therapy as a result of the CMR

“Medicare Advantage plans realize that better medication management can reduce medical costs and improve clinical outcomes,” said Matt Eyles, executive vice president at Avalere Health. “As a result, MA plans are much more active in reviewing beneficiary medications and making important changes compared to standalone Medicare drug plans.”

Please find Avalere’s full press release attached.

For more information about Medication Management Services, contact Caroline Pearson at CPearson@Avalere.com.


These findings are the result of an initial analysis of recently released plan data based on Part C and D Reporting Requirements as part of the Public Use File (PUF) by the Centers for Medicare and Medicaid Services (CMS). While a majority of Part D plans were included in the data file, six PDPs and 135 MA-PDPs were missing accounting for approximately 2.8 million lives. Historically, CMS has used Part C and D reporting requirements for data analyses, compliance and monitoring, oversight, and Star Ratings display measures. The new PUF contains data from calendar year (CY) 2012 (except where noted). Additionally, the June 2012 contract enrollment file was used to determine overall MA-PDP and PDP enrollment by parent organizations. The data were limited to individuals enrolled in Part D plans offered through Medicare Advantage or as standalone PDPs.

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