To Reduce Medicare Costs, Expand Medication Therapy Management Eligibility

Aimee Simone, Assistant Editor

A new study adds to the growing body of evidence that suggests increasing medication adherence can improve patient outcomes and reduce health care costs . The study , published in the July 2013 issue of Health Affairs, assesses the potential costs savings to Medicare from increased medication adherence and evaluates current eligibility criteria for medication therapy management (MTM) services in terms of their ability to select patients at the highest risk of non-adherence.All prescription drug plans under Medicare Part D are required to offer MTM services to patients with high annual drug spending and multiple chronic conditions. Some plans offer MTM services to all beneficiaries, but most offer them to less than 10% of their patients. For the study, the researchers analyzed a large sample of Part D beneficiaries to determine whether the small portion of patients currently receiving MTM services are those who need them most.The researchers collected data from a random sample of patients with diabetes, heart failure, or chronic obstructive pulmonary disease who were continuously enrolled in Medicare Parts A, B, and D from 2006 to 2008. After tracking medication adherence patterns for 3 years, the researchers categorized patients as regular users of a given drug (those who took the medication for each of the 3 years) or episodic users (those who stopped taking the medication for at least a year). The researchers then identified patients eligible for MTM based on the criteria most commonly used by plans in 2011. Finally, monthly spending on Medicare Parts A and B was calculated for patients in each adherence category, condition, and intervention eligibility group.Patients who achieved high levels of adherence were most likely to be regular medication users and were least expensive in terms of care covered by Medicare Parts A and B. The average monthly cost for constantly adherent patients was 29% to 49% lower than for those who were moderately adherent. Episodic medication users were the most expensive beneficiaries. Regular medication use was common among diabetes and heart failure patients, and 30% of patients with these conditions were highly adherent. Patients with chronic obstructive pulmonary disease, by contrast, were more likely to be episodic users, and only 12.3% reached high levels of consistent adherence. Beneficiaries with poor adherence cost from $49 to $840 more per month than their highly adherent peers.The researchers also found that costs were 56% higher among diabetes patients who qualified for MTM and 70% higher among heart failure patients who qualified for MTM compared with those who did not qualify. However, these findings were not consistent among all patient groups. Most heart failure patients who did not meet the requirements for MTM, for example, had higher adherence-related costs than patients with chronic obstructive pulmonary disease who met the requirements.To reduce adherence-related health costs and improve patient outcomes, the researchers suggest that eligibility for MTM be expanded to include beneficiaries with low adherence levels and high Medicare costs. “We believe that potential costs averted should be considered as a criterion for targeting [MTM] interventions and that attention therefore should be given to beneficiaries now excluded from review who display suboptimal adherence patterns associated with the highest Medicare costs,” the researchers write.