The current model for medication therapy management (MTM), under Medicare Part D, is based on a set of minimum performance standards that all participating plans must meet to qualify for payment. However this model incentivizes plans to offer a minimum set of services without accurately identifying at-risk patients.
To counter this shortcoming, Enhanced Medication Therapy Management (EMTM) was instituted in 2017 in a small subset of plans and regions. EMTM is designed to target some of the clinical and financial issues resulting from the original model.
Encouraging results for EMTM
EMTM’s focus areas enable performance incentives for participating prescription drug plans. These incentives encourage targeted, risk-stratified patient interventions that reduce Medicare costs. In its second year, the EMTM model saved participating plans $684 million (3.55%) across 1.7 million beneficiaries. Performance incentives were offered to plans based on overall spending reductions. According to CMS, 14 of the 22 plans achieved greater than 2% reductions in spending, six plans saw reductions less than 2%, and only two plans saw increases in spending.
The data required for risk stratification includes patient demographics, utilization, diagnoses, prescription fill information, co-morbidities and historic costs. Payers add these data points to their proprietary data sets to predict the best intervention strategy for each patient.
Get ready for the EMTM model to expand
After 2022 CMS will determine if EMTM incentives will be offered more broadly. Payers who want to take advantage of this opportunity need to effectively utilize risk-stratification data.
The role of artificial intelligence
AllazoHealth’s AI engine can analyze historical patterns for individuals with similar patient characteristics. AI can identify the relative risk of plan beneficiaries and recommend personalized interventions that maximize medication adherence. Effective targeting of patient interventions will decrease overall expenditures.
Once CMS expands the EMTM model, the payers that perform more effective patient interventions will benefit from the new incentives.