Catalyst Corner

This fall a number of IT and medication therapy management (MTM) developments have been released. The Office of the National Coordinator for Health Information Technology (ONC) released its final 10-year nationwide interoperability roadmap to advance the safe and secure exchange of electronic health data on Oct. 6, 2015. The same day, the Department of Health and Human Services (HHS) released the final rule changes to the Stage 1 and Stage 2 meaningful use electronic health record (EHR) incentive program and Stage 3 requirements. In addition, the Centers for Medicare and Medicaid Services (CMS) announced an Enhanced Medication Therapy Management model test for Medicare Part D programs.

I discussed the ONC roadmap draft in the May/June issue of ComputerTalk. The final Version 1.0 is entitled Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap, and it may be downloaded at ONC’s National Coordinator for Health Information Technology Karen B. DeSalvo, M.D., M.P.H., M.Sc., notes that the roadmap is “our vision for how interoperability is necessary for a ‘learning health system’ in which health information flows seamlessly and is available to the right people, at the right place, at the right time. Our vision: to better inform decision making to improve individual health, community health, and population health.” The roadmap outlines a 10-year phased-in plan for achieving interoperability.

Documents to Know

ONC Roadmap

Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap

Final Rules Relating to Meaningful Use


Pharmacists and pharmacies are among the specific stakeholders for whom the roadmap is applicable, as I noted in my previous column. The roadmap says that by 2024, individuals, care providers, communities, and researchers should have an array of interoperable health IT products and services that support continuous learning and improved health: Pharmacists and pharmacies are among the set of care providers noted.

Pharmacy system vendors, as entities that provide for information exchange, should be familiar with the major phases of the roadmap. For 2015 to 2017, the focus of the plan is on sending, receiving, finding, and using priority data to improve care quality and outcomes. By 2018 to 2020, expanded use of systems are called upon to address plug-and-play clinical decision support services. In 2021 to 2024, the plan focuses on achieving nationwide interoperability that enables a learning health system “with the person at the center of a system that can continuously improve care, public health, and science through real-time data access.”

The roadmap lists 16 areas within “Drivers,” “Policy and Technical Components,” and “Outcomes.” Within each area, background is provided along with an assessment of the current state of affairs, in addition to milestones for each three-year period. A supportive payment and regulatory environment is noted as the key driver to achieve the remaining goals. The roadmap calls for CMS to administer 30% of all Medicare payments to providers through alternative payment models intended to bolster interoperability, with that percentage rising to 50% by 2020 and becoming the majority of payment by 2024. This is consistent with HHS announcements in January 2015 on value-based payment goals. The health IT media outlets have been reporting generally favorable reception of the report across the IT community.
The CMS Enhanced MTM model represents a great opportunity for the pharmacy community to engage with the successful plans to assist them in meeting plan goals.
With regard to the final rules relating to meaningful use, they reflect earlier drafts for the most part and may be accessed at the Web address on page 34. Final rules for eligible providers in the EHR incentive program’s Stage 1 and Stage 2 center on reporting periods, changes in the number of objectives providers and hospitals need to meet, and putting a hardship rule in place for providers to report attestations for Stage 2. CMS did not meet calls to postpone Stage 3 meaningful use but did provide an additional 60-day comment period. Stage 3 focuses on interoperability. CMS did say it would use the comments to guide how the meaningful use incentive program gets transitioned into the broader Merit-Based Incentive Payment System (MIPS) that was ushered in through the Medicare Access and CHIP Reauthorization Act of 2015. The MIPS brings together the meaningful use, Physician Quality Reporting System (PQRS), and Value- Based Payment Modifier programs. Most Medicare Part B eligible providers must eventually participate in MIPS or incur penalties. Should the pharmacy community be successful in achieving provider status under Medicare Part B, an analysis of how they would report into the MIPS program would need to be undertaken.

Refining MTM

And the pharmacist’s role in medication therapy management (MTM) continues to be recognized through other means. The new CMS Medicare Part D Enhanced MTM (Enhanced MTM) model test is one of them. The Part D Enhanced Medication Therapy Management model is designed to test changes to the Part D program that would achieve better alignment of PDP sponsor and government financial interests, while also creating incentives for robust investment and innovation in better MTM targeting and interventions. The model will test ways of optimizing medication use and improving care coordination among beneficiaries in order to find effective ways to attain MTM program objectives. Stand-alone PDPs are being given flexibility to design enhanced MTM programs that include interventions beyond the traditional approach.

CMS is trying to remove disincentives for plans to invest in their MTM programs. Key elements of the model include:

  • Additional regulatory flexibilities to allow for more individualized and risk-stratified interventions.

  • A prospective payment for more extensive MTM interventions that will be “outside” of a plan’s annual Part D bid.

  • A performance payment, in the form of an increased direct premium subsidy, for plans that successfully reduce fee-for-service expenditures and fulfill quality and other data reporting requirements through this model.

CMS says in the announcement that if the model is successful, it “will result in stand-alone individual market basic PDP sponsors and CMS learning how to ‘rightsize’ the investment in MTM services and identify and implement innovative strategies to optimize medication use, improve care coordination, and strengthen system linkages.”

The agency will launch testing in five Part D regions beginning in 2017 and running through 2023 (see list in box at below).


Part D Regions

Those regions where CMS will launch testing from 2017–2023:
• Region 7 (Virginia)
• Region 11 (Florida)
• Region 21 (Louisiana)
• Region 25 (Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota, Wyoming)
• Region 28 (Arizona) 

CMS noted that a key element will be a “prospective payment to support more extensive MTM interventions that will be outside of a plan’s annual Part D bid.” Now, the Medicare Part D plan sponsors must account for MTM services as an administrative cost in the bid. The new per-member, per-month prospective payment incentive will be based upon a plan’s cost assumptions in the CMS-approved plan and will be paid across all the Part D plan’s beneficiaries, not just those enrolled in enhanced services. In addition, CMS will offer a performance-based incentive payment in return for a minimum reduction in Medicare Part A and Part B costs of care and successful data and quality reporting. The incentive will be set at a fixed $2.00 per-member amount and will be in the form of an increase in the government contribution to the plan premium.

Payment timing would be similar to the lag in the effect of the Part C and Part D star ratings on Medicare Advantage quality bonus payments. For example, performance results in model year 2017 will translate into a performance-based payment in 2019. In the announcement, CMS says it will develop new MTM-related data and metric collection requirements for both monitoring and evaluation purposes. The uniform set of data elements to be collected will include data on specific beneficiary-level interventions and outcomes using Systematized Nomenclature of Medicine (SNOMED) codes whenever practicable. The quality indicators will be developed based upon clinical significance and a clear link to improved outcomes. A contractor will be engaged to develop detailed data collection and validation specifications by mid-2016. CMS notes that they will consult with quality subject matter experts and external MTM quality stakeholders and that potential quality indicators may include the Pharmacy Quality Alliance (PQA) and the Joint Commission of Pharmacy Practitioners (JCPP) metrics.

The model design will include individualized MTM strategies that could enhance the pharmacist’s role. CMS identifies numerous examples in the model announcement, such as using team-based care delivery models, identifying at-risk beneficiaries and referring them for MTM services, and compensating for providing targeted counseling, among others. Any financial compensation to pharmacists under this model would be provided by the participating prescription drug plan (PDP) or contracted vendors, according to CMS — the same as is currently done.

The CMS Enhanced MTM model represents a great opportunity for the pharmacy community to engage with the successful plans to assist them in meeting plan goals. Applications are expected to be due near yearend 2015 or early 2016. I encourage pharmacy system vendors to download the announcement and track the progress of successful applicants, as their enhanced service success may point to new service pathways for their users. The full announcement may be accessed at CT

Marsha K. Millonig, R.Ph., M.B.A., is president of Catalyst Enterprises in Eagan, Minn. The firm provides consulting, research, and writing services to help healthcare industry players provide services more efficiently and implement new services for future growth. The author can be reached at mmillonig@