By Diana Frid, PharmD
The Centers for Medicare and Medicaid Services (CMS) have introduced significant updates to Medication Therapy Management (MTM) requirements, reshaping the landscape for Medicare plans, pharmacists, providers, and patients. These changes primarily impact patient eligibility and the delivery of Comprehensive Medication Reviews (CMRs). While they will not immediately affect Star Ratings, they set the stage for expanded access, enhanced patient engagement, and strengthened collaboration between pharmacists and providers.. Plans must be prepared for the measure’s anticipated return to the Star Ratings and ready to implement these changes by 2027 to align with the 2029 Star Ratings.
Updated CMR Requirements
The revised CMR requirements signal a shift toward more structured and inclusive patient care. Lowering the cost threshold and broadening the inclusion of Part D medications will significantly increase the number of Medicare beneficiaries eligible for MTM services. CMS projects that MTM participation will rise from 7% to 13%. Additionally, CMRs must now be conducted through direct patient interaction, with CMS specifying standardized methods for delivering findings to providers to ensure more meaningful engagement and improved care coordination.
Summary of Key Changes
- Lower Cost Threshold: The annual Part D drug cost threshold decreased from $5,330 to $1,623, expanding eligibility.
- Expanded Drug Inclusion: All maintenance medications covered under Part D are now included, rather than being limited to a specific drug list.
- Expanded Core Chronic Conditions: HIV is now included among the core chronic diseases considered in targeting criteria.
- Real-Time CMRs: CMRs must be conducted
- Standardized Summaries: Patients (or their caregivers) must receive a written CMR summary in the CMS-standardized format, delivered in person, by mail, or electronically.
- Provider Collaboration: Pharmacists must share CMR findings directly with prescribers, in a structured way reinforcing a more integrated approach to patient care.
The Path Forward: Personalized Medication Safety
These updates represent a major step forward. However, there are still opportunities to further align MTM with the value-based care goals of improved outcomes and reduced costs. Although CMS currently evaluates MTM programs based on process measures—such as CMR completion rates—there is increasing recognition of the need to assess their actual impact on patient outcomes and cost reduction. In fact, research suggests that some non-comprehensive medication reviews may be more cost-effective in preventing adverse drug events (ADEs) than traditional CMRs.
Discussions within the healthcare community emphasize performance-driven and patient-centered care. Experts are advocating for new quality measures that focus on:
- Patient-Reported Outcomes: Tracking improvements in medication knowledge and self-management capabilities rather than just completion rates.
- Adverse Drug Event Prevention: Evaluating how effectively MTM programs reduce medication-related harm.
- Patient Satisfaction and Engagement: Incorporating patient feedback into quality assessments to ensure CMRs truly benefit those they are designed to help.
Studies exploring patient experiences with CMRs have identified areas for improvement, reinforcing the need to align MTM evaluations with real-world patient benefits. While CMS has yet to implement outcome-based measures for CMR effectiveness, ongoing research and industry discussions suggest a future shift toward such evaluations. This evolution would bring MTM program assessments in line with broader healthcare priorities, including improved clinical outcomes, patient safety, and enhanced quality of care.
As healthcare continues moving toward a value-based framework, MTM programs must evolve beyond completion metrics to demonstrate their true impact on patient health. GalenusRx is ahead of the curve, going beyond traditional MTMs/CMRs to personalized medication safety reviews that optimize regimens through pharmacist-provider collaboration. These interventions can improve patient outcomes while reducing total cost of care. As Medicare plans prepare for 2029 Star Ratings, they should be looking for ways to prevent ADEs including falls, ER visits, hospitalizations, co-morbidities, and even premature death.
The evolving MTM landscape presents a pivotal opportunity for healthcare organizations to redefine medication management strategies. By embracing real-time pharmacist interventions, strengthening provider collaboration, and prioritizing patient-reported outcomes, plans can maximize the clinical and financial benefits of medication interventions. With regulatory shifts on the horizon, now is the time to implement proactive, evidence-based solutions that ensure both compliance and superior patient care. GalenusRx stands ready to support organizations in navigating this transformation, delivering innovative, patient-focused medication safety strategies that drive meaningful results.
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Castora-Binkley M, Hines L, Vaffis S, et al. It is time for a new comprehensive medication review quality measure. J Manag Care Spec Pharm. 2023;29(6):680-684. doi:10.18553/jmcp.2023.29.6.680
Castora-Binkley M, Selvarajah S, Felix M, et al. Patient perceptions of their experience with comprehensive medication reviews: A framework for continued quality improvement. J Manag Care Spec Pharm. 2024;30(12):1385-1394. doi:10.18553/jmcp.2024.30.12.1385.
