Abstract
BACKGROUND:
Low rates of beneficiary participation in medication therapy management (MTM) programs may be partly due to lack of awareness and understanding of the MTM program. To address this, the Centers for Medicare & Medicaid Services (CMS) requires Medicare Part D sponsors to provide online information about their MTM programs. An early study conducted in 2014 found low compliance rates, with only 59.5% of a small convenience sample of Part D plan contract websites compliant with CMS requirements. The current study provides a more recent evaluation of compliance with website requirements using a random sample of Part D plan contracts.
OBJECTIVES:
To (a) evaluate Part D sponsors’ compliance with MTM program website elements that are required and suggested by CMS and (b) investigate the use of elements recommended by the National Institute on Aging (NIA) for websites for older adults.
METHODS:
A random sample of 184 Part D plan contract MTM program websites was selected from a list of 624 approved Part D plan contracts for 2016. Duplicate and inaccessible websites were excluded. The remaining websites were reviewed to determine compliance with CMS-required, CMS-suggested, and NIA-recommended elements. Descriptive statistics were reported at the Part D contract level for compliance with individual elements, category elements (CMS-required, CMS-suggested, and NIA-recommended), and overall compliance. Overall compliance by category was also reported by Part D plan type.
RESULTS:
Of the 184 MTM websites that were reviewed, 106 remained after excluding duplicate (n = 67) and inaccessible (n = 11) websites: 81 from Medicare Advantage prescription drug (MAPD) plans, 16 from prescription drug plans (PDPs), and 9 from Medicare-Medicaid plans (MMPs). Overall, 51% of Part D plan contract MTM websites were compliant with all of the 14 CMS-required elements. The only element in the CMS-suggested elements category, “accessibility by clicking through a maximum of two links,” had a compliance rate of 79%. For the NIA-recommended elements category, 46% of the Part D plan contract MTM websites were compliant with the 4 elements.
CONCLUSIONS:
Medicare Part D plan sponsors are providing information about their MTM programs on plan websites. However, only 51% of Part D plan websites are fully compliant with CMS guidance, providing all required elements.
What is already known about this subject
In an online survey of 504 Medicare Part D enrollees published in 2008, 93% were unaware of their plan’s medication therapy management (MTM) program.
In 2013, the Centers for Medicare & Medicaid Services (CMS) began requiring Part D plans to provide online information about their MTM programs, with additional requirements added in 2014 and 2015.
A previous study using a convenience sample of MTM websites (n = 42), found 59.5% of Part D sponsors were compliant with the 2014 CMS guidance for MTM websites.
What this study adds
Of the 106 Part D websites evaluated, 51% and 79% were fully compliant with the 2016 CMS-required and CMS-suggested elements, respectively.
For plans that were not fully compliant with all of the 14 CMS-required elements, 15% were only missing 1 element to be fully compliant, and 8% were only missing 2 elements to be fully compliant.
Compliance rates of CMS-required elements were similar among Medicare Advantage prescription drug plans, Medicare prescription drug plans, and Medicare-Medicaid plans.
Under the Medicare Prescription Drug, Improvement and Modernization Act of 2003, Part D prescription drug benefit plan sponsors must offer a medication therapy management (MTM) program to eligible Medicare Part D beneficiaries.1 Through the MTM program, pharmacists or other qualified providers, such as physicians, nurse practitioners, or registered nurses, interact with eligible beneficiaries and/or their health care providers to ensure that medications are appropriately used to optimize therapeutic outcomes and reduce the risk of adverse events.2 MTM program eligibility is based on the beneficiary’s number of medications (threshold of 2-8 Part D medications); medical conditions (threshold of 2 or 3 specific chronic diseases from a list of diseases including Alzheimer disease, chronic heart failure, diabetes, dyslipidemia, end-stage renal disease, hypertension, respiratory disease, bone disease, and mental health); and anticipated annual drug spend (threshold of $4,044 in 2019).3 Because of the wide range of possible combinations to meet criteria of the Centers for Medicare & Medicaid Services (CMS), eligibility for MTM services varies yearly and by Part D plan contract.4 When beneficiaries meet eligibility requirements, they are automatically enrolled into the Part D plan’s MTM program, which includes an annual comprehensive medication review (CMR) and at least quarterly targeted medication reviews (TMR). A CMR is an interactive, person-to-person or telehealth consultation,3 which includes a thorough review of the beneficiary’s prescription, over-the-counter, and herbal medications. The TMRs are single-medication specific consultations to assess medication use.
Participation rates for enrolled beneficiaries in MTM programs are relatively low. Using data from 2016, the MTM program CMR completion rates for Medicare Advantage prescription drug (MAPD) plans and Medicare prescription drug plans (PDPs) were 61% and 33% in rating year 2018, respectively.5 The low participation rate is believed to be due to multiple factors, one of which is a lack of awareness and understanding about the program. Of 504 Medicare Part D enrollees from California sampled in an online survey, 93% were unaware of their plans’ MTM programs.6 Three other studies (a survey and focus group interviews) also support the lack of awareness about MTM services but note increased interest in MTM services if beneficiaries knew they were eligible, the service was free, and that MTM would help them take their medications.7-9 Participants in one of the focus group studies wanted to learn about MTM services and their eligibility through the internet.7
To encourage Part D sponsors to increase awareness and understanding of their MTM programs, CMS issued guidance in its annual memo on MTM programs for contract year 2014 about including MTM program information on the Part D plan sponsors’ websites.10 Two authors of the current study had previously examined compliance of MTM websites with 5 elements (dedicated MTM web page, web page within 2 clicks, basic information, eligibility information, and access to a personal medication list [PML]) from the 2014 CMS guidance.11 This previous study used a convenience sample (n = 42) and found that only 59.5% of Part D sponsors’ websites were compliant with these 5 elements.
In addition to CMS, other organizations, such as the National Institute on Aging (NIA), provide research-based guidelines for creating websites that are user-friendly for the older adult population.12 The NIA suggests that web designers organize the web information clearly, make the information easy to find, write text that is readable for older adults, and include other media in the web, such as video and animation.
To enhance our understanding of MTM information provided by Part D sponsors on their websites, we randomly selected Part D plan contracts’ MTM program websites and assessed their compliance with CMS-required and CMS-suggested elements, as well as NIA-recommended elements for websites aimed at older adults.12 The current study provides a larger and random sample and a longer duration from when these requirements were first mandated in which to evaluate compliance with MTM website elements.
Methods
Website elements examined from the CMS Contract Year 2016 (CY16) MTM Program Guidance and Submission Instructions,13 published in April 2015, were categorized as either CMS-required or CMS-suggested elements. The CMS-required elements category included 14 mandatory elements from the CMS CY16 MTM program guidance: a dedicated MTM page with information about MTM eligibility, the purpose of MTM, summary of MTM services and how sponsors offer CMR and TMR services, MTM service not a benefit but is free, time commitments for MTM services, how beneficiaries are notified about MTM services, provided MTM service documents including copy of PML, contacted for CMR and TMR, and who to contact for more information. The CMS-suggested elements category contained only 1 element, which was whether the MTM web page was accessible within 2 clicks from the home web page of the Part D sponsor’s main web page.
The NIA-recommended category included 4 elements: the web address listed on the 2016 CMS Part D sponsors list directly linked to the MTM web page, the presence of a search bar on the sponsors’ home web pages, the presence of a search bar on the MTM web page, and the use of the search phrase “medication therapy management” in the search bar on the homepage to find the MTM web page. The NIA-recommended elements were developed according to “Making Your Website Senior Friendly: A Checklist,” specifically “Use single mouse clicks” and “Choose a search engine that uses key words and doesn’t require special characters or knowledge of Boolean terms.”12
Part D plan contract MTM websites were reviewed in summer 2016 to determine whether they contained the CMS-required, CMS-suggested, or NIA-recommended elements. A publicly available list of 624 Part D plan contracts approved for 2016 was obtained from the CMS website.14 A random number generator tool assigned each Part D plan contract a number, which was then ordered numerically. Each Part D plan also had an associated MTM website address. To achieve a sample size of at least 100 Part D plan contract websites, 184 Part D plan contract websites were reviewed to identify unique and accessible Part D plan MTM websites. Duplicate Part D MTM website addresses were excluded to avoid sampling bias, since there may have been systematic differences between Part D plan websites that shared common website addresses compared with those that had a unique Part D plan website address. Part D plan websites not found or inaccessible were also excluded.
Compliance was determined binomially (yes or no) and reported as descriptive statistics at the Part D contract level for each element, each category of elements (CMS-required, CMS-suggested, or NIA-recommended), and overall elements.
The University of Maryland Baltimore Institution Review Board (IRB) determined that this research project met the definition of not human subjects research, so no further IRB oversight of the project was needed.
Results
The review of a random sample of 184 Part D plan contract MTM website addresses found 78 MTM websites that were duplicates (n = 67) or inaccessible/not found (n = 11). Duplicate website addresses may result from different Part D contracts hiring the same vendor to provide their MTM services. As such, the MTM vendor may have a common MTM website. After excluding duplicate and inaccessible websites, the resulting sample included 106 Part D plan contract MTM website addresses belonging to 81 MAPD plans, 16 PDPs, and 9 Medicare-Medicaid plans (MMPs).
The compliance rate of each element within each category (CMS-required, CMS-suggested, and NIA-recommended) is shown in Table 1. In the CMS-required elements category, 8 of the 14 elements had rates of 90% or more of compliance. The lowest compliance rate was found with “time commitments” (67%), “how sponsor will contact beneficiary about TMR” (73%), and “offering services of TMR and CMR” (73%). Overall, 51% of the plan sponsors were compliant with all of the CMS-required elements. In 15% of the Part D plan websites, only 1 element was missing to be fully compliant with CMS-required elements. Eight percent of the plans were missing 2 elements to be fully compliant with CMS-required elements.
TABLE 1.
Part D Plan Compliance with CMS-Required, CMS-Suggested, and NIA-Recommended Elements for MTM Program Websites
| MTM Program Website Elements | Compliance Rate, % (n) | |||
|---|---|---|---|---|
| All Part D Plans (N = 106) | MAPD Plans (n = 81) | PDP Plans (n = 16) | MMP Plans (n = 9) | |
| CMS-required elements | ||||
| Separate section or dedicated web page about MTM program | 96 (102) | 98 (79) | 88 (14) | 100 (9) |
| Part D sponsor’s MTM eligibility requirements | 95 (101) | 96 (78) | 88 (14) | 100 (9) |
| Statement informing beneficiaries who to contact at Part D sponsor for more information | 97 (103) | 98 (79) | 94 (15) | 100 (9) |
| High-level summary of services offered by MTM program | 94 (100) | 95 (77) | 88 (14) | 100 (9) |
| Explanation of the purpose/benefits of MTM | 94 (100) | 95 (77) | 88 (14) | 100 (9) |
| Statement explaining that MTM is a free service for eligible beneficiaries | 94 (100) | 95 (77) | 88 (14) | 100 (9) |
| Statement of how the notification will be sent to the beneficiary | 94 (100) | 95 (77) | 88 (14) | 100 (9) |
| Statement of how sponsors will contact the beneficiary about CMR | 90 (95) | 91 (74) | 81 (13) | 89 (8) |
| Statement of how sponsors will contact the beneficiary about TMR | 73 (77) | 73 (59) | 75 (12) | 67 (6) |
| Statement of how sponsors offering services of CMR and TMR | 73 (77) | 73 (59) | 75 (12) | 67 (6) |
| Statement describing time commitments of medication reviews | 67 (71) | 68 (55) | 69 (11) | 56 (5) |
| Statement of how the sponsor will provide MTM service documents other than personal medication list | 85 (90) | 89 (72) | 75 (12) | 67 (6) |
| Blank copy of personal medication list posted on website | 88 (93) | 89 (72) | 81 (13) | 89 (8) |
| Statement clarifying that these programs are not considered a benefit | 88 (93) | 91 (74) | 63 (10) | 100 (9) |
| CMS-suggested element | ||||
| Accessibility by clicking through a maximum of 2 links | 79 (84) | 78 (63) | 75 (12) | 100 (9) |
| NIA-recommended elements | ||||
| Website address goes directly to MTM pagea | 87 (92) | 85 (69) | 94 (15) | 89 (8) |
| Search bar on homepage | 71 (75) | 74 (60) | 38 (6) | 100 (9) |
| Search bar on MTM page | 64 (68) | 68 (55) | 31 (5) | 89 (8) |
| Search phrase “medication therapy management” | 58 (62) | 60 (49) | 25 (4) | 100 (9) |
aWebsite address for MTM program as listed in the CMS file of 2016 approved Part D contracts.
CMR = comprehensive medication review; CMS = Centers for Medicare & Medicaid Services; MAPD = Medicare Advantage prescription drug plan; MMP = Medicare-Medicaid plan; MTM = medication therapy management; NIA = National Institute on Aging; PDP = prescription drug plan; TMR = targeted medication review.
For the CMS-suggested element, 79% of Part D contract websites made their MTM websites accessible within 2 clicks from the Part D plan’s homepage, including websites providing links to MTM web pages from the first 5 results from the homepage when “medication therapy management” was searched.
Finally, for NIA-recommended elements, most sponsors’ web addresses went directly to their MTM web pages (87%). Search bars were found on the homepage and the MTM page in 71% and 64% of the Part D plan contracts’ websites, respectively. Typing “medication therapy management” in the search box on the MTM sponsors’ homepages brought up links to MTM web pages in the first 5 results in 58% of the Part D websites. For the 4 NIA-recommended elements (link to MTM page, search phrase “medication therapy management,” search bar on homepage, and search bar on MTM page), 46% of the plan sponsors were compliant.
When examining compliance by plan type, 51% of the 81 MAPD plans, 50% of the 16 PDPs, and 56% of the 9 MMPs met all of the CMS-required elements (Figure 1). There was wider variability in compliance rates with the CMS-suggested and NIA-recommended elements among the plan types.
FIGURE 1.
Compliance Rates for MTM Website Elements by Medicare Part D Plan Types
Discussion
Medicare beneficiaries have a limited awareness about MTM services and their eligibility for these services. Information about MTM eligibility and MTM program features is available in the “Medicare & You” handbook (mailed to all beneficiaries annually), the CMS “Medicare Plan Finder” website, and the beneficiary’s Part D plan sponsor’s MTM program website. However, only the Part D plan sponsor’s MTM website will have specific information about the plan’s eligibility criteria, contact information, and MTM services. We evaluated 106 unique Part D plan contract MTM websites and found that only about half of the websites were compliant with all of the CMS-required elements. Another 23% of Part D plans would have been compliant if they had met 1 or 2 additional elements.
The elements with lower compliance rates included TMR-related content. There were 2 elements about how sponsors will contact the beneficiary about MTM services, one for CMR and the other for TMR. These 2 elements allow comparison of compliance rates of 90% for CMR and 73% for TMR. Another element that included CMRs and TMRs within the same element—how sponsors offer services of CMR and TMR—was also 73%. The lower rates of compliance with these elements may be because TMR service is less defined than CMR service, and the implementation of TMR processes vary among Part D plans. While the CMR definition includes an interactive, person-to-person component and focuses on the beneficiary and/or caregiver, TMRs may only engage the prescriber.15 In addition, the CMS star ratings include a measure on CMR completion rates, so more attention has been placed on CMRs.
Beneficiaries use the internet, seek health information from the internet, and are interested in learning about their eligibility for MTM services through the internet.7,16,17 However, even when Part D plans do provide MTM program information on their websites, Medicare beneficiaries may still have challenges with locating the information and understanding the features of the MTM programs.
The Website Evaluation Questionnaire (WEQ) was administered to 10 Medicare beneficiaries after they had reviewed a Part D plan website. Only 30% and 40% agreed with “I consider this website user friendly,” and “I find this website easy to use,” respectively.18 None of the participants strongly agreed with those statements. When reviewing a second Part D plan website, there were more beneficiaries, 60% and 80%, respectively, who agreed or strongly agreed with those statements. The authors of this study suggested that the higher ratings when reviewing the second website may be a result of increased beneficiary comfort with examining a subsequent Part D plan website. However, even after reviewing the second Part D plan website, there were still only 30% of participants who agreed or strongly agreed that the Medicare Part D plan home web page clearly directed them to the MTM website. The beneficiaries commented that they found the search option misleading or produced too many results.
In our study, the element with the lowest compliance rate was finding information about the MTM program after typing the term “medication therapy management” in the search box on the homepage. Only 58% of the Part D plan websites provided a link to the MTM program within the first 5 search results. The results may be more disappointing if beneficiaries or their caregivers type in a less technical term for “MTM.”
While CMS offers guidance for content of MTM program information, the required elements for MTM program website content has not changed since 2015. However, plans can look to the NIA and other trusted sources to improve user friendliness, such as putting key information first, using consistent navigation throughout the site, having menus that open and close on a single click, and minimizing technical terminology.12 A case study showed that redesigned websites for older adults using NIA guidelines and other resources enhanced the usability as determined by a group of older adults.19 Making user friendly Part D MTM program websites would also enhance their usability by caregivers, especially for beneficiaries who are physically or cognitively impaired.
With the wide use of smartphones and tablets, many Part D plans offer health care applications (apps). MTM-eligible beneficiaries may learn and benefit from an MTM app to address the MTM programs’ eligibility criteria, CMR, TMR, contact information, and other information to improve their medication management. However, no published studies evaluating MTM program information on Part D plan contract apps were found.
While providing information about the MTM program online is a step toward increased awareness and understanding of the MTM program, the Center for Medicare & Medicaid Innovation (CMMI) is engaging in other endeavors that may have a far greater effect. In January 2017, approved Part D plans that are part of a test model are determining whether regulatory flexibility can enhance the uptake of, and outcomes resulting from, MTM services.20 In this test model, CMS is encouraging plans to promote awareness of MTM services and provide beneficiaries with incentives to improve MTM participation. An evaluation of participating plans’ MTM websites and other ways they are engaging Medicare beneficiaries to participate in MTM services should be forthcoming.
Limitations
There are some limitations to this study to consider. While there were criteria to assess whether an element was met, there is still subjectivity in the decision. As a check, a pharmacy summer intern also performed a review of these websites, and discrepant decisions were reviewed again. We did not obtain plan size (i.e., number of covered lives), which may have explained lower compliance rates in plans with smaller enrollment due to fewer resources. We did not investigate reasons for noncompliance. Most importantly, a beneficiary may have different perceptions or understanding of the terminology of the MTM web pages and interpret the information, and thus compliance, differently than the investigators.
Conclusions
CMS and Medicare Part D plan contracts are increasing awareness of the MTM program and its features through online websites. Since the first requirements were mandated in 2013, compliance rates from 2014 do not appear to have improved several years later. Full compliance with all of the CMS requirements for MTM program information on Part D plan websites hovers around half of the Part D MTM websites. Future research is needed to examine website usability and the effect of MTM program website elements on CMR completion rates and other medication-related outcomes.
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