AH043 - Pharmacy Benefits 101: DMP & MTM, Explained, with Nash Albadarin, PharmD

Transcript

Lightly edited for clarity.

[00:27] Justin Venneri: Hello and thank you for listening to this episode of the Astonishing Healthcare Podcast. This is Justin Venneri, your host and Director of Communications at Capital Rx. And in the studio with me today is Nash Albadarin, a Senior Clinical Program Manager and pharmacist on our team who is responsible for programs including the Drug Management Program and Medication Therapy Management. We've got some updates to discuss that we'll build on the other content on these programs, and I'll link that for reference in the show notes. But let's just get right into it. Nash, thanks for joining me in the studio today.

[00:57] Nash Albadarin, PharmD: Thank you so much, Justin. I appreciate being on the podcast.

[01:00] Justin Venneri: Let's start off with your background. What was your path to Capital Rx like? And tell us a bit about your role and responsibilities here managing these programs.

[01:08] Nash Albadarin, PharmD: Yeah, absolutely. So I'm originally from Kansas City. I did my pharmacy schooling out at Drake University, which is in Des Moines, Iowa. I completed my pharmacy schooling, got my business degree, and then decided to go down the path and complete my managed care residency. And I did that at Outcomes MTM, which is really what fueled my passion for MTM at that time, and still today. I've been working in managed care and in PBM for about eight years now.  

Much of my experience has been in the pharmacy benefit management world. And when I started, I did a little bit of everything, you know, like formulary management, PA, drug rebates, just to try and really better understand the various parts of PBM operations.  

For about five years now, I've been really focused on developing and managing clinical programs at Capital Rx. I've been doing this for two years now and manage, like you mentioned, our drug management program, MTM, and others as well. And I'm focused on the government sector, so Medicare and Medicaid and developing programs for them.

[01:57] Justin Venneri: Got it. DMP and MTM, or so the acronyms are, can you give us the basics, the high level on these programs? What are they?

[02:05] Nash Albadarin, PharmD: Yeah, yeah, absolutely. So Drug Management Program is our DMP program, and we also have medication therapy management, MTM.

Now in terms of MTM, this is really a service that's designed to optimize therapeutic outcomes for patients. We focus on improving medication use. We're trying to reduce adverse drug events or side effects and improve their adherence. MTM is a CMS-required program for Part D sponsors, but there is utility outside of that. So our goal really with MTM is we're trying to target patients that have multiple chronic conditions who are taking multiple meds and that exceed a certain specified drug cost threshold or drug spend basically. So we're really trying to target like the highest risk members with MTM. And the goal ultimately is that we're trying to empower them to reach their goals. And we do this through an annual comprehensive medication review and targeted medication reviews that resolve adherence issues, gaps in care, drug interactions.  

The CMR really is the critical part of MTM. So that comprehensive medication review, basically it's an intervention between a pharmacist or a healthcare provider. What we're trying to do is review all the patients' medications that they're taking, including prescriptions, over-the-counter drugs, supplements, vitamins. So we reconcile everything, we try to identify if there are any issues like duplicate therapies that you're on, any drug interactions between two drugs that are critical that we need to resolve any issues with your adherence. You know, how can we make it easier for you to be adherent to your medications? These are the goals of MTM that we're trying to accomplish, and for DMP, really where DMP kind of differs is that this is also a CMS-required program. So that's a similarity there. Right? So it's, it's Part D required, but its design is different. So it's designed really to look at addressing prescription drug misuse and abuse, particularly with like opioids and frequently abused drugs and other high-risk meds.  

DMP - Drug Management program - this really is looking to identify these members who are at risk for this opioid overutilization or overuse or using multiple prescribers or multiple pharmacies. If you guys have heard of like the doctor shopping, that's kind of what that's referring to, of going to different doctors to try and get these prescriptions. So we're trying to combat that.

[03:59] Justin Venneri: Okay, that makes sense. If I recall correctly from episode five with Jay Tran, PharmD, MTM is growing or the population is expected to grow, so that more Part D members are covered by the program or service. Are there any updates there for 2025 worth noting?

Related Content

• Pharmacy Benefits 101: What’s the Drug Management Program (DMP)?‍
• AH005 - Star Ratings, MTM, & CMS Translation Requirements with Jay Tran, PharmD
• ‍Pharmacy Benefits 101: Medicare Star Ratings
• AH035 - Pharmacy Benefits 101: Clinical Programs, with Bonnie Hui-Callahan, PharmD

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[04:14] Nash Albadarin, PharmD: Yeah, absolutely. So I think since speaking to Jay in that podcast, there have been some changes. So the final rule has been finalized. Right. So CMS did release their final rule on April 4th of this year, and it detailed all the updates of the criteria that are going to be utilized for next year, for January 1, 2025.  

And so what this means is that they finalized some of the changes, and some of the key factors they didn't. So we'll get through that. But ultimately, what we're estimating right now is that the number of MTM enrollees, based off the final rule, is expected to increase member enrollment from 7 to 13%. So not as significant or drastic as we initially thought, based off of the recommended criteria, which CMS was estimating like a two to three times increase in the number of MTM enrollees. So ultimately, what they decided to move forward with is that plan sponsors must now include all core chronic disease states in their targeting rather than a subset of these disease states. So, yeah, the final rule that CMS released on April 4 actually detailed out the requirements and changes for next year, which will take effect January 1, 2025.  

Now, what they're estimating based off of the final rule is that 7 to 13% increase in MTM members that will be enrolled in the program. This is less than initially was expected. Based off what they proposed, they were expecting potentially like two to three times an increase in MTM member enrollees. But based off what was actually in the final rule, that increase should only be like 7 to 13%.

[05:38] Justin Venneri: Okay.

[05:39] Nash Albadarin, PharmD: And it's because they didn't adopt one of the recommended changes that we'll talk through here. But before it was like a subset that you could pick from. But now they're saying that all core chronic disease states have to be included in your eligibility targeting. And they also did include a new one for HIV. So that's part of the core required disease states to cover.  

In addition to that, they did lower the drug cost spend threshold. So the amount of spend that a member has to have on their Part D drugs to qualify for this program, they lowered that about a fourth of what it currently is. So it's now with an average cost of eight drugs, which is $1,623 is what they're putting that threshold at. So it is a lot lower. So we're expecting more people to qualify now because we've dropped that threshold.  

The last thing that they adopted was that they're including all Part D maintenance drugs when calculating the number of drugs that a member's taking. And I will note this is one thing that they did not move forward with is the fact that one of the recommended changes was to decrease the max number of Part D drugs that a member needs to qualify from eight to five. They did not move forward with this. And so doing so would have increased the membership quite a lot for MTM, but they did not move forward with reducing the number of Part D drugs that you need to qualify from 8 to 5.

[06:44] Justin Venneri: That makes sense. So it's why the 7 to 13% versus 7 to well over 14% of the population. Right, because that 3 drug threshold difference makes a big difference, right?

[06:56] Nash Albadarin, PharmD: That's exactly it. Yeah. The initial estimates were like, we're expecting two times, three times the number of MTM members to be enrolled. But because of the. That rule that they didn't adopt at the end there, it should only be a step to 13%.  

And one other thing, the most significant change here for next year is that because of the finalized criteria and the changes that CMS made, they were significant enough and substantial enough that CMS is going to be moving the CMR completion rate Star measure to a display measure for two years. And so something really notable, it is expected that this measure will return as a star rating in 2027 measurement year for the 2029 Star Ratings.

[07:32] Justin Venneri: Okay, got it. And there's been a lot of press for years around opioids and being careful with their use, identifying opportunities to help when there may be a risk of misuse or abuse. That's why DMP started, right?

[07:45] Nash Albadarin, PharmD: Yeah, no, you're absolutely right. So the drug management program, it was really largely developed in response to the opioid crisis and the growing concern for the misuse or overuse of these poor medications. The rise in opioid addiction and overdose deaths that we've heard about really has brought urgent and critical attention to the need for better control around these prescription opioids.  

You know, again, specifically, the rise in addiction and overdose deaths related to these prescription opioids, as well as over-prescribing and inappropriate use of these medications, has shed a lot of light on the chronic pain management world. So as a result of all that, CMS introduced the drug management program at the start of 2022 and required all Part D sponsors to have a DMP program as part of their series of efforts really to combat these issues.

[08:28] Justin Venneri: And I think not all, but some plans had DMP programs or something like it in place right prior to this.

[08:33] Nash Albadarin, PharmD: Yeah, there's been a lot of iterations and versions of this. Really what CMS tried to do was standardize this and formalize it so that it was required for all Part D sponsors. Now, some of them did have programs that were similar to this, but really the CMS wanted to kind of lay a foundation down and standardize this across the board.

[08:49] Justin Venneri: Okay. And so how does the DMP program work?

[08:51] Nash Albadarin, PharmD: That's a great question. So again, with a lot of our CMS programs, it's a pretty standardized process. So, I’ll kind of walk through generally what a DMP program does.  

It starts off by identifying the members who may be at risk for opioid overutilization. So we call them potentially at-risk beneficiaries or PARBs. Typically what you're trying to do is identify these potentially at-risk members and enroll them in your DMP program, wherein once they're enrolled, you do like a clinical case review and case management where you'll look through the member's claims history to see if they have overuse, any concerns. You will want to reach out to the prescribers and pharmacies and just really validate and get an understanding of the indications for what they're being used for. This step really does help us understand the member's situation and gather insights from their providers to confirm if there is like a real risk of overutilization.  

Once you've done all that, then we go into our notifications and interventions stage of DMP. So if we do feel that there is an overwhelming risk for this member, that's where we can implement our interventions. Where in the DMP world those are typically going to be considered lock-ins or restrictions. So lock-ins are a common term in DMP. Ultimately it means restricting a member to only being able to fill prescriptions from a specific prescriber or fill out a specific pharmacy or filling specific medications. So really trying to not really limit their medication use and make it difficult for them. We're really just trying to provide a little more oversight for these members that are at risk for this overuse.

And then ultimately, like I mentioned, once you set those restrictions in place, that's where your limitations come in. The point of sale edits to let the pharmacies know that hey, this person's locked in, you probably shouldn't be filling for them if they're locked in somewhere else. So again, each of these steps in the DMP program, they're really designed to support the safe medication use and to help members manage their opioid prescriptions responsibly, not to try and make it difficult for them. Overly difficult. You know, the entire process really is fairly smooth and efficient. With the right technologies, of course, it can be very smooth and efficient. This entire process.  

[10:44] Justin Venneri: That's a perfect segue to my next question for you, which is how does Judi, our adjudication platform, factor into the equation here. Is there a difference in leveraging modern technology for these programs, or are there any new or particularly interesting platform features on Judi that you can talk about?

[11:01] Nash Albadarin, PharmD: Yeah, so I will say Judi plays like a central role in our drug management program. It is fundamental to it. It makes the whole process efficient, effective, and very, very user-friendly.  

From the beginning, you know, when we identify members, we've like fully streamlined the case management process because our DMP program is fully integrated in Judi, which means like all DMP activities, so identifying members, conducting the clinical reviews, managing outreach, all of that happens seamlessly within a single platform.  

A really cool aspect of what Judi can do is its ability to analyze data and flag potential at-risk beneficiaries. So obviously, you know, we have the ability to ingest the CMS acumen files to identify these at-risk members, but we also run our own logic to try and capture anyone else that may have fallen through and target them for this case management as well.  

Judi is really, really cool as well because we allow and provide the ability to see like a holistic view of the members. So we pull in the member's claims, we pull in any prescriber outreach efforts. All of that's documented in there, any exemptions. So if they have cancer, are in hospice, all of that we can document. And it's all in one whole picture in Judi. So really provides like the pharmacists and the case managers a complete view and real-time member history to help with your case management, make a well-informed, timely decision.  

I think the other really powerful feature in Judi is the ability to apply lock-in restrictions at the point of care all within the app and tool. So like when a lock-in is determined, you can go into our tool, implement a coverage limitation or lock-in that restricts the member, like I mentioned, to a specific prescriber, pharmacy, or to a specific drug. All of this is done in real-time again, so we can manage that fully within the tool.  

And one of the cool things, honestly, that I really like is the automation of the CMS-required reporting, the OMS reporting. So typically CMS gives you an Excel template that you have to fill out manually. We've automated that fully to really make the user's life easy. So you can just drop the files in there. It fully populates. It's really, really cool and really slick. So I love that feature, actually.

[12:56] Justin Venneri: No, it sounds solid. And by user, you mean a health plan executive, somebody responsible for the program on the plan side? Right. Or we can help with that, of course.

[13:04] Nash Albadarin, PharmD: Yeah, absolutely. So our DMP program that we've built out can be full service. So we can handle it end to end, do all the work and everything, do all the case management. We also have the ability more recently that we've added to allow that self-service functionality. So if you have your own resources, we have the solution here. The DMP program and the software that you can just fully leverage so you can go in there, use the case management functions, do all the reporting yourself. So very slick design.

[13:29] Justin Venneri: And this seems like another example. I mean we've had a couple on the show, but there's plenty in real life. You know, these government programs, there could be applications or utility on the commercial side. Is that in the works? Can you share anything on that or are there variations out there are things that employer plan sponsors should consider if they're listening to this episode?

[13:49] Nash Albadarin, PharmD: That's a really great question. So there is a lot of utility across different populations and lines of business. Now if we look at DMP for example, there are similar programs in Medicaid that are deployed. They call them state restricted recipient programs, very similar to DMP, but Medicaid plans have their own. Now they may vary from state to state because they're regulated at the state level. So in terms of like the way they target members and how they might do their interventions, they may differ slightly, but they're similar in a nutshell to a DMP program.  

Now the cool thing again with our DMP tool is that we can support those state-level Medicaid restricted recipient programs too. So that's definitely a functionality. So within the Medicaid line of business, there's utility there for DMP and again in general for DMP, you know, opioid misuse and use of high-risk meds are not unique to Medicare members. Implementing a DMP program really can help plan sponsors just oversight and control over their members in terms of their opioid and high-risk medication use. Trying to really mitigate these risks associated with opioid dependence and overall just improving safety for your population. It's not a Medicare-specific issue, if you will.  

MTM is very similar as well, I will say. So MTM, while it's Medicare-required, really does have a lot of utility. We know that for chronic conditions and complex medication regimens are not just in the Medicare population. Many members, you know, face issues with high prescription drug costs, taking multiple medications, struggling with adherence. All of these increase the risk for medication-related complications that are not unique to Medicare. Right. So I think there's a lot of utility there for MTM as well as DMP and other lines of business.  

Now the nice thing about these programs, both of them, is that they're really highly customizable, so plans outside of Medicare can kind of flex and make them work for their specific and unique population and scenario. So there's definitely a lot of utility there. And leveraging MTM and DMP in the commercial sector really does just promote safer medication use, improve your overall like medication health outcomes and ultimately it helps control costs and enhance the wellbeing and productivity of your members.

[15:41] Justin Venneri: All right, and here we are at the end. Nash, thanks for taking the time today and sharing all this helpful background info on these programs and ideas about how they can be used. The most astonishing thing you've seen that you can share, of course, as it relates to our discussion today. What would you say that is?

[15:57] Nash Albadarin, PharmD: You know, I've been in this industry for over eight years now, and I think being at Capital Rx and working with Judi, it's kind of a game changer. It's really refreshing and it's the mentality of, you know, if you can dream it, we can build it.

DMP Tool is just one example of many I think that we've built here that I've been blown away by, that I haven't seen done in my previous roles. Really with Judi, there's like full flexibility to implement any clinical program we envisioned. The way we leverage data and technology through our platform is remarkable. It allows us really to connect the data rapidly and promote kind of access to these automated processes and streamline our workflows to deliver these top-tier services. It really does stand out like as an advanced adjudication platform.

[16:41] Justin Venneri: Cool. Nash, thanks for taking the time. Hope to have you back on as things evolve and we launch more programs and your responsibilities grow.

[16:49] Nash Albadarin, PharmD: I appreciate it. Thank you.

[16:51] Justin Venneri: All right, have a great day.

[16:52] Nash Albadarin, PharmD: You too.

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