CMS releases Medicare Final Rule for 2024 – Proposed CMR criteria changes removed. Key provisions for Adherence and Others Finalized
On April 5, 2023 the Centers for Medicare and Medicaid (CMS) announced its Final Rule for Medicare Advantage and Part D plans for 2024. Among many updates, the Final Rule included modifications to adherence measures, a continued emphasis on health equity and a reduction in the weight of member experience and access measures.
Notably, the Final Rule did not include the provision to standardize MTM program eligibility criteria that was outlined in the Proposed Rule, which was estimated to triple the number of Part D enrollees eligible for MTM services. The Final Rule may feel like a bit of a reprieve for health plans worried about supporting MTM criteria expansion on a fixed budget. However, a pause in the effective date does not necessarily eliminate the need for urgency in developing new MTM strategies.
News of the potential CMR criteria expansion was first heard in December 2022 in the CMS Proposed Rule. In the Final Rule, CMS noted they intend to address the remaining proposals outlined in the Proposed Rule in subsequent rulemaking. Dani Markus, Director of Payer Products and Clinical Programs at Outcomes®, says that while health plans may initially feel the pressure has been lifted, she strongly encourages them to consider the longer-term return opportunity from increased access to high quality MTM services.
“CMS clearly believes in the importance of ensuring Medicare beneficiaries have access to medication therapy management (MTM) services, demonstrated in the proposed rule by CMS recognizing the fact that evidence exists to show MTM services may generate overall medical savings. This aligns with the results we’ve seen from payer studies showing MTM services such as a Comprehensive Medication Review (CMR) can drive additional value,” says Markus. “MTM services can save plans up to $4000 per patient on total cost of care in addition to decreasing hospital readmissions, increasing patient engagement, and improving medication adherence. The pharmacy profession has a clear opportunity to raise awareness to publications that further demonstrate this value to support CMS’s desire to quantify expected savings from its Medicare MTM program,” Markus continues.
Beyond the provision to standardize MTM program eligibility, CMS is moving forward with implementing risk adjustment based on sociodemographic status (SDS) characteristics to the three Part D adherence measures for the 2028 Star Ratings (2026 measurement year) as proposed. The risk adjusted adherence measures will be on the display page for the 2026 and 2027 Star Ratings while the current adherence measures will remain included as triple-weighted Star ratings until the new measures move to Star ratings.
CMS’s continued focus on adherence creates an opportunity for health plans to reimagine their approach to these measures with an increased focus on health equity.
The final rule also solidified the proposal to decrease the weighting of the patient experience/complaints and access measures from a weight of 4 to a weight of 2 beginning with the 2024 measurement year (2026 Star ratings). The rationale for this change was cited by CMS as these measures currently having undue weight in the overall Star ratings program as they account for 58% of the total overall rating for MA-PDs in the 2023 Star ratings. The decrease in weight will lower the impact to 41% with the 2026 Star ratings, which remains significant.
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