One of the objectives of the Patient Protection and Affordable Care Act (2010) is to provide access to educational resources to improve health-related beneficiary decision making. Various initiatives relating to Medicare Part D Medication Therapy Management (MTM) services have been undertaken to achieve this objective. For example, the Centers for Medicare & Medicaid Services (CMS) included additional information in the 2013 Medicare and You Handbook to educate beneficiaries as well as their caregivers on Medicare Part D MTM programs and the Standardized Format for summarizing a comprehensive medication review (CMR). In addition to printed resources, there is interest in providing health-related information online. Internet use is gaining ground among adults 65 and older. In 2015, 58% reported using the internet, compared with only 14% in 2000, 28% in 2005, and 43% in 2010 (Perrin & Duggan, 2015). Among adult older internet users, 58% have sought health information online (Fox & Duggan, 2013).
With the growing use of the internet, CMS recognized the value of providing information online. CMS takes responsibility for providing certain information about Part D plan options on the webpage, Medicare Plan Finder. CMS has also provided guidance through the annual Call Letters to Part D plans for information that should be posted on their websites. The Call Letter provides requirements and recommendations for various aspects of Medicare prescription drug plans, including Medicare Advantage Prescription Drug Plans (MA-PDs), MA-PD Special Needs Plans (MA-PD SNPs), Medicare–Medicaid Plans (MMPs), and Prescription Drug Plans (PDPs). Call Letters are finalized and released in April of the year prior to when they go into effect, allowing contract sponsors time to prepare their bids and implement necessary changes to align with any new guidance. In addition, CMS publishes memoranda to provide guidance to Part D sponsors regarding MTM Program guidance and submission instruments. On April 10, 2012, the CMS (2012) memorandum for covered year (CY) 2013 MTM Program Guidance and Submission Instructions offered guidance about MTM program information on the Part D sponsor's website. The website was expected to contain information about the plan's MTM eligibility requirements, who to contact for more information, and a high-level summary of services offered as part of the MTM program. Sponsors were also encouraged to provide access to a blank Personal Medication List (PML) (i.e., post a copy or provide information about how to obtain). The PML is a component of the Standardized Format document summarizing a CMR. The following year, on April 5, 2013, CMS issued another memorandum that expanded the guidance about MTM program information provided on Medicare prescription drug plan websites (Table 1) (CMS, 2013). The guidance for CY2014 included additional expectations from CY2013 for MTM program information, such as a webpage dedicated to MTM with all of the requirements from CY2013, access to a PML, and a description of how a beneficiary is notified of MTM program eligibility. CMS also provided a suggestion that, if possible, the dedicated webpage should be accessible by two or fewer clicks from the sponsor's Medicare drug plan website.
Guidance from Centers for Medicare & Medicaid Services (CMS) for Medication Therapy Management (MTM) Program Websites for Covered Year 2014
In December 2012, prior to the effective date to implement the recommended CY2013 website content, a preliminary review of contract sponsor websites (n = 28) was conducted by the current authors. Information describing MTM services and eligibility were each included in 46.4% of websites, albeit not all the same websites. Only 17.9% provided access to a blank copy of a PML. The same proportion of websites, 17.9%, required two or fewer clicks to access the MTM webpage. Despite the fact that search bars aid beneficiaries in navigating a website (National Institute on Aging [NIA], 2016), only one half of contract websites contained search bars to aid beneficiaries in locating MTM program information. To follow this, in January 2014, an evaluation of a sample of Medicare Part D contract sponsors' websites was conducted. The primary objective was to examine the level of compliance with CY2014 CMS guidance for Medicare prescription drug contract MTM websites. The work evaluating the Call Letter guidance for MTM information on Part D contract websites was conducted per a CMS Contract.
Contracts included in the evaluation were selected from those listed on the “2014 Plan MTM Program Eligibility Information” document, available as a download from the CMS webpage (CMS, 2014). Based on grouping the contracts by type (e.g., PDP, MA-PD, MA-PD-SNP/MMP) and geographic region, a convenience sample was obtained to identify a 7:6:1 distribution of contract types, respectively, with at least one contract in each geographic region. Geographic region was defined by the coverage area of the plan, which was then standardized according to the U.S. Census Bureau's (n.d.) regions and divisions. Contracts with coverage areas not included in the Census Bureau's regions and divisions were designated according to the most appropriate region (i.e., one contract located in Puerto Rico was designated in the South region). The “2014 Plan MTM Program Eligibility Information” file also listed a webpage address for each contract's MTM program. This web address was used to find the MTM program information.
The sample contract websites were evaluated to determine compliance with CMS CY2014 guidance for information about the MTM program on the sponsor's website. The guidance was categorized into five elements: (a) dedicated webpage, (b) basic information about the MTM program, (c) eligibility requirements about the MTM program, (d) access to a PML, and (e) ease of access of dedicated webpage or MTM information. The element of a dedicated webpage was met if most information on the webpage related to the MTM program. In addition, a linked text document or portable document format (PDF) could serve as a dedicated webpage. The element of basic information contained two components: a high-level summary of MTM services offered and who to contact for more information about the MTM program. If the website included a description about MTM, this was considered sufficient to have met the criterion for high-level summary. A name and phone number were considered sufficient for contact information. Both components had to be met to be compliant with the basic information element. For the element of MTM eligibility requirements, a description of any length and detail that discussed eligibility requirements was sufficient. If the website provided a blank copy of the PML or information on how to access one, that met the element for access to a PML. Lastly, if the MTM webpage, or for those without a dedicated webpage, the first page that contained MTM program information, was accessible by two or fewer clicks from the contract's home webpage, then that element was met. The home page for the contract's website was found by entering the name of the contract into an internet search engine (e.g., Google), along with the keyword “Medicare.” The contract's homepage was found by clicking the contract sponsor logo at the top of the webpage (if a homepage was embedded in it) or by clicking “home” if any such link could be found on the page.
Although not a requirement in the CMS CY2014 guidance, the presence of a search bar and ability to find a contract's MTM page using “medication therapy management” as the search term were also assessed in the current investigation. If there was a search bar on the home screen of the website, the keyword “medication therapy management” was used to identify relevant information pertaining to MTM services. If no search bar was available, links were selected related to Part D contracts, member services, benefits, and formularies. Terms used to identify whether there was a PML included: “PML,” “personal medication,” “personal medication list,” “MAP,” and “medication action plan.” A maximum of 20 minutes was spent on each website to locate the relevant information.
Compliance with five elements of the CY2014 guidance, the presence of a search bar, and whether the MTM page could be located using the search term “medication therapy management,” was determined binomially (i.e., yes or no). Compliance rates were then calculated as percentages for each of the elements among the whole sample, and by plan type.
At the time this study was performed, there were 685 unique Medicare Part D contracts (85% MA-PDs, 11% PDPs, and 4% MA-PD SNPs/MMPs). Sample selection and data collection were completed in January 2014. A total of 42 contracts (50% PDPs, 42.9% MA-PDs, 7.1% MA-PD SNPs/MMPs) were reviewed. National contracts comprised 23.8% (n = 10) of the sample. Table 2 describes the characteristics of contracts included in the current study. For each individual element, compliance ranged from 79% to 93% (Figure 1). There were 85.7% (n = 36) of contracts with a dedicated MTM webpage, linked text document or PDF, or linked text document dedicated to MTM. Two or fewer clicks to access the MTM webpage was required in 78.6% (n = 33) of contracts. Basic MTM information and eligibility requirements were each provided on the websites of 92.9% (n = 39) of sponsors. Thirty-four of the 42 contracts (81%) provided a copy of a PML or link to the CMR Standardized Format (which contained the PML). The overall compliance rate for the five examined elements from the CY2014 guidance was 59.5%. Approximately 7% (n = 3) of contracts did not meet any of the five elements. For the remaining 33.4% of contracts that were partially compliant, each was only missing one element to be fully compliant with the 2014 guidance: 14% (n = 6) required more than two clicks to access the MTM webpage, 12% (n = 5) did not have a blank copy of the PML or a link to one, and 7% (n = 3) did not have a webpage dedicated to MTM.
Characteristics of Medicare Part D Contracts (N = 42)
Compliance with five elements from Centers for Medicare & Medicaid Services CY2014 guidance for Part D MTM contract websites (N = 42).
Note. MTM = medication therapy management; PML = personal medication list.
A review of compliance by plan type (i.e., MA-PD, MA-PD SNP/MMP, PDP) is shown in Figure 2. When comparing MA-PD plans to PDP plans, both plan types had similar compliance with each of the five elements.
Compliance with five elements from Centers for Medicare & Medicaid Services CY2014 guidance for Part D MTM contract websites by contract type (N = 42).
Note. MA-PD = Medicare Advantage Prescription Drug Plan; MA-PD SNP = Medicare Advantage Prescription Drug—Special Needs Plan; MMP = Medicare-Medicaid Plan; PDP = Prescription Drug Plan; MTM = medication therapy management; PML = personal medication list.
For the additional element of having a search bar and the ability to search for the MTM page, 54.8% (n = 23) of contract websites contained search bars and of those, 73.9% (n = 17) enabled the user to find the MTM webpage or information when “medication therapy management” was used as a search term.
One of the overarching goals of the CMS-guided MTM program for Part D contracts is to optimize patient-related health outcomes through the use of medications (CMS, 2016). One of the ways to enhance this goal is to provide information to beneficiaries so they better engage in their health care. CMS sets forth guidance to assist Part D contracts with achieving this goal. Starting in 2013, CMS expected Part D contracts to provide information about the plan's MTM eligibility requirements, who to contact for more information, and a high-level summary of services offered as part of the MTM program on their websites. Prior to any of the CMS guidance for MTM program information on the contract's website, a review of contract websites in December 2012 showed that only a minority of plans provided MTM information. Based on the current authors' review of contracts in January 2014, shortly after additional website requirements went into effect, there was a substantial increase in the proportions of contract sponsor websites that included information describing MTM services and eligibility, from 46.4% each in December 2012 to 92.9% each in January 2014. These aspects were expected starting in January 2013, so contract sponsors had a longer period to implement the changes. Furthermore, although 92.9% of the sample provided a high-level summary of MTM services offered according to the methods used, interpretation of this information is fairly subjective. Because the goal of the CMS guidance is to enhance the accessibility of information to an older adult population, plans may actually undermine that goal while attempting to comply with the guidance. For example, a plan's interpretation of a “high-level summary” may result in the inclusion of text that incorporates medical or plan-related jargon and may be difficult to comprehend.
There was a dramatic increase in the number of websites that provided a blank copy of a PML or made one available to its members, from 17.9% to 81% during the same comparative time frame of December 2012 to January 2014. In CY2013, the CMS guidance suggested posting a blank copy of a PML or access to one, and was reinforced with the guidance for CY2014.
In general, the percentages are lower for the new guidance from the CY2014 Call Letter than those previously expected in CY2013. Fewer contract sponsors (85.7%) have a webpage dedicated solely to these services. For the approximately 15% of contract sponsors who do not dedicate a separate page to MTM, this important information may be lost or difficult to find for beneficiaries seeking it. Having a clearly linked page dedicated to MTM should allow for easier access to the information and less confusion on the part of the beneficiary.
Ease of information access has also appeared to improve overall. In 2012, only 17.9% of MTM webpages were found within two or fewer clicks, compared to 78.6% meeting this guidance in January 2014. Although this increase represents a significant improvement in accessibility, the need for additional progress remains, as not having information readily available to beneficiaries is a major roadblock in improving education about MTM services.
Because of the known challenges associated with providing online information to older adults, the NIA (2016) has developed research-based guidelines for creating websites that are user-friendly for the older adult population. The NIA's recommendations include that website navigation should be simple and clear, with informative headings, adequate font size (i.e., 12- to 14-point or larger), single clicks, limited scrolling, and minimal use of technical terminology. Although the CMS guidance for MTM websites touches on some of these aspects, more explicit incorporation of the NIA recommendations might aid in accomplishing the ultimate goal of enhancing beneficiaries' understanding of MTM programs and services.
During the same comparator time frame of December 2012 to January 2014, there was no apparent change in the statistic that approximately one half of contract sponsor websites provided a search bar for visitors. In keeping with the NIA's recommendations for websites geared toward older adults, MTM contract sponsors' websites should contain usable search bars. In addition, even when the sampled website contained a search bar, there were 26.1% of searches using the term “medication therapy management” that did not yield the MTM page, but were accessible by other means such as through the web address listed on the “2014 Plan MTM Program Eligibility Information” document, available as a download from the CMS webpage (CMS, 2014). It is believed to be unlikely that beneficiaries would find and download this file and then search for their specific contract, which may be named differently than listed on the file.
There are several limitations. First, sample selection was not randomized, so true compliance rates may differ from what the results of the current study suggest due to selection bias. In addition, interpretation of the CMS guidance can be somewhat subjective. For instance, Medicare drug program websites are expected to contain a high-level summary of MTM services, which may be interpreted differently among contract sponsors and/or those conducting data collection for the current study. Hence, the data found in this investigation may not fully or accurately represent how easily accessible MTM program information is on these contracts' websites, and certainly, among all contract sponsors' websites.
Medicare prescription drug plans are increasing MTM program information availability and accessibility on their webpages according to guidance set forth by CMS. However, there lacks an ability to find MTM webpages through search bars and some websites have a greater ease of use when compared to others, which contribute to variable accessibility to MTM information among plans. These barriers to current resources present an opportunity for nurses, pivotal in the education of older adults and their care support team, to improve understanding and application of health plans' Part D MTM programs. In addition, nurses can assist individuals with navigating the various Medicare Part D plan choices and programs, including the MTM program, during annual open enrollment from October 15 to December 7 each year.
Although the current report provides information about online MTM program information, future research should focus on whether implementation of the guidance translates into an improved understanding of MTM services and/or increased use of MTM services among eligible beneficiaries.
Guidance from Centers for Medicare & Medicaid Services (CMS) for Medication Therapy Management (MTM) Program Websites for Covered Year 2014a
|Guidance from 2014 CMS Call Letter|
|Website includes a page dedicated to MTM, which is linked from the Medicare drug plan website|
|Information on dedicated webpage includes the following, written in plain language appropriate for beneficiaries:|
| • Plan's specific MTM eligibility requirements|
| • Who to contact for more information, with customer service personnel prepared to answer questions about the MTM program|
| • High-level summary of services offered as part of the MTM program, explanation of the purpose and benefits of MTM, and that service is free for eligible beneficiaries|
| • Description of how beneficiaries will be notified that they are eligible and enrolled in the MTM program; how they will be contacted and offered services, including the comprehensive medication review and targeted medication reviews; and a description of how the reviews are conducted and delivered, including time commitments and materials beneficiaries will receive|
| • How beneficiaries may obtain MTM service documents, including a blank copy of the Personal Medication List|
|If possible, the dedicated webpage should be accessible by two or fewer clicks from the Medicare drug plan website|
Characteristics of Medicare Part D Contracts (N = 42)
|Plan Type (n, %)||Region||Contracts, n (%)|
|PDP (21, 50)||Midwest||3 (7.1)|
|MA-PD (18, 42.9)||Midwest||2 (4.8)|
|MA-PD-SNP/MMP (3, 7.1)||Northeast||1 (2.4)|