AARP

JUNE 2023

PUBLIC POLICY INSTITUTE

Fact Sheet

Medication Literacy Series: Medication

Management

James McSpadden
AARP Public Policy Institute

Taking the right drug at the right time is not always easy.

An individual must be able to recognize the medication,
understand the prescription instructions, and take it both

at the appropriate time and in the prescribed manner. Many
individuals must be able to reconcile multiple medications,
coordinating the use of prescription medications with
over-the-counter drugs. This set of behaviors, which guide
appropriate medication use, is commonly known as medication
management.

Research has repeatedly shown that when older adults
effectively manage their medications, they can prevent
adverse events and improve health outcomes.! Yet many
older adults do not participate in formal, health care
provider-led medication management programs that conduct
a comprehensive review of all medications and generate

a standardized action plan and may lack access to other
helpful innovations, tools (e.g., pill organizers and blister
packs), and strategies (€.g., written medication routines).
Thus, for many older adults-particularly those with multiple
chronic conditions, a high number of daily prescriptions, and
complex medication regimens-managing medications can be
challenging.

This Fact Sheet explores the range of formal medication
management programs that are available and the challenges
that older adults, especially those with limited medication
literacy-the ability to obtain information about medication,
process it, and use the information to make medication
decisions-and their family caregivers face when trying to
manage their medications.

What is medication management?

"Medication management" is an inclusive term that describes
the motivations and means that individuals use to coordinate
their medication regimens meaningfully and accurately. For
older adults, 40 percent of whom take five or more medications
daily, medication management is a fundamental activity for
coordinating daily medications.'

Key Takeaways

Y Most older adults take

at least one prescription
medication and, as such,
engage ina form of
medication management-
that is, the coordination of
tasks required in safely and
effectively taking prescribed
and over-the-counter
medications.

¥ Awareness of and enrollment

in formal medication
management programs are
low among older adults.

¥ Many older adults and

their family caregivers,
particularly those with
limited medication literacy,
could face challenges

in employing the skills
necessary to manage their
medications effectively.
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Medication management can take a variety of
forms, from a formal program with structured
interventions and clearly defined outputs to
informal tools and strategies used to facilitate
self-management. In all its forms, though,
medication management is built around a
combination of elements:

e@ participants-an older adult and, often,
a combination of care team members,
including a caregiver, primary care
provider, pharmacist, or other health
professionals;

e goals-both short-term, such as reconciling
medications after hospitalization, and
long-term, such as reducing adverse
drug events, that give purpose to the
intervention or behavior;

e process--the range of facilitating programs,
tools, interventions, and strategies used by
an older adult; and

e drug list-an inclusive and accurate listing
of all prescription and over-the-counter
drugs taken by an older adult.

Formal medication management programs
Medication therapy management

Medication therapy management (MTM) is a
broad range of health care services that help
optimize prescription drug therapy. MTM
brings together pharmacists, providers, and
patients to resolve and prevent medication-
related problems and improve medication
use. The model MTM program includes a
core set of services and products: medication
therapy review, an up-to-date personal
medication record, a medication action plan,
necessary interventions, and documented
follow-up.

Medicare Part D-Medicare's MTM program
is well-known. Since 2006, Medicare has
required all Part D plans to offer MTM as a
benefit. Medicare's MTM offers participants
an annual, real-time consultation with

a pharmacist or their representative
(comprehensive medication review, or

CMR); quarterly interventions that focus

on identified or potential medication issues
(targeted medication reviews, or TMR); and a
formal, written action plan.

Medicare Part D plans set MTM eligibility
criteria to target beneficiaries who are at
highest risk of adverse medication events.
Although the Centers for Medicare & Medicaid
Services (CMS) requires plans to use a set of
minimum eligibility standards (see sidebar),
plans have the flexibility to go beyond the
minimum standards and offer MTM to more
enrollees. Even so, nearly three-quarters

(73 percent) of Part D plans closely follow CMS
standards.*®

Enrollment in Medicare MTM has remained
historically low. In 2008, 11 percent of Part

D beneficiaries were eligible for MTM; that
number dropped to 8 percent in 2011.6 By
2022, only 9 percent of Part D beneficiaries
were eligible for the program. To address this
issue, CMS recently proposed new eligibility
criteria, including reducing the number of
minimum drugs an eligible beneficiary takes
from eight to five and lowering the medication
cost to reflect high generic utilization
($1,004); CMS estimates these changes would
increase eligibility to 23 percent.'

These changes may also help address
longstanding racial and ethnic disparities in
Medicare MTM utilization. Research indicates
that a higher portion of Black, Hispanic, and

Medicare Part D Medication Therapy
Management Eligibility Criteria (2023)

* Living with a minimum of two or three chronic
diseases. Plans may select from a core set of
chronic conditions;

* Taking a minimum of between two and eight
Part D medications;

* Likely to incur annual medication costs over
an established threshold ($4,935 in 2023).

 
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Asian beneficiaries opt out of such services,
and there are similar disparities in the
duration between MTM enrollment and the
beneficiary being offered or receiving an
MTM-required comprehensive medication
review.® Similarly, the most recent evaluation
of Medicare's Enhanced MTM pilot showed
that while certain at-risk (medically complex)
populations have benefitted from MTM,
receiving services at higher rates, other
subpopulations (Black beneficiaries and those
with the low-income subsidy) have continued
to receive services at lower rates.°

Medicaid-Federal law neither requires that
states provide nor sets the conditions for
Medicaid MTM, and data on such programs
remain limited. As of 2020, 11 state Medicaid
programs offered MTM and 9 additional state
Medicaid programs offered at least one MTM
component." Each of the states has used a
combination of state laws, agency regulations,
and MTM best practices to guide the delivery
and assessment of MTM services."

Like in Medicare, Medicaid's MTM

program is available to a limited number

of beneficiaries.'2 While all states have
designed eligibility criteria to target a subset
of enrollees-those who are at highest risk
for medication-related problems--the state
approaches differ. For example, Tennessee's
pilot MTM program determines eligibility
by assessing a beneficiary's health risk and
targeted disease state and calculating a risk
score." Under these criteria, Tennessee
provided MTM to less than 1,400 Medicaid
beneficiaries between 2018 and 2020.
Alternatively, Wisconsin's MTM targets
beneficiaries who take multiple medications
and need care coordination as they transition
from one care setting to the next.

Research suggests that factors in addition to
the narrow design of eligibility criteria may
influence MTM enrollment. Among these are
reluctance by some providers to participate
in the program due to low reimbursement,
uncertainty about how to integrate

the program into workflows, and time

constraints of pharmacy staff.'* Also cited
are low consumer awareness and consumers'
resistance to involving pharmacists in their
care.

Other formal medication management
services

Beyond MTM, providers, insurers, and
vendors have operationalized several other
medication management interventions.
Comprehensive medication management
(CMM) is a formal medication program that
has a broader focus and more expansive goals
than MTM. CMM wholistically assesses, in real
time, the appropriateness and effectiveness

of all of an individual's medications, embeds

a patient's pharmacist directly into the care
team, and seeks to resolve complex medical
problems." To date, CMM has principally been
used in coordinated care programs, such as
patient-centered medical homes. However,
there is growing interest by provider

groups and policymakers to integrate CMM
into commercial plans and make it a fully
reimbursable service like MTM.®

More targeted interventions also dot

the health care landscape. Examples
include certain clinically based efforts

such as medication reconciliation during
hospitalization or as part of the post-

acute transition to the community,
pharmacogenomic screening that pinpoints
the ability of an individual to metabolize
prescribed medications, and deprescribing
to reduce or eliminate certain drugs that
may be causing harm. Awareness of and
access to such interventions may depend on
factors such as where an older adult lives,
their insurance coverage, or their health care
provider network."

Patient contributions to medication
management

All forms of medication management require
a level of consumer agency. Whether an older
adult participates in a formal medication
management program or a less formal
intervention or self-manages their medication,
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they must be able to perform a set of actions
to organize their medication therapy.

To manage medications effectively, an

older adult must employ certain skills or
strategies. These may include basic skills @.g.,
reading medication labels, comprehending
instructions for use, and ordering refills),
interpretive skills (¢.g., knowing how to take
appropriate action when a medication-related
problem emerges), and integrative skills (e.g.,
adopting strategies to organize medications
into a daily routine)."°

Yet not all older adults are able to employ
these skills. For example, a longitudinal study
exploring the difficulties older adults face
when managing medications showed that
adults ages 65 to 69 reported less difficulty
(10 percent) managing medications than did
adults ages 85 and over (38 percent). Older
adults with reduced cognitive functioning,
regardless of age, had a higher risk for error
in self-management." Another study exploring
medication management capacity among
patients with a heart condition noted that
participants had greater difficulty identifying
all of their medications if they were age 65 or
older or were cognitively impaired."

These challenges also extend to family
caregivers. AARP research has shown that
82 percent of family caregivers manage
medications for a loved one."? Nearly half
(44 percent) perform this task multiple
times a day, and most manage medications
in addition to other tasks. Unsurprisingly,
AARP's research also found that many
caregivers find medication management
difficult, citing their fear of making a mistake
or the need to provide constant attention
when performing the task.

Role of medication literacy

Limited medication literacy-a subset of health
literacy that considers an individual's ability
to obtain information about medication,
process it, and use the information to make
medication decisions-may also diminish an
older adult's capacity to manage medications
effectively. Thirty-four percent of adults

ages 50 to 64 and 59 percent of adults ages
65 and older had limited literacy levels and
may lack the foundational skills to perform
basic management tasks, such as locating
information on a drug label. Moreover,

53 percent of adults ages 50 to 64 and

38 percent of adults ages 65 and older had
intermediate literacy and may have difficulty
navigating more complex integrative and
interpretive skills.**

Medication management interventions may
be particularly helpful for older adults and
family caregivers with limited medication
literacy. Evidence shows an association
between low medication literacy and poor
self-management of medications among
older adults. A study of older adults showed
that those with limited health literacy were
less likely to recognize indications on their
medications and less likely to understand
instructions and dosage."*®

Older adults enrolled in formal medication
management programs may have access

to and benefit from tools that account for
varying literacy levels. Many participating
health care providers receive training in
how to tailor MTM services to enrollees
with limited literacy.?® They may also use
specifically designed resources that target
limited-literacy enrollees, such as the Agency
for Healthcare Research and Quality's
provider resource page, which ties specific
literacy tools to various MTM components.""

Conclusion

Medication management may look different
for each older adult who takes prescription
medications. That is because older adults, in
coordination with their family caregiver or
other representative, can personalize their
medication management process using the
tools available to them and in a way that best
suits their needs. Whether an older adult
follows the formal protocols of a medication
management program, uses targeted
interventions, or incorporates tools and
strategies into a system of self-management,
JUNE 2023

they create a process that will help them and family caregiver access-particularly for
manage their drugs and remain healthy. those with low medication literacy and others
who face challenges enrolling in or utilizing
services-to the range of programs and

tools that support and encourage effective
medication management.

One key to successful medication
management is identifying and limiting the
barriers that impede an older adult's ability
to act when optimizing their medications.
Another is to ensure appropriate patient

 

1 Melissa Johnson et al., "Evaluation of an Academic-Community Partnership to Implement MTM Services in Rural Communities to
Improve Pharmaceutical Care for Patients with Diabetes and/or Hypertension," Journal of Managed Care & Specialty Pharmacy 24,

no. 2 (2018): 132-41, https://www.jmcp.org/doi/pdf/10.18553/jmcp.2018.24,.2.132.

2 Shannon Brownlee and Judith Garber, Medication Overload: America's Other Drug Problem (Brookline, MA: Lown Institute, 2019),
https://lowninstitute.org/wp-content/uploads/2019/08/medication-overload-lown-web.pdf.

3 "Medication Therapy Management" in National Board of Medication Therapy Management, ed. Dustin J. Thomas and Julien

Tran (Online: 2020), accessed March 14, 2023, https://www.nbmtm.org/mtm-reference/medication-therapy-management/?cn-

re =1.

4 Ibid.

5 CMS, "2019 Medicare Part D Medication Therapy Management (MTM) Programs," Fact Sheet on 2019 MTM Programs, September
2019, h J//www.cm v/Medicare/Prescription-Drug-Cover PrescriptionDri vContra/Down Y¥2019-MTM-F
Sheet.pdf.

6 Cori Gray, Catherine E. Cooke, and Nicole Brandt, "Evolution of the Medicare Part D Medication Therapy Management Program
from Inception in 2006 to the Present," American Health & Drug Benefits 12, no. 5 (2019): 243-51, https://www.ncbi.nlm.nih.gov/

pmc/articles/PMC6979045/.
7 "Medicare Program; Contract Year 2024 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription

Drug Benefit Program, Medicare Cost Plan Program, Medicare Parts A, B, C, and D Overpayment Provisions of the Affordable
Care Act and Programs of All-Inclusive Care for the Elderly; Health Information Technology Standards and Implementation

Specifications," Federal Register 87, no. 247 (December 27, 2022): 79699, https://www.govinfo.gov/content/pkg/FR-2022-12-27/
pdf/2022-26956.pdf.

8 Xiaobei Dong et al., "Racial and Ethnic Disparities in Medicare Part D Medication Therapy Management Services Utilization,"

Exploratory Research in Clinical and Social Pharmacy 9, no. 100222 (2023), https://doi.org/10.1016/j.rcsop.2023.100222.

9 Acumen LLC, "Evaluation of the Part D Enhanced Medication Therapy Management (MTM) Model: Fourth Evaluation Report," April
2022, https://innovation.cms.gov/data-and-reports/2022/mtm-fourth-evalrept

10 Centers for Disease Control and Prevention, Pharmacist-Provided Medication Therapy Management in Medicaid (Atlanta, GA: Centers
for Disease Control and Prevention, U.S. Department of Health and Human Services, 2021), https://www.cdc.gov/dhdsp/docs/
MIM_in. Medicaid-508.pdf.

11 "State Medicaid Requirements for CMRs and TMRs," in National Board of Medication Therapy Management, ed. Dustin J. Thomas

and Julien Tran (Online: 2020), accessed March 14, 2023, https://www.nbmtm.org/mtm-reference/state-medicaid-requirements-
cmrs-tmrs/.

12 Centers for Disease Control and Prevention, Pharmacist-Provided Medication Therapy Management in Medicaid.

13 Division of TennCare, "Medication Therapy Management (MTM) Pilot Program: Provider Operations Manual," July 6, 2020,
https://www.tn.gov/content/dam/tn/tenncare/documents/MTMOperationsManual.pdf.

14 Kenneth C. Hohmeier et al., "The Tennessee Medicaid Medication Therapy Management Program: Early Stage Contextual Factors
and Implementation Outcomes, BMC Health Services Research 21, no. 1189 (2021), https://doi.org/10.1186/s12913-021-07193-7.

15 Wisconsin Badger Care, "Covered and Noncovered Services: Medication Therapy Management," accessed March 14, 2023,

 
JUNE 2023

16 Manouchehr Saljoughian, "Top Challenges in Medication Therapy Management," US Pharmacist 47, no. 2 (2022): 44-46,

https://www.uspharmaci m/arti -challenges-in-medication-therapy-management.

17 Terry McGuiness and K. Capps, Get the Medications Right: A Nationwide Snapshot of Expert Practices-Comprehensive Medication
Management in Ambulatory/Community Pharmacy (Health2Health Resources, May 2016), https://gtmr.wpenginepowered.com/wp-
content/uploads/2016/10/GetTheMedicationsRight.v22final-5.20.pdf.

18 Kristen Tripicchio et al., "Making the Economic Value Proposition for Pharmacist Comprehensive Medication Management
(CMM) in Primary Care: A Conceptual Framework," Research in Social & Administrative Pharmacy 16, no. 10 (2020): 1416-21,

https://doi.org/10.1016/j.sapharm.2020.01.001.

19 For an example of a study that notes variation in access due to providers, see Stephen D. Persell et al., "Effect of Electronic
Health Record-Based Medication Support and Nurse-Led Medication Therapy Management on Hypertension and Medication
Self-management: A Randomized Clinical Trial," JAMA Internal Medicine 178, no. 8 (2018): 1069-77, https://doi.org/10,1001/

jamainternmed.2018.2372.

20 This description of skills is meant to be illustrative. For an example of a scientific framework for medication literacy skill, see Jenny
Gentizon et al., "Conceptualization and Content Validation of the MEDication Literacy Assessment of Geriatric Patients and Informal
Caregivers (MED-fLAG)," Journal of Patient-Reported Outcomes 6, no. 87 (2022), https://doi.org/10.1186/s41687-022-00495-2.

21 Nienke Bleijenberg et al., "Difficulty Managing Medications and Finances in Older Adults: A 10-year Cohort Study," Journal of the
American Geriatrics Society 65, no. 7 (2017): 1455-61, https://doi.org/10.1111/jgs.14819.

22 Sunil Kripalani et al., "Predictors of Medication Self-management Skill in a Low-literacy Population," Journal of General Internal
Medicine 21 (2006): 852-56, https://doi.org/10,1111/j,1525-1497,2006.00536.x.

23 Susan Reinhard et al., Home Alone Revisited (Washington, DC: AARP Public Policy Institute, April 2019), https://doi.org/10.26419/
ppi.00086,001.

24 Mark Kutner et al., The Health Literacy of America's Adults: Results from the 2003 National Assessment of Adult Literacy, NCES 2006-
483 (Washington, DC: National Center for Education Statistics, September 2006), https://n Vv, 2 20064 f.

25 Stephen D. Persell et al., "Associations between Health Literacy and Medication Self-Management among Community
Health Center Patients with Uncontrolled Hypertension," Patient Preference and Adherence 14 (2020): 87-95,
h ://www.ncbi.nlm.nih.gov/pme/arti PMC6970267/.

26 "Medication Therapy Management" in National Board of Medication Therapy Management.

27 Agency for Healthcare Research and Quality, "Health Literacy Tools for Providers of Medication Therapy Management," accessed
March 14, 2023, https://www.ahrq.gov/health-literacy/improve/pharmacy/medication-mgt.html.

Fact Sheet 1616803, June 2023

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