Can Pharmacy Squeeze the Devil Out of the Medicare Part D Details?

Pharmacy Times, Volume 0,0

When the new Medicare Part D prescriptiondrug benefit takes effect onJanuary 1, 2006, the nation's pharmacistswill begin playing a broader andmore meaningful role in the deliveryof health care services. The medicationtherapy management (MTM) servicesthat pharmacists (and other healthcare providers) will be encouraged tooffer under that program pack thepromise of improved outcomes for millionsof seniors, reduced health carecosts for patients and taxpayers, and amore satisfying practice for pharmacyprofessionals.

Additionally, Part D will open thedoor for pharmacists to secure reimbursementfor nondispensing activities,including patient counseling, diseasemanagement, and other MTMservices.

Pharmacy leaders agree that theMedicare Modernization Act's MTMrequirements represent a positive stepforward for the profession. Yet, bothpharmacists and patients will face anumber of challenges under this newinitiative.

For pharmacy, one of the most troublingaspects of the MTM regulationslaid down earlier this year by theCenters for Medicare and MedicaidServices (CMS) is the agency's failure toestablish any reimbursement standardsfor pharmacists who provide theseservices to patients. Instead, pharmacybenefit managers and other sponsorsof the prescription drug plans (PDPs)that will administer Part D benefits willhave a free hand in establishing compensationlevels for MTM services.Although these plans will be requiredto disclose and explain the fees theypay to pharmacists for MTM, the governmentwill not require any specificreimbursement for these services.

Futhermore, pharmacists who aredissatisfied with the MTM fees, orwho believe that they are being shortchangedby the drug plan, will not beable to count on any help fromWashington. In their final rules, CMSofficials made it clear that "we willnot adjudicate any specific disputes"between pharmacists and drug plansover payments for MTM services. Inview of the difficulties pharmacistshave faced securing fair reimbursementfor their services under Medicaidduring the past 40 years, pharmacy'slack of MTM fee-negotiatingleverage under the new Medicare drugbenefit does not bode well for the profession.

Identifying Medicare beneficiarieswho qualify for MTM services may be apotentially serious source of confusionfor the new drug program. The broadparameters of patient eligibility forthese services are spelled out in boththe law and the final CMS regulationsestablishing the prescription benefit.To be eligible to receive MTM services,the patient must suffer from multiplechronic diseases (eg, diabetes, asthma,hypertension); must be taking multipleprescription drugs covered by Part D;and must be identified as incurringmore than $4000 in annual Part Ddrug expenses.

So far the regulations seem fine, butissues are certain to surface as prescriptiondrug plans begin to design MTMprograms and pharmacists begin toimplement them:

  • How many chronic diseases must apatient suffer from in order to betargeted for MTM services?
  • What constitutes a "chronic" conditionfor the purposes of this eligibilitytest?
  • How many Part D prescriptiondrugs must a patient be taking inorder to qualify?

These are questions that CMSdeclined to answer in the final rulesthat created Part D. As a result, eachindividual prescription drug plan willestablish its own specific standards forMTM eligibility—an approach likely tocreate considerable confusion amongMedicare beneficiaries.

The rules also open the door for controversyin other areas of the processfor targeting patients for MTM services.Pharmacists (and patients themselves)may play a key role in screening, identifying,and referring Medicare beneficiariesfor MTM—but only if the policiesof the patient's PDP permit suchinvolvement.

As a result, some plans may invitepharmacists to assume a lead role in targetingMedicare beneficiaries for MTMservices; others may allow pharmaciststo play a more limited part in the identificationof eligible patients; and stillothers may lock pharmacists andpatients out of the process altogether.

As untidy as these procedures seemto be, the process for identifying MTM-eligiblepatients will not be nearly asbad for pharmacists as it would havebeen a decade ago, before pharmacycomputerization streamlined third-partyprocessing chores. CMS officialsexpect drug plans to use "system edits"(computerized notices that appear onthe pharmacists'computer when abeneficiary fills a prescription) to providepharmacists with instant verificationof each Medicare beneficiary's eligibilityfor MTM services.

Computers, however, will not eliminateall of the potential pitfalls facingpharmacists under the new Medicaredrug benefit. Pharmacists, PDP sponsors,and government officials willhave to work together if the promise ofMTM is to be realized.

Mr. Rankin is a freelance medical writer.