New Medicare Quality Measures May Affect Pharmacy Operations


Changes to Medicare Part B, Part C, and Part D regulations affect 3 specific areas that may impact pharmacy operations.

Changes to Medicare Part B, Part C, and Part D regulations affect 3 specific areas that may impact pharmacy operations, said R. Jeffrey Hedges, President and CEO of R.J. Hedges & Associates, during the 2015 Pharmacy Development Services Conference in Orlando, Florida.

These areas cover compliance with government regulations, health insurers’ requirements, and medication adherence—each of which is equally important for staying competitive in the independent pharmacy space, Hedges noted.

Medication adherence is a new quality measure for all 3 Medicare plans that falls under the patient management umbrella. Compliance with the measure will affect a pharmacy’s Medicare star ratings, which in turn will impact reimbursement for services.

“[Medication therapy management (MTM)] will be a key feature for you,” Hedges said. “How many patients have you lost by not doing MTMs?...If you settle for the status quo, your patients are going to go to your competitors.”

A key area within government regulations is compounding, which is likely to involve state regulations related to the practice. Pharmacists in states that monitor compounding regulations and compliance should check the state’s compounding definition, Hedges said.

Despite a push for compounding accreditation from certain insurance companies, it is not yet a government requirement, Hedges explained.

“You, at the local level, can influence your state,” Hedges said. “You want to be sure you have reasonable regulations.”

Other government-related requirements include HIPAA regulations, specifically as they apply to data breaches involving protected health information. The requirements mandate investigation into the breach’s extent, as well as reports on the number of breaches.

As insurance companies integrate medication adherence into Medicare compliance measures, pharmacy operations will be impacted significantly. Although insurance companies have not been aggressive about pursuing compliance measures in the past, payers are becoming more aggressive in this space now, Hedges noted.

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