Value-Based Medicare Part D Demonstration Launched

Medicare will implement an experimental medication therapy management model for several Part D plan sponsors.

The Center for Medicare and Medicaid Innovation recently announced 6 participants in the Part D Enhanced Medication Therapy Management model, which is an experimental demonstration of value-based healthcare.

This new model offers financial incentives for basic Part D prescription drug plans in selected regions to offer medication therapy management instead of the standard model, according to a press release from the Centers for Medicare and Medicaid Services (CMS).

The goal of the model is to improve care and reduce costs. To do so, CMS will examine if the changes to the Part D program will align prescription drug plan sponsors with government financial interests.

Through the model, stand-alone prescription drug plan sponsors will be able to implement strategies to optimize medication use, improve care coordination, and strengthen system linkages, according to the CMS.

The test starting in 2017, will be conducted for 5 years. Included in the model will be Blue Cross and Blue Shield of Florida, Blue Cross and Blue Shield Northern Plains Alliance (Great Plains region), CVS Health, Humana Insurance Company, UnitedHealthcare, and WellCare Prescriprtion Insurance Co. The latter 4 will be operating in the Arizona, Florida, Louisiana, Virginia, and Great Plains regions.

The regions included are broadly representative of national market characteristics, and will give an accurate view of how these models would affect beneficiaries and sponsors, according to CMS. The 6 plan sponsors have 22 plan benefit packages, and will provide health insurance to approximately 1.6 million beneficiaries in the selected regions.

The plan sponsors will be able to select the intensity and type of interventions they will offer, and will be able to provide individualized outreach to the beneficiaries and their providers. CMS said the sponsors can leverage the core competencies of their organizations, network pharmacy providers, and prescribers, to identify and intervene with patients whose medication management have caused adverse outcomes or non-drug program utilization and costs.

Under the Medicare Modernization Act, each Part D program must offer a medication therapy management program to their beneficiaries. The medication therapy management program is intended to make sure patients are taking their medications properly, addressing any issues that arise, and alert the treating physician about medication issues.

These programs save money and improve patient outcomes, according to the CMS. The current medication therapy management programs offered are falling short of expectations, likely due to financial and regulatory reasons.

Medicare’s regulations for medication therapy management programs require uniform offerings and may not be able to include the resources and activities needed for the most positive outcomes.

The enhanced medication therapy management model would include regulatory flexibilities and financial incentives for plan sponsors. Under the model, beneficiaries will be able to receive more individualized care and have reduced cost-sharing.

Plan sponsors will also be able to experiment with communication strategies that aim to improve coordination. The more extensive interventions will be covered by a plan-specific prospective payment, so the plan premiums will not be effected by costs outside of the plan’s Part D bid.

They will also have the opportunity to qualify for a performance payment if the sponsor achieves a 2% reduction in expected fee-for-service expenditures, according to the press release.

Part A and B claims data will also be available to further assist care coordination for high-risk beneficiaries. It is expected that participating sponsors will also try new ways to integrate pharmacists into physician medication management workflows, the CMS wrote.

Current Medicare standards will be adhered to, and the plan sponsors may not restrict benefits or increase cost-sharing to prevent use of prescription drugs as a way to lower costs. Any beneficiaries in the selected regions may opt out of the program at any time.

The CMS will monitor the sponsors to make sure that the interventions are being implemented as intended and the funding is being properly used.

Evaluation of the program will include an analysis of qualitative and quantitative data to understand the effects of the program. Researchers will compare pre-model data from 3 to 5 years of performance data to plans where the model was not implemented.

These studies will demonstrate whether or not this model was successful and should be implemented among other plans.