Medicare reform bill includes medication management services

Pharmacists concerned about reimbursement for Part B-covered drugs

The new Medicare Prescription Drug, Improvement, and Modernization Act, signed into law by President Bush in early December, contains a victory for pharmacists. However, some drug reimbursement changes are also cause for concern.

Pharmacists are cheering the medication therapy management program in the bill. "For the first time under Medicare, pharmacists can be paid for their services for medication therapy management," says Kristina E. Lunner, director of federal government affairs for the American Pharmacists Association (APhA) in Washington, DC.

The bill says that to be part of the benefit, a drug-plan sponsor must have several programs in place, one of which includes medication therapy management. A pharmacist may furnish these services, according to the bill’s language. The program should be designed to ensure, with respect to targeted beneficiaries, that covered Part D drugs under the prescription drug plan are appropriately used to optimize therapeutic outcomes through improved medication use, and to reduce the risk of adverse events, including adverse drug interactions.

The targeted beneficiaries are described as individuals who have multiple chronic diseases (such as diabetes, asthma, hypertension, hyperlipidemia, and congestive heart failure), who are taking multiple covered Part D drugs; and who are identified as likely to incur annual costs for covered Part D drugs that exceed a level specified by the Secretary of the Department of Health and Human Services.

The bill suggests that the medication therapy management program promote enhanced enrollee understanding of the appropriate use of medications and the risk of adverse effects; increased enrollee adherence with prescription medication regimens through medication refill reminders, special packaging, and other compliance programs and other appropriate means; and detection of adverse drug events, and patterns of overuse and underuse of prescription drugs.

The bill suggests that the program be developed in cooperation with licensed and practicing pharmacists and physicians. In addition, the drug-plan sponsor should account for resources used, and time required, to implement the medication therapy management program when the sponsor is establishing fees for pharmacists and others providing services under the plan.

"[The language] speaks to the fact that pharmacists could provide the services, but the program is not limited to them," Lunner says. Unfortunately, a one-year assessment of pharmacist services was dropped in the final conference agreement of the bill.

Reimbursement of Part B- covered drug changes

One provision of the bill that does not thrill many pharmacists has to do with changes in the way Part B covered drugs are reimbursed. Instead of the drugs being reimbursed at 95% of the Average Wholesale Price, the legislation shifts the reimbursement to a system based on the average sales price (ASP) of the drugs.

APhA was disappointed in these reforms, Lunner says. "While the scope of the drugs is limited, it will have an impact. It is a concern that [the government] is decreasing the reimbursement but in most cases is not providing a dispensing fee to pay for some of the pharmacist services."

APhA is also not happy that durable medical equipment (DME) reimbursement will go out to a competitive bidding program in the future. "We’re concerned that pharmacists, which would be considered small providers of DME, would be less likely to win in a competitively bidding environment," Lunner says. "[This provision] has the potential of having a negative impact in pharmacists’ ability to continue to provide those services to patients."

Overall, Lunner sees the Medicare reform bill as imperfect, but it still is a starting place. "We thought it was a good opportunity to set a floor that we can work from."