[Congressional Bills 111th Congress]
[From the U.S. Government Publishing Office]
[S. 3543 Introduced in Senate (IS)]

111th CONGRESS
  2d Session
                                S. 3543

  To amend title XVIII of the Social Security Act to expand access to 
medication therapy management services under the Medicare prescription 
                             drug program.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

                             June 29, 2010

Mrs. Hagan (for herself and Mr. Franken) introduced the following bill; 
     which was read twice and referred to the Committee on Finance

_______________________________________________________________________

                                 A BILL


 
  To amend title XVIII of the Social Security Act to expand access to 
medication therapy management services under the Medicare prescription 
                             drug program.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Medication Therapy Management 
Expanded Benefits Act of 2010''.

SEC. 2. FINDINGS.

    Congress finds the following:
            (1) Medications are important to the management of chronic 
        diseases that require long-term or lifelong therapy. 
        Pharmacists are uniquely qualified as medication experts to 
        work with patients to manage their medications and chronic 
        conditions and play a key role in helping patients take their 
        medications as prescribed.
            (2) Nonadherence with medications is a significant problem. 
        According to a report by the World Health Organization, in 
        developed countries, only 50 percent of patients with chronic 
        diseases adhere to medication therapies. For example, in the 
        United States only 51 percent of patients taking blood pressure 
        medications and only 40 to 70 percent of patients taking 
        antidepressant medications adhere to prescribed therapies.
            (3) Failure to take medications as prescribed costs over 
        $290,000,000,000 annually. The problem of nonadherence is 
        particularly important for patients with chronic diseases that 
        require use of medications. Poor adherence leads to unnecessary 
        disease progression, reduced functional status, lower quality 
        of life, and premature death.
            (4) When patients adhere to or comply with prescribed 
        medication therapy it is possible to reduce higher-cost medical 
        attention, such as emergency department visits and catastrophic 
        care, and avoid the preventable human costs that impact 
        patients and the individuals who care for them.
            (5) Studies have clearly demonstrated that community-based 
        medication therapy management services provided by pharmacists 
        improve health care outcomes and reduce spending.
            (6) The Asheville Project, a diabetes program designed for 
        city employees in Asheville, North Carolina, that is delivered 
        by community pharmacists, resulted over a 5-year period in a 
        decrease in total direct medical costs ranging from $1,622 to 
        $3,356 per patient per year, a 50 percent decrease in the use 
        of sick days, and an increase in productivity accounting for an 
        estimated savings of $18,000 annually.
            (7) Another project involving care provided by pharmacists 
        to patients with high cholesterol increased compliance with 
        medication to 90 percent from a national average of 40 percent.
            (8) In North Carolina, the ChecKmeds NC program, which 
        offers eligible seniors one-on-one medication therapy 
        management consultations with pharmacists, saved an estimated 
        $10,000,000 in healthcare costs and avoided numerous health 
        problems in the first year of the program for the more than 
        15,000 seniors receiving such consultations.
            (9) Results similar to those found under such projects and 
        programs have been achieved in several other demonstrations 
        using community pharmacists.
            (10) In recognition of the benefits of medication therapy 
        management, enhancement of the medication therapy management 
        benefit the Medicare prescription drug program under part D of 
        title XVIII of the Social Security Act was an important 
        component of the national health care reform agenda during 2009 
        and 2010.

SEC. 3. IMPROVEMENT IN PART D MEDICATION THERAPY MANAGEMENT PROGRAMS.

    (a) Increased Availability and Community Pharmacy Involvement in 
the Provision of Medication Therapy Management Services.--
            (1) Increased beneficiary access to medication therapy 
        management services.--Section 1860D-4(c)(2) of the Social 
        Security Act (42 U.S.C. 1395w-104(c)(2)), as amended by section 
        10328 of the Patient Protection and Affordable Care Act (Public 
        Law 111-148), is amended--
                    (A) in subparagraph (A)--
                            (i) in clause (ii)(I), by inserting ``or 
                        any chronic disease that accounts for high 
                        spending in the program under this title, 
                        including diabetes, hypertension, heart 
                        failure, dyslipidemia, respiratory disease 
                        (such as asthma, chronic obstructive pulmonary 
                        disease or chronic lung disorders), bone 
                        disease-arthritis (such as osteoporosis and 
                        osteoarthritis), rheumatoid arthritis, and 
                        mental health (such as depression, 
                        schizophrenia, or bipolar disorder)'' before 
                        the semicolon at the end; and
                            (ii) by adding at the end the following new 
                        clause:
                            ``(iii) Identification of individuals who 
                        may benefit from medication therapy 
                        management.--The PDP sponsor shall, subject to 
                        the approval of the Secretary, establish a 
                        process for identifying individuals who--
                                    ``(I) are not targeted 
                                beneficiaries described in clause (ii);
                                    ``(II) are not otherwise offered 
                                medication therapy management services; 
                                and
                                    ``(III) a pharmacist or other 
                                qualified provider determines may 
                                benefit from medication therapy 
                                management services.
                        For purposes of this paragraph, any individual 
                        identified under this clause shall be treated 
                        as a targeted beneficiary described in clause 
                        (ii).'';
                    (B) by redesignating--
                            (i) subparagraphs (E), (F), and (G), as 
                        redesignated by paragraph (1) of such section 
                        10328, as subparagraphs (G), (H), and (I), 
                        respectively; and
                            (ii) subparagraph (E), as added by 
                        paragraph (2) of such section 10328, as 
                        subparagraph (F); and
                    (C) by inserting after subparagraph (D) the 
                following new subparagraph:
                    ``(E) Medication reviews for dual eligibles and 
                enrollees in transition of care.--Without regard to 
                whether an enrollee is a targeted beneficiary described 
                in subparagraph (A)(ii), the medication therapy 
                management program under this paragraph shall offer the 
                following:
                            ``(i) In the case of an enrollee who is a 
                        full-benefit dual eligible individual (as 
                        defined in section 1935(c)(6)), a comprehensive 
                        medication review described in subparagraph 
                        (C)(i). The review under the preceding sentence 
                        shall be offered at the time of the initial 
                        enrollment of such individual in the 
                        prescription drug plan.
                            ``(ii) In the case of any enrollee who is 
                        experiencing a transition in care (such as 
                        being discharged from a hospital or other 
                        institutional setting), a targeted medication 
                        review described in subparagraph (C)(ii) of any 
                        new medications that have been introduced to 
                        the enrollee's therapy. The review under the 
                        preceding sentence shall be offered at the time 
                        of such transition.''.
            (2) Access to medication management therapy.--Section 
        1840D-4(c)(2) of such Act (42 U.S.C. 1395w-104(c)(2)) is 
        further amended--
                    (A) by redesignating--
                            (i) subparagraphs (G), (H), and (I), as 
                        redesignated by paragraph (1)(B)(i), as 
                        subparagraphs (H), (I), and (J), respectively; 
                        and
                            (ii) subparagraph (F), as redesignated by 
                        paragraph (1)(B)(ii), as subparagraph (G); and
                    (B) by inserting after subparagraph (E), as 
                inserted by paragraph (1)(C), the following new 
                subparagraph:
                    ``(F) Access requirements.--In order to assure that 
                enrollees have the option of obtaining medication 
                therapy management services under this paragraph, a PDP 
                sponsor shall offer any willing pharmacy in its network 
                and any other qualified health care provider the 
                opportunity to provide such services.''.
            (3) Appropriate reimbursement for the provision of 
        medication therapy management services.--Section 1860D-
        4(c)(2)(J) of such Act (42 U.S.C. 1395w-104(c)(2)(I)), as 
        redesignated by paragraph (2), is amended--
                    (A) in the heading, by striking ``Considerations in 
                pharmacy fees'' and inserting ``Reimbursement'';
                    (B) by striking the first sentence and inserting 
                the following: ``The PDP sponsor shall reimburse any 
                willing pharmacy in its network and other qualified 
                health care provider furnishing medication therapy 
                management services under this paragraph based on the 
                resources used and the time required to provide such 
                services.''; and
                    (C) in the second sentence, by striking ``any such 
                management or dispensing fees'' and inserting ``any 
                such reimbursement''.
            (4) Effective date.--The amendments made by this subsection 
        shall apply to plan years beginning after the date of enactment 
        of this Act.
    (b) Incentives Based on Performance.--
            (1) Evaluation of performance for payment incentives.--
        Section 1860D-4(c)(2) of the Social Security Act (42 U.S.C. 
        1395w-104(c)(2)), as amended by subsection (a), is further 
        amended by adding at the end the following new subparagraph:
                    ``(I) Evaluation of performance.--
                            ``(i) Data collection and performance 
                        measures.--
                                    ``(I) In general.--For plan years 
                                beginning after the date of enactment 
                                of the Medication Therapy Management 
                                Expanded Benefits Act of 2010, the 
                                Secretary shall establish measures and 
                                standards for data collection by PDP 
                                sponsors to evaluate the performance of 
                                pharmacies and other entities in 
                                furnishing medication therapy 
                                management services under this 
                                paragraph.
                                    ``(II) Measures.--Measures 
                                established under subclause (I) shall 
                                be designed to help assess and improve 
                                the overall quality of care, including 
                                a reduction in adverse medication 
                                reactions, improvements in adherence 
                                and persistence in chronic medication 
                                use, and a reduction in drug spending, 
                                where appropriate.
                                    ``(III) Inclusion of certain 
                                measures with respect to pharmacist.--
                                In the case of pharmacists who furnish 
                                medication therapy management services, 
                                the measures established under 
                                subclause (I) shall include measures 
                                developed by the Pharmacy Quality 
                                Alliance.
                                    ``(IV) Encouraging participation of 
                                entities that achieve better 
                                outcomes.--The Secretary shall compare 
                                the outcomes of medication therapy 
                                management services based on the type 
                                of entity offering such services and 
                                shall develop appropriate incentives to 
                                ensure broader participation in the 
                                program offered by the plan sponsor 
                                under this paragraph of entities that 
                                achieve better outcomes (as defined by 
                                the Secretary) with respect to such 
                                services.
                            ``(ii) Continual development and 
                        incorporation of medication therapy management 
                        measures in broader health care outcomes 
                        measures.--The Secretary shall support the 
                        continual development and refinement of 
                        performance measures established under clause 
                        (i)(I), including the incorporation of 
                        medication use measures as part of broader 
                        health care outcomes measures. The Secretary 
                        shall work with State plans under title XIX to 
                        incorporate similar performance-based measures 
                        into drug use review programs under section 
                        1927(g).
                            ``(iii) Incentive payments.--For plan years 
                        beginning on or after January 1, 2011, 
                        pharmacies and other entities that furnish 
                        medication therapy management services under 
                        this paragraph shall be provided (in a form and 
                        manner specified by the Secretary) additional 
                        incentive payments based on the performance of 
                        such pharmacies and entities in meeting the 
                        performance measures established under clause 
                        (i). Such payments shall be made from the 
                        Medicare Prescription Drug Account under 
                        section 1860D-16, except that such payments may 
                        be made from the Federal Hospital Insurance 
                        Trust Fund under section 1817 or the Federal 
                        Supplementary Medical Insurance Trust Fund 
                        under section 1841 if the Secretary determines, 
                        based on data under this part and parts A and 
                        B, that such services have resulted in a 
                        reduction in expenditures under part A or part 
                        B, respectively.''.
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