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 are adherent; similarly, only 40 to 70 percent of patients taking antidepressant medications adhere to prescribed therapies. (3)Failure to take medications as prescribed costs over $177 billion 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, their 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 those who care for them. (5)Studies have clearly demonstrated that community-based medication therapy management (MTM) services provided by pharmacists improve health care outcomes and reduce spending. For example, the Asheville Project—a diabetes program designed for city employees in Asheville, North Carolina, and 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. Another project involving pharmacist-provided care to patients with high cholesterol increased compliance with medication to 90 percent from a national average of 40 percent. In North Carolina, the ChecKmeds NC program, which offers eligible seniors one-on-one MTM 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 MTM. Similar results have been achieved in several other demonstrations using community pharmacists. (6)Therefore, enhancement of the MTM benefit under part D of the Medicare program should be a key component of the national health care reform agenda.

Improvement in part D medication therapy management (MTM) programs

(a)

Improvements to required interventions

Section 1860D–4(c)(2)(C) of the Social Security Act (42 U.S.C. 1395w–104(c)(2)(C)) is amended— (1)by amending clause (i)(I) to read as follows:

(I)shall include a review of the individual’s medications, creation of a personal medication record, and a recommended medication action plan in consultation with the individual and the prescriber; and

; and

(2)by redesignating clause (ii) as clause (iii) and inserting after clause (i) the following new clause:

(ii)Targeted medication reviews furnished person-to-person by a licensed pharmacist offered no less frequently than once every quarter to assess medication use since the last annual comprehensive medication review, to monitor unresolved issues, to identify problems with new drug therapies or if the individual has experienced a transition in care.

(b)

Increase availability of MTM services to beneficiaries and increase community pharmacy involvement in provision of MTM services

(1)

Increased beneficiary access to MTM services

Section 1860D–4(c)(2) of such Act (42 U.S.C. 1395w–104(c)(2)) is further amended— (A)in subparagraph (A)(ii)(I), by inserting before the semicolon at the end the following: or any chronic disease that accounts for high spending in the Medicare program 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); (B)by adding at the end of subparagraph (A) the following new clause:

(iii)

Identification of individuals who may benefit from medication therapy management

The prescription drug plan sponsor shall identify a process subject to the Secretary’s approval that allows licensed pharmacists or other qualified providers to identify for medication therapy management interventions potential enrollees who are not described as targeted beneficiaries under clause (ii) or are not otherwise offered services described in subparagraph (C).

;

(C)by redesignating subparagraphs (F) and (G) as subparagraphs (I) and (J), respectively; (D)by redesignating the subparagraph (E), relating to development of program in cooperation with licensed pharmacists, as subparagraph (H); (E)by redesignating subparagraph (D) and the subparagraph (E), relating to automatic enrollment with ability to opt-out, as subparagraphs (F) through (G), respectively; and (F)by inserting after subparagraph (C) the following new subparagraph:

(D)

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 program shall offer— (i)a comprehensive medication review described in subparagraph (C)(i) at the time of initial enrollment under the plan for an enrollee who is a full-benefit dual eligible individual (as defined in section 1935(c)(6)); and (ii)a targeted medication review described in subparagraph (C)(ii) for any enrollee at the time of transition of care (such as being discharged from a hospital or another institutional setting) where new medications have been introduced to the individual’s therapy.

(2)

Community Pharmacy Access

Section 1840D–4(c)(2) of such Act, as amended by paragraph (1), is further amended by inserting after subparagraph (D) the following new subparagraph:

(E)

Pharmacy access requirements

A prescription drug plan sponsor shall offer any willing pharmacy in its network the ability to provide medication therapy management services to assure that enrollees have the option of obtaining services under the medication therapy management program from community-based retail pharmacies.

(c)

Reimbursement and incentives based on performance

(1)

Appropriate reimbursement for the provision of MTM services

Section 1860D–4(c)(2)(J) of such Act (42 U.S.C. 1395w–104(c)(2)(J)), as redesignated by subsection (b)(1)(C), is amended by striking the first sentence and inserting the following: The PDP sponsor shall reimburse pharmacists and other entities furnishing medication therapy management services under this paragraph based on the resources used and the time required to provide such services.. (2)

Evaluation of performance for payment incentives

Section 1860D–4(c)(2) of such Act (42 U.S.C. 1395w–104(c)(2)), as amended by subsection (b), is further amended by adding at the end the following new subparagraph:

(K)

Evaluation of performance

(i)

Data collection and provider measures

The Secretary shall establish measures and standards for data collection by prescription drug plan sponsors to evaluate performance of pharmacies and other entities in furnishing medication therapy management services. Such measures and standards shall be developed by such date as to allow the application of such measures under this subparagraph beginning with the first plan year beginning after the date of the enactment of the Medication Therapy Management Benefits Act of 2011. Such measures shall be designed to help assess and improve 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. Prescription drug plan sponsors shall use such measures to compare outcomes based on the type of entity offering such services and shall ensure broader participation of entities that achieve better outcomes with respect to such services. The measures established under this clause shall include measures developed by the Pharmacy Quality Alliance (PQA) in the case of pharmacist providers. (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 described in clause (i), including the incorporation of medication use measures as part of broader health care outcomes measures. The Secretary shall work with State Medicaid programs to incorporate similar performance-based measures into State drug use review programs provided pursuant to section 1927(g). (iii)

Incentive payments

(I)

In general

Subject to subclause (II), for plan years beginning on or after the date that is 1 year after the date the establishment of measures and standards under clause (i), pharmacies and other entities that furnish medication therapy management services under this part shall be provided (in a manner specified by the Secretary) with additional incentive payments based on the performance of such pharmacies and entities in meeting the such measures and standards. Such payments shall be made from the Medicare Prescription Drug Account except that such payments may be made from the Federal Hospital Insurance Trust Fund or the Federal Supplemental Medical Insurance Trust Fund 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. (II)

Limitation

The total amount of additional incentive payments made under subclause (I) for a plan year may not exceed the amount by which the Secretary determines there are reductions in expenditures under this title during such plan year resulting from medication therapy management services furnished under this part.