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MTM: The promise, the challenge
uring the Capitol Hill debate over health care reform (HCR), APhA and much of pharmacy focused like a laser on making sure that medication therapy management (MTM) made the cut when the Affordable Care Act (ACA) passed Congress and was signed into law by President Barack Obama. With that accomplished, now comes another equally daunting challenge: getting funding for the MTM grants program authorized in the law and negotiating with federal officials—especially those in the important Agency for Healthcare Research and Quality (AHRQ)—on just how the funds will be used.
program. “The grant program will allow us to test MTM in different care settings and answer some of the questions that policymakers continue to ask,” Lunner said. “The goal is to identify the best way to deliver MTM services and use that information to expand patient access to these services.”
Tick tock, tick tock
“I am waiting, as are many pharmacists, to see what grant opportunities emerge from the HCR legislation,” said Stephanie Ferreri, PharmD, CDE, FAPhA, Clinical Associate Professor in the Division of Pharmacy Practice and Experiential Education at the University of North Carolina (UNC) at Chapel Hill. “I see my current MTM practice being able to possibly expand with these grants. I am hoping these grants will lead to MTM being provided to any patient who needs medication management.” Under the Medicare Modernization Act of 2003 that created the Part D prescription drug benefit, many targeted Medicare patients are already receiving MTM services. Patients with multiple chronic conditions and receiving multiple medications expected to cost at least $4,000 per year are eligible for MTM services. ACA takes this a giant leap further. “The requirements in the grant program are more expansive than the Medicare Part D MTM because the grant program is not specific to Part D,” said Anne Burns, Vice President of Professional Affairs at APhA. A larger number of patients will be eligible for MTM services when the grant program is funded.
With Congress focused on a difficult midterm election year, pharmacy may be running out of time to get MTM provisions funded before the federal government’s fiscal period begins October 1. “The politics of an election year will hamper efforts to fund many of the HCR initiatives, including the MTM grant program,” said Kristina Lunner, Vice President of Government Affairs at APhA. “While APhA continues to work to secure such funding, we are also looking for near-term opportunities for pharmacists to engage in activities with AHRQ that may provide pharmacy the opportunity to “tell the MTM story.’” The MTM grant program is addressed in Section 3503 of the Patient Protection and Affordable Care Act (P.L. 111-148) part of the ACA law. As noted in the law, the grant program would seek to improve the quality of care and reduce overall cost of treatment of chronic diseases through pharmacist-provided MTM services. Grant programs fund services (paying practitioners to provide care, so tha the number of patients getting such services is increased), infrastructure (increasing the number of practitioners set up to provide services), and research (assessing the best ways of implementing a new service). The use of the initial grant funds is still being discussed. The Health Care Reform Pharmacy Stakeholders, co-chaired by APhA, were instrumental in securing the grant language and have now turned their efforts to securing appropriate funding for the
Caiola said. “One, what would be adequate reimbursement for the service and two, in what way would service delivery models that allow pharmacists to perform the service be set up?” The details remain to be worked out about the needed physical facilities, appointment schemes, and documentation and communication processes with payers and prescribers, he added. “I don’t know what will happen with the MTM initiatives in community pharmacy,” Cailoa said. “However, I can say that most schools and colleges of pharmacy now are educating their students in the process, using one or more of the platforms available. So, in some ways, the future looks bright, as today’s students and grads are ‘ready to go’ in delivering MTM services.” Pharmacists and student pharmacists are working hard to be ready to build practices on provision of MTM ser-
Pharmacy is ready
When the grant program is funded, pharmacists will be ready to go. Just a few details remain to be worked out, explained Stephen Caiola, MS, Associate Professor and Chair of the Division of Pharmacy Practice and Experiential Education at UNC Chapel Hill. “The bottom line issue is obvious,”
vices. But now, the profession again looks to Congress to act on the needed funds. APhA is working on Capitol Hill to secure funding. “Like many other programs in the health care reform legislation, MTM is in for a tough fight for securing money in fiscal year 2011,” Lunner added. As this effort goes on, APhA and the stakeholders are working to identify other opportunities at AHRQ and in the private sector for expanding their capabilities to help patients improve their medication use and quality of life.
—Oriana Pawlyk 2010 APhA Intern in Political Journalism
q FDA: July 22–23 public advisory committee meeting on Risk Evaluation and Mitigation Strategies (REMS) for extended-release and long-acting opioid analgesics q FDA: July 27–28 public meeting on REMS Regulations whose comment periods have closed q FDA regs on direct-to-consumer advertising q FDA collecting information on experimental study of patient information prototypes q CMS interim final rule on inclusion of National Provider Identifier (NPI) in applications to participate in and claims filed under Medicare and Medicaid programs
What is happening noW!
Proposed regulations receiving public comments/upcoming public meetings q FDA: July 13–14 public advisory committee meeting on cardiovascular safety of rosiglitazone maleate (Avandia, GlaxoSmithKline)
Etc. q Be sure to download a flyer showing the timeline of events on the Hill that led to passage of health care reform. In the APhA Government Affairs section of pharmacist.com, the staff has posted a straightforward, 1-page timeline illustrating the process leading to passage and signing of this legislation. It’s available online in the Government Affairs section of pharmacist.com, and it’s a great tool for visualizing the events leading to passage of the Affordable Care Act. q A complete list of issues and regulations being monitored and acted on by APhA are in the Government Affairs section of pharmacist.com. q Hyperlinks to pharmacist.com, Federal Register notices, and other useful websites can be accessed in Hub articles on www.pharmacytoday.org.
Checks in the mail: Part D gap begins closing
s a first step in closing the Medicare Part D coverage gap by 2020, beneficiaries who enter the doughnut hole this year and are not eligible for Medicare Extra Help are starting to receive a one-time, taxfree $250 rebate check from Medicare.
The first checks were mailed on June 10, Peter Ashkenaz, a spokesperson for CMS, told Pharmacy Today. Checks will be mailed monthly as beneficiaries reach the coverage gap. Medicare Extra Help is a program for low-income beneficiaries. CMS posted a brochure in English and Spanish, titled Closing the Prescription Drug Coverage Gap, to provide information about the checks. CMS and the pharmaceutical industry are also ramping up for 2011 to implement the Medicare Coverage Gap Discount Program in the Affordable Care Act (the health care reform law). Changes will affect pharmacists, once again putting them in the position of explaining the changes to patients. Beneficiaries who reach the doughnut hole next year and are not eligible for the Medicare Extra Help program will receive a 50% discount on brand-name and some generic prescription drugs. The discount program, which will be effective January 1, 2011, represents the second step in closing the Medicare Part D coverage gap. According to the discount program’s final guidance, released by CMS on May 21, beneficiaries will see the 50% discount when they pick up their medications at their local pharmacy. At the point of sale
(POS), Medicare Part D plan sponsors will be responsible for determining if beneficiaries are eligible for a discount and if the drugs are discountable drugs, calculating the discount amounts on doughnut-hole claims, and including that information in adjudicated-claims response messages back to the pharmacies. Plans must reimburse pharmacies for the discounts within the same timeframe as Medicare Part D claims—14 days if submitted electronically or 30 days if submitted otherwise. Drug manufacturers will pay for the discounts to the plans after the claim is adjudicated; when manufacturers will pay is not certain, according to Ashkenaz. CMS released the final guidance to Medicare Part D plans to help them prepare for their 2011 bids, which were due June 7. CMS will coordinate all of this through a third-party administrative contractor, which also will help verify the accuracy of the manufacturer discounts reported by the Medicare Part D plans. In related activity, on June 1, CMS hosted a public meeting with drug manufacturers, Medicare Part D plans, and advocates for Medicare beneficiaries to discuss the final guidance and the draft manufacturer agreement. Manufacturers of applicable Part D drugs must sign agreements to participate in the discount program. APhA had earlier commented to CMS on the draft guidance; its comments
focused on the need to limit the discount program’s impact on pharmacy workflow and operations at the POS. APhA also expressed appreciation for CMS’s efforts to evaluate implementation options to minimize administrative challenges and financial burdens on pharmacists. APhA also recommended that CMS collaborate with APhA and other pharmacy stakeholders to develop educational tools about the discount program for pharmacists and pharmacies; work with the National Council for Prescription Drug Programs to ensure that POS claimsadjudication response messages clearly identify the discount or reason why the discount does not apply; and provide extra education and outreach to beneficiaries to limit confusion at the pharmacy.
HUB ON HEALTH CARE REFORM
provides readers with practical information on health care reform issues, what APhA is doing to keep pharmacists’ important role front and center with decision makers, and simple ways for pharmacists to participate in the processes that will determine the structure, function, and processes of a reformed American health care system. Send an e-mail message to APhA at gvtaff@ aphanet.org to offer suggestions for future content, ask questions, make comments, or request permission to use or copy this issue. © 2010 by the American Pharmacists Association. All rights reserved. Printed in U.S.A.
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