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NACDS: MTM needs to be part of health care reform
June 8th, 2009
WASHINGTON – The prospects for meaningful health care reform are better than at any time since President Clinton’s first term, creating an opportunity for the National Association of Chain Drug Stores and its allies in community pharmacy to achieve two long-sought-after goals.
The first — to stave off cuts in Medicaid payments that would entail a shift in the way reimbursements are calculated — is essentially defensive. The objective is to prevent changes that would make it unprofitable for pharmacies to participate in the program.
The second — to foster more widespread use of medication therapy management (MTM) and mandate payment for it — is potentially transformative. It would represent a major step toward changing the basis on which community pharmacy is compensated from one that focuses on product reimbursement to a payment model that also recognizes the value of accurate reimbursement for such professional services as MTM.
Establishing a place for MTM in the health care continuum would elevate the standing of the profession and put it in a better position to help rein in the growth of health care spending.
NACDS is working to convince members of Congress and the Obama administration to make both objectives a reality. While tangible progress has been made on the Medicaid front, MTM remains a more elusive, but arguably more significant, target.
An important cornerstone was achieved with the Medicare Modernization Act (MMA), which included a requirement that Part D plans offer MTM services to eligible beneficiaries. According to NACDS vice president of government affairs Paul Kelly, it was the first federal recognition of the pharmacist’s critical role in providing MTM services.
But MMA suffers from some serious weaknesses in regard to MTM that NACDS is currently striving to correct.
“There was not a lot of empirical evidence to demonstrate the value of MTM, and Congress did not want to be too prescriptive, so they gave the health plans flexibility in how they delivered MTM services,” Kelly explains. “So there’s a real lack of standardization in the benefit.”
Many plans, for example, do not provide Part D beneficiaries with the option to obtain MTM services from local community pharmacies, instead offering less interactive methods such as newsletters and telephone refill reminders. Moreover, beneficiaries who switch plans for formulary reasons may find that their new plans do not offer the same MTM services as their old ones.
“We don’t think that’s a quality benefit,” says Kelly. “So we’re proposing that MTM should be provided by a pharmacist, and that priority should be given to a face-to-face encounter whenever possible, because some of the research available now indicates that is how to obtain the highest value and the best service.”
In addition, MMA placed sharp restrictions on who could receive MTM services. Patients must have multiple chronic diseases and be taking multiple drugs covered by Part D, for example. Moreover, Part D plans are free to decide how they define multiple diseases or multiple drugs, causing even more inconsistency. As a result, only 10% of Part D beneficiaries were deemed eligible for MTM services in 2007.
“We point out to people on the Hill or in the media that fully 77% of those eligible take advantage of the benefit,” Kelly remarks. “We think that indicates there is great understanding on the beneficiaries’ part that these are very valuable services.”
Consequently, he adds, the twin focus of NACDS’ efforts is on standardization of benefits across different plans and on broadening the eligibility criteria so that more patients can take advantage of MTM.
By sometime this autumn, NACDS and its allies on Capitol Hill and within the administration should receive help in the form of prescription spending data being compiled by the Centers for Medicare and Medicaid Services that will illustrate the impact of Part D on overall health care costs.
“This will link Part D data back to Parts A and B, hospital and physician services, and will enable us to research and analyze how the use of prescription medications has impacted expenditures in the other two key parts of the Medicare program,” says Carol Kelly, NACDS’ senior vice president of government affairs and public policy.
“We would expect that as MTM becomes more standardized and targeted, and is able to help beneficiaries more, we will see even greater savings through less use of hospital and physician services because people are staying on their medication regimens.”