The Academy of Managed Care Pharmacy (AMCP) sent a letter the Centers for Medicare & Medicaid Services (CMS) commenting on proposed changes to the Medicare pharmacy benefit in 2013. AMCP’s comments pertain to the following issues in CMS’s 2013 draft Call Letter for Medicare Advantage (MA) and Part D prescription drug plans (PDPs):
- 2013 Plan Ratings: New Measures
- Integration with Accountable Care Organizations and Other CMS Innovation Models
- Medication Therapy Management (MTM) Programs
- Improving Drug Utilization Review Controls in Part D
To read AMCP’s March 2 letter, click here or visit the Letters, Statements and Analysis 2012 page at www.amcp.org/2012/. The following is a brief summary of AMCP’s comments:
2013 Plan Ratings: New Measures
- Measure of quality improvement: AMCP is pleased that CMS is working to account for contracts already achieving high scores and that CMS indicates that the methodology will not penalize high-performing plans and will not reward improvement over attainment. The Academy is concerned that CMS is introducing a measure when it does not appear that this measure has been tested and thoroughly vetted by the Medicare plans and other stakeholders. AMCP recommends that CMS take the time to thoroughly test and evaluate this measure, and either delay its introduction to 2014 or implement it as a Display Measure for 2013.
- High-Risk Medication (HRM) measure (Part D): The Academy encourages CMS to work with the Pharmacy Quality Alliance (PQA) to explore any changes to the technical specifications such as accounting for transition fills or single prescriptions. AMCP is pleased that CMS will apply changes in specification and on the medication list beginning in 2014 and not retroactively for the 2013 Plan Ratings.
Integration with Accountable Care Organizations (ACOs) and Other CMS Innovation Models
Coordinating the transfer of drug utilization information and partnerships in medication management between ACOs and PDPs should improve appropriate medication use and patient care. However, such coordination will not address the fundamental concern that Part D expenses are the only health care expenditures not assigned to an ACO. Physicians have strong incentives to manage all health care expenditures except Part D drug costs. CMS should consider aligning incentives by including some measure of appropriate Part D drug utilization as part of the measures used to evaluate ACOs.
Medication Therapy Management (MTM) Programs
CMS indicates it is considering including the PQA-approved MTM Completion Rate for Comprehensive Medication Review (CMR), which measures the percentage of MTM-eligible beneficiaries who received a CMR. The PQA measure sets the denominator as the number of MTM eligible beneficiaries and the numerator as the number of beneficiaries in the denominator who received a CMR. AMCP supports the inclusion of this PQA-developed MTM measure as part of the CMS star ratings. Including the measure in CMS’s star ratings will recognize the performance of Medicare Advantage (MA) and PDPs in delivering MTM services to their eligible patients.
Improving Drug Utilization Review (DUR) Controls in Part D
The Academy joins CMS in its concern about reports of fraud, waste and abuse within Part D. AMCP supports sensible changes to current regulations that would allow Part D plan sponsors to help combat the problem of prescription drug abuse. These include the Call Letter’s proposed three levels of acceptable drug utilization review (DUR) controls, to which AMCP has provided detailed comments:
- Level One: Improved Use of Concurrent Claim Edits (safety controls at point of service);
- Level Two: Improved Use of Formulary Utilization Management Designs (quantity limits at point of service);
- Level Three: Improved Retrospective DUR Programming and Case Management
In addition, the Academy supports CMS’s decision to allow Part D plan sponsors to implement beneficiary-level edits at point of service at all pharmacies, including the rejection of claims or rejection of quantities in excess of plan established limits of opioid analgesics. Similar beneficiary-level edits are commonly used in commercial and Medicaid benefits.
Although the language in the Call Letter further clarifies CMS’s intent and expectation in this area, it is still not entirely clear what plans may and may not do without being in danger of being cited for impeding beneficiary access to medications. AMCP encourages CMS to continue to work with Part D plan sponsors to define scenarios that may or may not be acceptable for beneficiary-level edits.
To read all of AMCP’s March 2 comments to CMS on the draft Advance Notice of Changes for Calendar Year 2013 in the 2013 Call Letter, visit www.amcp.org/2012/.