Part D: Medication Therapy Management Quality Measurement Improvement Kim A. Caldwell, RPh Senior Director Pharm

1. Part D: Medication Therapy ManagementQuality Measurement & Improvement Kim A. Caldwell, RPh Senior Director  Pharmaceutical Outreach/ReimbursementAbbott LaboratoriesFormer Division Director Clinical and Economic PerformanceMedicare Drug Benefit Group/CMS

2. Goals of the Presentation Review Part D value proposition Highlight MTM opportunities Other issues

3. Part D Challenges Access– To ensure that plans are available nationwide-both Prescription Drug Plans and Medicare Advantage – Minimum 2 per region Operations—To ensure that plans provide high quality service to beneficiaries and that they are able to operate effectively Education, Outreach, and Enrollment—To ensure that over 42 million Medicare beneficiaries can make confident decisions on their prescription drug coverage Three main challenges. Access– To ensure that plans are available nationwide-both Prescription Drug Plans and Medicare Advantage 2. Operations—To ensure that plans provide high quality service to beneficiaries and are able to operate effectively 3. Education, Outreach, and Enrollment—To ensure 42 million Medicare beneficiaries can make confident decisions on their prescription drug coverage All involve coordination and collaboration across the entire agency. Successful outreach also depends on successful collaboration with our partners. Three main challenges. Access– To ensure that plans are available nationwide-both Prescription Drug Plans and Medicare Advantage 2. Operations—To ensure that plans provide high quality service to beneficiaries and are able to operate effectively 3. Education, Outreach, and Enrollment—To ensure 42 million Medicare beneficiaries can make confident decisions on their prescription drug coverage All involve coordination and collaboration across the entire agency. Successful outreach also depends on successful collaboration with our partners.

4. Medicare Prescription Drug Coverage BACKGROUND Today, ~24% of Medicare beneficiaries DO NOT have prescription drug coverage Estimated 43 million Medicare beneficiaries will be eligible for Medicare prescription drug coverage in 2006

6. Part D Conclusion: Part D Drug Coverage will help beneficiaries pay for the medications that they need Prescription Drug Coverage is available to all Medicare Beneficiaries regardless of age For those beneficiaries who need it most, there is additional assistance available The Medicare Drug Benefit provides coverage for a broad range of prescription medications – brand and generic For those who qualify, Medication Therapy Management Programs are included in Part D

7. Question #1: How will you help your Medicare eligible friends, relatives pick a Part D Plan? Answer: Stick to the point…>

9. Medication Therapy Management CMS reviewed all submitted programs Following negotiations with Part D Plans, MTMP were accepted prior to contracts Oversight of MTM will be handled by CMS QIO’s have a responsibility to offer assistance for MTM as well as engage in other quality and clinical activities Programs can be quite varied Must meet all 3 criteria to be MTM Does NOT have to involve face-to-face

10. MTM Issues For 2006, CMS does not expect a rapid uptake into MTM programs Beneficiaries will be enrolling in new Plans Criteria must be met Plan enrollment is voluntary Anticipation that few will qualify for MTM prior to 2nd or 3rd Quarter of 2006 Data to determine actual health outcomes for 2006 programs will not be available until mid to late 2007

11. Medication Therapy Management Medication Therapy Management Programs (MTMP) are designed to: Ensure optimum therapeutic outcomes for targeted beneficiaries through improved medication use Reduce the risk of adverse events Reduce drug-drug interactions

12. Medication Therapy Management Part D provides both the opportunity and the mechanism for those beneficiaries identified as most in need (due to utilization and/or risk) to receive additional benefit Part D Plan Sponsors must make available MTM programs to qualified beneficiaries

13. MTM: The Future Collaboration with stakeholders to establish criteria for minimum quality standards, standards of care for interventions, and validate new measures Establish uniform methods for provider reimbursement Identify and effectively characterize beneficiaries who derive the greatest benefit from MTMP interventions

14. Electronic Prescribing/EMR Final Rule posted November 7, 2005 Effective date of Rule requirements is January 1, 2006 Rule is intended to cover transactions involving the electronic transmission of prescriptions and certain other information for covered Part D drugs prescribed for Part D eligible individuals Emphasis added --

15. State Preemption ‘CMS is’ interpreting section 1860D-4(e)(5) of the Act to preempt all contrary State laws that are applicable to a prescription that is transmitted electronically not only for those individuals who are enrolled in Part D, but for all Part D eligible individuals. RED FLAG: this can create 2 sets of standards within State regulatory boundaries if States do not adjust their Rules

16. Thoughts for the Day Electronic Prescribing and Electronic Medical Records are virtually here. States should take a proactive role in assuring uniformity when possible to eliminate double standards based upon MMA 2003 preemption authority. Safety, Quality, Cost-containment are critical reasons to support and push electronic prescribing.

18. Other Issues: Data and Data-mining Fraud, Waste, Abuse Oversight Long-Term Care ??