CMS Interested In Part D Plan Collaboration With Medicare ACOs
This article was originally published in The Pink Sheet Daily
Executive Summary
In a draft version of its annual instructions to Part D plans, CMS says it is seeking feedback from Part D sponsors and other stakeholders on “possible strategies for achieving better coordination” between stand-alone Medicare Part D plans and accountable care organizations to improve pharmacy care.
The Centers for Medicare and Medicaid Services is seeking comment on ways stand-alone Medicare Part D plans might collaborate with accountable care organizations to improve “coordination of pharmacy care,” the agency said in a draft version of its annual “call letter” to plan sponsors, released Feb. 17. The call letter provides instructions to sponsors for the 2013 benefit year.
“We are very interested in Part D sponsors of stand-alone prescription drug plans playing a greater role in managing the care of our beneficiaries in original Medicare and contributing to overall health outcomes,” CMS says. “One possible strategy under consideration to further this goal would be to enable business arrangements between the new Medicare shared savings program accountable care organizations (ACOs), or Pioneer ACOs, and Part D sponsors.”
Created under the Affordable Care Act, ACOs are organizations composed of the providers who interact with Medicare beneficiaries – from primary care and specialty physicians to hospitals and long-term care facilities – that are focused on coordinating care and controlling health care costs. Through the associated Medicare Shared Savings Program, ACOs will share in the cost savings achieved or be penalized for cost over-runs based on a spending benchmark, all while having patient outcomes measured to ensure care is improving.
Thirty-two ACOs, which CMS is calling “Pioneer ACOs,” started up Jan. 1 and other ACOs will be added during the year.
CMS is interested in feedback from Part D sponsors and other stakeholders on “possible strategies for achieving better coordination” between PDPs and ACOs. “We would like to receive information on specific activities that such coordination could consist of and on the benefits that could accrue to beneficiaries and the Medicare program from such interventions,” the agency says.
Promoting Better Medication Adherence
CMS adds that it is interested in comments from plan sponsors on payment or service delivery models that promote improved medication adherence. The ACO program currently involves managing drugs paid for under Medicare Parts A (administered in hospitals) and B (administered in physicians’ offices) but not outpatient drugs covered under Part D. Nevertheless, some of the patient care quality measures in the ACO program relate to promoting adherence with Part D drugs such as oral anti-platelet therapies, cholesterol reducers and anti-hypertensives.
CMS has already said it plans to provide Part D claims data to ACOs so they can see overall drug utilization and ensure compliance. Pharmacy groups are gearing up to partner with ACOs on proper medication management as well.
Allowing ACOs access to Part D claims data might help address a concern held by biopharma stakeholders that financial incentives for ACOs could promote inappropriate shifts in prescribing from the Part B benefit to Part D (Also see "Medicare ACO Cost Incentives For Part B-To-D Rx Shifts Worry Stakeholders" - Pink Sheet, 13 Jun, 2011.). In its final rule on the ACO program, CMS said it is confident there are enough protections in place to detect inappropriate B-to-D shifts that are driven by cost considerations. “To the extent that these lower cost therapies are not the most appropriate and lead to subsequent visits or hospitalizations under Parts A and B, then any costs associated with not choosing the most appropriate treatment for the patient would be reflected in the ACO's per capita expenditures," the agency maintained.
Closer collaboration between PDPs and ACOs also might allow some of the Part D formulary policies aimed at facilitating drug access to influence policies developed by ACOs. Drug companies have urged CMS to require ACOs to update evidence-based treatment guidelines in a timely manner as new treatments become available (Also see "Medicare ACO Rules For Adopting New Drugs Could Follow D Model – PhRMA" - Pink Sheet, 20 Jun, 2011.). CMS declined to do so in the final ACO rule, stating it believes “it is important that ACOs retain the flexibility to define processes that are best suited to their own practices and patient populations" (Also see "Final Medicare ACO Rule Rejects Pharma Industry Requests For Rx Access Protections" - Pink Sheet, 20 Oct, 2011.).
The ACO program is expected to intensify the need for drug manufacturers to demonstrate that their products can enhance patient outcomes while also reducing overall health care costs (Also see "Looking Ahead To 2012: ACOs Get In Gear, Accelerating The Need to Prove Biopharma Products' Overall Value In Health Care" - Pink Sheet, 2 Jan, 2012.). One other possible result of drawing Part D plans closer to the ACO environment is that it might increase scrutiny of costs for outpatient drugs as well.
Comments on the draft call letter are due March 2, and a final call letter is scheduled to be released April 2.