Humana, UnitedHealthcare and Blue Cross Blue Shield are among organizations selected by the Centers for Medicare and Medicaid Services to participate in a new Part D enhanced medication therapy management model.
Medication therapy is to help ensure that medications, particularly high-risk medications, are taken properly and not overused. The result should be improved care and significant savings from reduced hospital and emergency room visits.
CMS is giving the six model participants financial incentives to change the status quo and to innovate Part D prescription drug plans. Those that achieve a 2 percent reduction in fee-for-service expenditures will qualify for a performance payment in the form of an increased beneficiary premium subsidy.
Also, plan-specific prospective payments will support more extensive interventions outside of a plan's annual Part D bid, and it will not impact premiums, CMS said.
In addition, the model plans will have the ability to get CMS beneficiary-level Parts A and B claims data to assist with the identification of individuals at risk for medication-related problems.
Plan participants can eliminate duplicative therapies, as well as switch to similar, lower-cost medications, both of which can reduce prescription drug costs, CMS said.
The five-year model begins January 1, 2017 in selected regions in the states of: Virginia, Florida, Louisiana, Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota, Wyoming and Arizona.
The six organizations taking part during the first year operate a total of 22 plan benefit packages, providing benefits to an estimated 1.6 million beneficiaries, CMS said.
They are: Blue Cross Blue Shield of Florida; Blue Cross Blue Shield of Northern Plains Alliance in the Great Plains Region; CVS Health in Arizona, Florida, Louisiana, Virginia and the Great Plains Region; Humana in Arizona, Florida, Louisiana, Virginia and the Great Plain Region; UnitedHealthcare in Arizona, Florida, Louisiana, Virginia and the Great Plains Region; and Wellcare Prescription Insurance in Arizona, Florida, Louisiana, Virginia and Great Plains Region.
The Great Plains Region is comprised of Iowa, Minnesota, North Dakota, South Dakota, Nebraska, Wyoming and Montana.
Evidence suggests that the current, uniform Part D plan services fall short of their potential to improve quality and reduce unnecessary medical expenditures, CMS said.
Key elements of the model include: Greater regulatory flexibility; flexibility in communication strategies between beneficiary, pharmacist, and medical provider; the ability to offer cost sharing reductions to financially needy beneficiaries; and the ability to offer different services to individual enrollees based on their level of medication-related risk.
Drug plans can work with their network pharmacy providers and prescribers to identify and intervene with beneficiaries who have issues with medication management that have caused, or are likely to cause, adverse outcomes and increased costs.
Upon approval from CMS, selected prescription drug plan participants can vary the intensity and type of interventions they provide based on beneficiary risk level and individualize outreach and engagement.
The model aims to achieve better alignment of prescription drug plan and government financial interests, while also creating incentives for investment and innovation, CMS said.
Beneficiaries who do not want enhanced therapy management services may opt out of any offered assistance at any time.