1. coordinating medical & pharmacy care

For most patients, the current health care delivery system lends itself to fragmented, uncoordinated care.  They are typically seen in a clinical setting, where the patient is diagnosed, and travel to the pharmacy where they receive their medications, but there is rarely a clinical feedback loop between settings. Patients can get help managing their medications from both settings, but oftentimes these services are provided in clinical silos as funding streams are disparate. In order to more successfully manage patients’ medications and their adherence to a care plan, pharmacy and medical care should be better coordinated. Doing so has the potential to eliminate duplication and confusion. P4HA is working with Congress and the Administration to ensure that Federal Health Programs more effectively coordinate pharmacy and medical services for beneficiaries.

• Advocate for legislation that provides Medicare A/B claims data to Part D Plans in order to enhance the effectiveness of current and future medication management programs.
• Advocate for State Medicaid Programs to link claims data between the pharmacy and medical benefits.
• Explore options for leveraging data standards to more effectively link pharmacy and medical care on an individual patient level.
• Explore policy options for realigning incentives between Medicare A/B and D to develop more robust adherence programs.
   

2. achieving safe harbor protection for adherence interventions

Robust adherence programs can help patients achieve better health outcomes and contain health care costs. Unfortunately, health care providers, plans, and drug manufacturers are discouraged from developing and carrying out programs to improve patient adherence because of the risk that such programs will implicate the federal anti-kickback statute. A well-designed “safe harbor” to the anti-kickback statute can fill an important gap in the current regulations, which have not been updated in years. P4HA will advocate for a safe harbor that allows for investments in strategies that promote adherence and persistence to medications.

• Advocate for a regulatory safe harbor that protects adherence programs.
• To support the safe harbor proposal, P4HA will release a white paper describing the need for adherence programs to be protected under a safe harbor, and continue to build third party support around a safe harbor proposal.
   

3. medication therapy management

In 2003, the Medicare Part D Medication Therapy Management (MTM) benefit was established to provide medication counseling for beneficiaries with multiple chronic conditions, who are on multiple medications  and who spend nearly $4000 on those medications. In 2015, CMS formally recognized that the MTM program wasn’t working well and established the Enhanced MTM demonstration project through the Innovation Center (CMMI). P4HA is working with Congress and the Administration to shape policies reforming MTM, thereby creating a more flexible program that effectively targets medication management services to those who need them most.

• Reform the MTM program by changing eligibility criteria to ensure the benefits are targeted to those in need.
• Ensure incentives are properly aligned to lower costs and improve outcomes.
• Monitor the Enhanced MTM demo and engage with CMMI as opportunities arise to shape the program.
   

4. other medication management programs

Comprehensive Medication Management (CMM) and Medication Synchronization are two promising programs that can help patients achieve better health outcomes and contain health costs; these have been rolling out in the private sector. P4HA is working with Congress and the Administration to embed successful programs that improve outcomes and reduce overall health costs within the Medicare program.

• Advocate for the inclusion of CMM as an “improvement activity” under the Merit-Based Incentive Payment System (MIPS), established in the Medicare Access and CHIP Reauthorization Act (MACRA).
• Expand the use of CMM in state programs- such as Medicaid and in the State Employee Health Benefit Programs- for beneficiaries with complicated medication regimens or for those beneficiaries who are high utilizers of health services due to medication complications.
• Promote the appointment-based synchronization model in states and for Medicare beneficiaries.   

5. Health IT Tools

There are many health IT tools and standards that can be leveraged to help patients manage their medications. P4HA is working with the Administration and Congress to promote incentives to adopt and use technologies that promote improved adherence.

• Promote standards that coordinate various EHR functions, such as e-prescribing, disease management, medication reconciliation and electronic prior authorization, into a working, electronic-based system that promotes high quality care delivery.
• Promote the bidirectional exchange of information (i.e. fill/refill data, medication management interventions) and interoperability across prescribers, pharmacists and patients.