Earlene Lipowski, PhD

Most Medicare providers and beneficiaries are unaware of the provision for comparative effectiveness research which is part of the Medicare Modernization Act. Politicians, policymakers, and manufacturers view it as a key initiative for the future of Medicare and beyond.

The shift from Republican to Democratic control of Congress ensures ongoing debates about requiring Medicare officials to negotiate directly with pharmaceutical firms for lower drug prices. The Medicare Modernization Act (MMA) expressly forbids interference from the HHS secretary in negotiations between manufacturers and pharmacies or PDP sponsors, and prohibits the establishment of a formulary or price structure for reimbursement under Part D.

As many pharmacists are aware, all Medicare Part D plans must offer medication therapy management (MTM) to assist beneficiaries who (1) have multiple chronic diseases, (2) take multiple medications, and (3) are likely to spend more than $4,000 on medications annually. MTM services are intended to promote patient understanding about medication use, increase adherence to drug regimens, and detect drug-related problems.

Medicare Part D has gone a long way toward closing an important gap in healthcare coverage by providing a prescription drug benefit to enrollees. Now several government agencies are aiming to close the gap between the availability and use of covered preventive services among persons with Medicare. The goal is to do more to help beneficiaries manage their medical care rather than just paying the bills.

It is probably safe to say that pharmaceutical manufacturers as a group approached the implementation of Medicare Part D with mixed feelings. Although the benefit is seen as likely to increase access to medication among those eligible, large government programs run the risk of concentrating purchasing power, thereby lowering prices and decreasing profits over time. Early indicators remain mixed.

Previous columns examined the Medicare decisions that plans faced for 2007 and the choices available to enrollees. Pharmacists, too, will be facing some plan adjustments as the new year begins. In some cases pharmacy providers must sign and return a contract to continue their participation in pharmacy networks associated with the plans. Many pharmacies work with a third-party contracting organization that will sign the agreement on their behalf. Although many existing contracts expire on Dec. 31, 2006, CMS is encouraging plans to adopt automatic renewals, or evergreen contracts, for subsequent years.

Very few drug plan providers left the Medicare market in 2007, but their offerings have shifted. There are fewer plans offering basic coverage and more offering enhanced coverage. Beneficiaries in most states have 50-60 prescription drug plans to consider including 15 or 16 that offer partial or complete coverage in the donut hole.