Montana Proposed Prescription Monitoring Program FAQ

Information for Pharmacists About the Proposed Prescription Monitoring Program in Montana

What is a Prescription Monitoring Program? A prescription monitoring program (PMP) utilizes a centralized database to collect controlled substance prescription information which is submitted by pharmacies licensed by the state. Prescribers, pharmacists, and patients may request information from the PMP which lists the prescriptions filled for a patient during a specified time period including drug, quantity, prescriber, pharmacy, and method of payment.

What is the purpose of a PMP? A PMP is intended to be a source of information for prescribers and pharmacists to use in the care of patients. It should be used to supplement a patient evaluation, to confirm a patient’s medication history, or to document compliance with a therapeutic regimen. A PMP is also a tool to help deter prescription drug abuse and diversion. A PMP is NOT intended to prevent patients from obtaining needed medication or to interfere with legitimate prescribing.

What other states have implemented PMPs? 29 states have implemented prescription monitoring programs and another 9 states have passed legislation and are in the process of implementing their programs. All of the states bordering Montana have active prescription monitoring programs, except South Dakota, which is also introducing PMP legislation.
The proposed PMP in Montana differs from all other states in that information on ALL prescription drugs, not just controlled substances and drugs of abuse, would be available. Since the goal of the PMP is to provide information to prescribers and pharmacists in the care of their patients, a complete medication list would provide the best information.

Does Montana have a prescription drug abuse problem? YES! According to a national survey conducted annually by the Substance Abuse and Mental Health Services Administration, Montana ranks 5th in the U.S. for illicit use of drugs and Montana teens rank 2nd for abuse of prescription pain relievers. Data from the Montana State Crime Lab in 2007 shows 8 deaths attributed to methamphetamine versus 141 deaths attributed to prescription opioids.
How does a PMP work? Prescription information is submitted electronically to the PMP by pharmacies on a weekly or biweekly basis. Prescribers and pharmacists must apply for an account and be credentialed prior to receiving access to the PMP. Once access is granted, a prescriber or pharmacist must have a patient relationship with the person on whom a report is requested. The PMP is accessible via computer 24/7 and in most cases a report is available in less than a minute.

How is patient privacy protected? The information in the PMP is protected health information under HIPAA. HIPAA allows heath care providers to access patient information for the purpose of providing treatment to a patient. Under HIPAA, law enforcement can access protected health information with a subpoena or search warrant so the information in the PMP would only be released to law enforcement with a subpoena or search warrant. The PMP does not provide any additional access to information that health care providers or law enforcement currently have or that is allowed under HIPAA.

Is the PMP database secure? The information in the PMP is stored on secure servers that are dedicated to the prescription monitoring program, and PMP information is exchanged via a secure network. Access to the network is granted when providers are approved for an account. These are the same security measures implemented by health care organizations to protect electronic medical records.

Where will the PMP database reside? The PMP will be located in and administered by the Board of Pharmacy. The Board will employ a pharmacist PMP administrator to oversee the program. The PMP database is a stand alone system. It will not be part of the state’s computer system.
What is the cost of the PMP and who will pay for it? The start up cost of a PMP in Montana is estimated to be $365,000. Federal grant monies are available to help states implement or enhance their PMPs. In 2007, Montana was awarded a $400,000 PMP grant however the money could not be accepted because the PMP legislation failed to pass. We will apply for the same grant in 2009. The annual maintenance cost of a PMP is estimated to be $210,000. If grant monies are not available, the program would be sustained by increasing licensing fees of prescribers, pharmacists, pharmacies, and drug wholesalers. Based on the current number licensees in Montana, the fee increase is expected to be approximately $20 per year if it is spread evenly.

The cost to pharmacies to submit their prescription data is expected to be minimal to none. Since the majority of states already have PMPs, the technology and programming are already available in contemporary pharmacy information systems. The workload burden on pharmacy staff is also expected to be no more than calling up a report, typing in a date range, and clicking the send button. If electronic submission of PMP data imposes an undue burden on a pharmacy, the Board will work with that pharmacy to determine a mutually acceptable method of reporting.

Save Our Hospices From Devastating CMS Cuts!

On April 28, 2008, The Centers for Medicare and Medicaid Services (CMS) acted on a provision in the Administration’s FY09 budget proposal that would cut hospice reimbursement rates by altering the wage index adjustment (phasing out the budget neutrality factor). CMS has stated publicly that the final rule on this provision is expected on August 1, 2008.

While this may seem like a regulatory adjustment that would make minor changes to hospices wage formula, the regulation would take more than $2.3 billion from a health care sector that has 3.4% margins, according to a recent MedPAC study. Once fully implemented, this regulation would cut reimbursement in some areas by more than 18%. Make no mistake, these cuts will force programs to decrease services or close their doors completely. For example, in Texas, hospice programs will be especially hard hit. In Houston/Harris County, full implementation will bring rate reductions of 6.89%. Dallas/Dallas County programs will see losses of 7.74%. More rural areas, such as Lampasas County and McLennan County, will see cuts of 13.11% and 7.5%, respectively.

Hospice programs all across America served more than 1.3 million patients and families last year, in the place they call their homes, and that number is expected to continue to rise as more terminally ill patients seek high quality, compassionate end-of-life care. Additionally, research shows that hospice is cost effective. An independent Duke University study in 2007 showed that patients receiving hospice care cost the Medicare program about $2,300 less than those that did not. This amounts to more than $2 billion of savings each year.

Each day, thousands of people enter hospice programs, along with their families. This signifies their decision to spend their last days, weeks or months in the place they call home, relatively free of pain and intrusive medical interventions. They are surrounded by their families, friends and spiritual counselors. They die with the comfort of knowing that the grief and bereavement needs of their loved ones will be taken care of once they are gone. This is a choice that is free of political, racial or gender limitations. More than 80% of Americans making this choice each year are Medicare beneficiaries and their families are counting on this service to remain intact for future generations. Interestingly, more than 98% of these families would recommend hospice for another loved one.

On behalf of the millions of Americans who benefit each year from compassionate end-of-life care and bereavement services, I respectfully ask that you to halt further action on this regulation. I sincerely hope that you will stand with me in supporting continued access for all Americans to hospice care.

From National Hospice and Palliative Care Organization (http://www.nhpco.org/)

Please contact our representatives to urge them to save our Hospice programs at http://www.grizrph.com/repcontact.htm. You are welcome to use this letter that the National Hospice and Palliative Care Organization has provided for us to send.

Thank you!

We're Saved! Presidents veto of HR 6331 has been overridden by Congress!

On July 15th, Congress overrode the President's veto of HR 6331, the "MEDICARE IMPROVEMENTS FOR PATIENTS AND PROVIDERS ACT OF 2008". This bill had seen a lot of action in just a short period of time since it was introduced into the House on June 20th, 2008 and redrafted 4 times in which to pass both Senate and House by July 10th only to have the President veto the bill on July 15th. Later that day, both the House and the Senate overrode the veto with 2/3rd majority. This was a major victory for pharmacy!

With this bill as law, Physicians will actually get a 0.5% increase rather than a 10.6% decrease in reimbursement that was retroactive back to July 1, 2008.

For Pharmacy:

1. Requiring a 14-day reimbursement cycle for electronic Medicare Part D claims. Unfortunately this provision of the bill doesn't go into effect until 1/1/2010.

2. A further delay to Oct. 1, 2009 in instituting AMP-based Medicaid generic drug reimbursement cuts.

3. Postponement of the Medicare DME competitive bidding program for 18 to 24 months. CMS has clarified this as a postponement on implementation of Competitive Bidding Round 1, and a cancellation of accreditation deadlines for Competitive Bidding Round 2. CMS also clarifies that the deadline of September 30, 2009 that was previously established by which ALL DMEPOS suppliers must be accredited is still in effect.

The DME Competitive Bidding areas for Round 1 now are NOT subject to implementation: (1) Charlotte-Gastonia-Concord, NC-SC, (2) Cincinnati-Middletown, OH-KY-IN, (3) Cleveland-Elyria-Mentor, OH, (4) Dallas-Fort Worth-Arlington, TX, (5) Kansas City, MO-KS, (6) Miami-Fort Lauderdale-Miami Beach, FL, (7) Orlando-Kissimmee, FL, (8) Pittsburgh, PA, (9) Riverside-San Bernardino-Ontario, CA, and (10) San Juan, PR.

The votes were 383-41 in the House and 70 to 26 in the Senate, meeting the constitutional requirement for two-thirds margins to enact legislation without the president's signature. "The passage of this bill will guarantee community pharmacies the ability to help millions of patients and to compete on a level playing field," said Bruce T. Roberts, RPh, NCPA executive vice president and CEO.

Please thank your Representatives.all of them were for passage of HR 6331 and they got the job done.this wasn't any easy task! Use this link for their contact information: www.grizrph.com/repcontact.htm

HR 6331 passed Senate today and goes to President for Signature

With pressure on Senators from the American Medical Association as well as TRICARE and the re-election status for Senators, the Senate passed HR 6331, legislation that includes a 14-day reimbursement cycle for Medicare Part D claims, a further delay in AMP-based Medicaid generic drug reimbursement cuts, and suspension of the Medicare DME competitive bidding program. The cloture vote was 69 to 30. Sixty votes were required to move to final passage of the measure, whose main focus has been on preventing a 10.6% cut Medicare payments to physicians. Two previous attempts failed in the Senate last month. The House passed the bill with a cloture vote of 355-59 on June 24th. This bill will very shortly move to the President’s desk for signature.

Senate Democrats reminded members every chance they could that Medicare physician payment cuts will not just jeopardize seniors health care, but that of the nations troops and veterans. Military Officers Association of America on Tuesday sent 14,000 emails to their senators reminding them off this, since TRICARE rates are linked to Medicare rates by law.
Please send Senator Baucus a sincere thank you for all the hard work he has done to preserve the future of pharmacy and a thank you to Senator Tester as well for his strong support of pharmacy by supporting all our bills and vote for HR 6331.

In addition, if you hadn’t sent a thank you to Congressman Rehberg on voting for HR 6331, please do so. Representative contact information on http://www.grizrph.com/.

PBM Settles Rebate Scheme Charges With States

Express Scripts last week reached a $9.3 million settlement with 29 states resolving claims that it engaged in deceptive business practices by encouraging doctors to switch patients to different brand name drugs that would produce higher rebates for the giant PBM and were more expensive to plans and patients. As part of the settlement, the company is required to "significantly" change its business practices.The settlement is the third entered into in recent years by various groups of states and the country's largest PBMs aimed at cleaning up the industry. In February, Caremark agreed to pay $38.5 million and reform its business practices. In April 2004, Medco agreed to pay $29.3 million and end its malpractices.These settlements are not related to cases that certain PBMs have settled with the Department of Justice. In October 2006, Medco paid $155 million to settle civil fraud and kickback claims. In September 2005, AdvancePCS, now a Caremark subsidiary, resolved similar allegations with a $137.5 million payment. Both PBMs also were required to enter into extensive corporate compliance agreements with the government.

by the National Community Pharmacists Association

Impact of AMP on states: report by Price Waterhouse Coopers

PriceWaterhouseCoopers claims that 11,105 pharmacies will close due to the Average Manufacturer Price (AMP) provisions in the Deficit Reduction Act of 2005 (DRA).

The Medicaid program pays retail pharmacies a dispensing fee plus a reimbursement rate meant to cover the cost of acquiring the drug from the manufacturer for Medicaid prescriptions. The federal government imposes a federal upper limit ("FUL") on reimbursement rates for certain generic drugs that states generally adopt under their Medicaid programs. The Deficit Reduction Act of 2005 ("DRA") generally decreased FULs by changing their calculation method, but litigation has prevented the new reimbursement levels from being implemented. The changes in the Medicaid reimbursement rates under the DRA would dramatically lower pharmacy reimbursement rates. The decline in the profitability of pharmacies participating in Medicaid could result in thousands of pharmacies closing, making pharmacies less accessible to Medicaid participants. If reduced accessibility of pharmacies made beneficiaries less likely to utilize prescription drugs, their health could be adversely affected.

The National Association of Chain Drug Stores and the Food Marketing Institute engaged PricewaterhouseCoopers to analyze the potential impact of the DRA on pharmacies by state.

Montana: DRA cuts could cause 51 pharmacies to close (24.6% of our rural pharmacies), affecting 324 direct jobs and 688 jobs across the entire state economy.

Please read the Full Report

Democrats to write their own bill for Medicare/ Medicaid Fix

05/21/2008
Baucus: No Bipartisan Deal For Medicare Payment Fix
by Anna Edney


Senate Finance Chairman Max Baucus has ruled out the possibility of reaching a bipartisan compromise on legislation to prevent Medicare physicians from taking a pay cut, saying today Democrats would move forward with their bill that will include offsets staunchly opposed by the White House. "It seems clear to me that we're not going to get agreement in time to meet the deadline," Baucus said after a meeting with Finance Committee members. The pay cut is set to take effect July 1. Republicans offered Democrats a counterproposal, but Democrats appear to have walked away from the table without giving the GOP an answer, a Republican aide said. The Republican offer included $10 billion in private Medicare Advantage cuts as well as marketing restrictions for the private plans and beneficiary improvements totaling $3 billion, a GOP aide said. Baucus was unsure how much his bill might cost, but previously estimated between $15 billion and $18 billion.Baucus said that the bill, which he will work on over Memorial Day recess, will prevent the 10 percent physician pay cut for 18 months and include an increase. Baucus was not sure what the pay increase would be but characterized it as "a little bump." The bill will be paid for through cuts in Medicare Advantage private fee-for-service and indirect medical education, offsets that are likely to draw a veto. The private fee-for-service plans are paid more than traditional Medicare plans to provide extra benefits, while indirect medical education payments are made to teaching hospitals but considered duplicative. The administration refuses to greenlight cuts to any private plans. "They're afraid of the White House," Senate Finance Health Subcommittee Chairman John (Jay) Rockefeller, D-W.Va., said of Republicans. "All they think about is will this get vetoed or not. They never think about will this help patients [and] beneficiaries."Baucus said the Democrats' bill will include electronic prescribing requirements and changes to an asset test for low-income beneficiaries to qualify for prescription assistance. The bill also will have a provision that pharmacy groups pushed for to require pharmacy benefit managers to reimburse pharmacies for Medicare prescriptions more quickly than the current payment period of 30 days or sometimes longer. Baucus expects the Democrats' bill to bypass the committee and go straight to the floor. Finance ranking member Charles Grassley said today he still will attempt to reach a compromise. If that does not happen, Grassley said, Republicans will offer their own proposal.

Opposition to H.R.5839 by NCPA, NACDS, and FMI

NCPA, NACDS, FMI Oppose Unfunded E-Pedigree Mandate Retail pharmacy groups are united in their opposition to legislation as currently written that includes "an unproven, unfunded electronic pedigree/track and trace requirement." NCPA, the National Association of Chain Drug Stores, and the Food Marketing Institute, said in a letter to members of the House Energy & Commerce Committee:



"First, track and trace systems are many years away from full development and have not been thoroughly tested."



"Second, track and trace systems in their current form could be hugely disruptive to the efficient delivery of prescription drugs and pharmacy care."



"Finally, track and trace could be hugely expensive, costing each pharmacy location several thousands of dollars to purchase and install new hardware and software programs."



The groups said that they support the goal of the legislation, H.R.5839, to help secure the prescription drug distribution system against counterfeit drugs, but not the "unproven, disruptive, and costly" unfunded mandate.



from NCPAnet.org

AMP...Loose Ends?

The NCPA/NACDS Federal Court injunction bought us some time (about 6 months to a year) until we are able to provide a fix for AMP (Average Manufacture Price). This is the time we need to utilize our resources, pull together, and FIX AMP before it “fixes” us. Even though we need to work towards the AMP FIX goal, it is unlikely that S.1951/ H.R.3700 will get pushed through Congress this year. The physician Medicare fee cuts are coming up at the end of June and this is perhaps what we can “tie” another delay to. I know it seems kind of cheesy to delay only to delay again, but the alternative is much worse. Basically, if there isn’t time to fix AMP and find a large piece of legislation to “tie” it to in which to get through Congress (ie: Medicare package), then a delay is what we need for the time being. We already have Baucus and Tester on board in our Senate, we must have Congressman Rehberg on board as well. HR3700, the `Fair Medicaid Drug Payment Act of 2007' in the House of Representatives, is the exact same bill as Baucus’s S.1951 in the Senate. By the way Senator/ Presidential Candidate Barack Obama [IL] is a co-sponsor of S.1951 and S.1954 since 12/03/07.

Rehberg has been a wonderful supporter of community pharmacy but we need his help now more that ever! Bring these points to his attention: (Please also visit www.grizrph.com/spotlight.htm for more information on this important pharmacy legislation including SAMPLE LETTERS)

The devastating effects of AMP if implimented:
1. The Government Accountability Office (GAO) identified the reimbursement on average is 36% less than the acquisition costs for generic medications
2. Director of the PRIME Institute at the University of Minnesota, argued that with the 250% of AMP rule, as many as 10,000 to 12,000 pharmacies in rural and underserved urban communities would close, causing irrevocable harm
3. President Bush’s 2009 Fiscal Budget includes another 1.1 BILLION in cuts from pharmacy reimbursement which would equate to 150% of AMP not just 250% of AMP which would seal all our fates if ever enacted.
4. According to NCPA and CMS, community pharmacies would lose $5.5 million a day under the rule as written.

Why H.R.3700 and S.1951:
1. Remove mail order transactions and certain other discounts, rebates, and price concessions from calculation of AMP
2. Base pharmacy payment on average AMP, instead of the lowest AMP
3. Apply the AMP formula only when three or more alternatives are available, instead of two or more
4. Raise Medicaid payment to 300% of AMP instead of 250%
5. Require prior authorization for brand name drugs that are more expensive than other biologically and therapeutically equivalent drug products
6. Senator Baucus, the chair of US Senate Committee on Finance, and Representative Pallone, the chair of the Subcommittee on Health in the Energy and Commerce Committee, are in strong positions to move their respective legislation.
7. Make sure to ask him to co-sponsor H.R.3700 as well as attach a delay to the June 30th physician Medicare cut bill.
8. Don’t forget to thank him for his support on H.R.971, and H.R.1474.


Sample letter to Congressman Rehberg (HR 3700) ; Bag Stuffers for loyal customers; Contacts for Congressman Rehberg.

NEW OIG REVIEW

In addition, please visit GrizRPh NEWS on www.grizrph.com for the new Office of Inspector General (OIG) report for the new figures on Medicare reimbursement to community pharmacies. Thanks to Tobey Schule for sharing this report with us. Please click on the pdf link to veiw the full document.

Here is a very brief summary:
This review was conducted at the request of 33 Senators. Medicare Part D payments, excluding dispensing fees, to local, community pharmacies exceeded the pharmacies' drug acquisition costs by an estimated 18.1 percent when the analysis included rebates that drug wholesalers paid to pharmacies. Excluding rebates, Part D payments exceeded drug acquisition costs by an estimated 17.3 percent. The estimated difference between Part D payments and drug acquisition costs was $9.13 per prescription including rebates and $8.78 excluding rebates. The estimated average Medicare Part D dispensing fee paid to local, community pharmacies was $2.27 per prescription, about $2 less than the average Medicaid dispensing fee. It was recommended that Congress and CMS consider the results of the review, including the data provided, in any deliberations regarding Medicare Part D reimbursement. CMS concurred with the recommendation.

AMP

AMP
On 12/19/2007, Royce C. Lamberth, United States District Judge, signed Court Orders to postpone AMP (Average Manufacture Price) and to postpone the posting of AMP on a public website. At this time, if there is no appeal to the courts by CMS, which will cause further delays, this will give us some time to try to get something passed that makes sense so pharmacies can keep their doors open to Medicaid patients. Thanks to NCPA and NACDS for their strategic lawsuit and thanks to all those individuals who put forth so much effort trying to convince Congress of CMS’s ill conceived AMP proposal. NCPA’s Chris Parinello explained we have about 2 months, hopefully longer, for the lawsuit to hold and hopefully we are able to get a further delay at least until June about the time the physicians Medicaid bill gets revisited after their delay, and pass legislation to fix AMP…much more on this issue later.