Quality improvement panels to oversee Part D

August 22, 2005

When the Medicare Part D program starts up next year, one group that will be monitoring the quality of services provided by pharmacists is made up of the state-based quality improvement organizations (QIOs). So reported Karen Bell, M.D., M.S., division director of the Quality Improvement Group at the Centers for Medicare & Medicaid Services.

When the Medicare Part D program starts up next year, one group that will be monitoring the quality of services provided by pharmacists is made up of the state-based quality improvement organizations (QIOs). So reported Karen Bell, M.D., M.S., division director of the Quality Improvement Group at the Centers for Medicare & Medicaid Services.

In a new function for those 53 federally contracted organizations, which evolved from PROs (peer review organizations), QIOs are to work with and monitor both the prescription drug plans (PDPs) and R.Ph.s and other providers. CMS has one QIO under contract in each state and territory in the nation. The QIOs have long worked with physicians and hospitals to improve quality of care. They also guard against Medicare fraud and investigate complaints about quality of care.

In this additional mandate, the QIOs will use data from the Part D benefit to analyze drug therapy, and they will examine issues including use of avoidable drugs, generic prescribing ratios, the functioning of the new medication therapy management (MTM) services, and drug interactions.

The recently developed eighth scope of work for QIOs, covering three years beginning in August, also calls for them to help the PDPs and providers develop quality measures for drug therapy and help physicians adopt electronic prescribing. The organizations are also to carry out projects for improved disease-specific therapy, patient medication self-management, and improved prescribing.

What's more, in what Bell calls a critical piece, CMS is working to overcome legal and technical hurdles to linking data from the new Medicare Part D to the data streams from the other major parts of Medicare: Part A for hospitalization and Part B, which is essentially for outpatient services. That linkage, she said, would give QIOs information about drug-disease interactions and about therapeutic monitoring that happens with certain medications.

In terms of the new MTM services mandated under Part D, Bell said PDPs are responsible for ensuring that pharmacies have the MTM programs in place, but the QIOs will be required to seek out the plans "to determine which pharmacies are expected to be able to provide these services and to work with the pharmacies to help them get these services on board. So the QIOs become an operational arm of the PDPs."

Bell also told the audience that the pharmacist each QIO will hire to deal with these functions is to be aware of all the MTM programs in the area, supporting them and giving them guidelines as necessary.

The QIOs' work on MTM will include ensuring that the plans are appropriately compensating pharmacies for those services, she stressed. What happens if it turns out there is not enough money in a PDP's CMS contract to reimburse for the needed MTM? That's one of the things that CMS is still working out, Bell replied. She noted that the QIOs' prescription oversight begins in August 2006, but, in the meantime, each QIO is to develop its program, including working with the PDPs, "to ensure that everyone is cognizant of the deliverables" and hiring a pharmacist with expertise on issues including medication errors. She cautioned, however, that even on the federal level, the effort is still "a work in progress."

On QIOs' work on drug interactions, Bell said that CMS would consider the use of a list of important drug interactions that the U.S. Pharmacopeia is developing now.

Bell was also asked, relating to CMS' emphasis on "pay for performance," what would happen if a pharmacy or other provider is not performing well enough. She responded that CMS is discussing many options.

"There's clearly a need to ensure, either through public reporting or pay for performance, that the public is aware if there are problems in the delivery system," Bell said. "But it's also important that if there are problems, a provider has an opportunity to correct them."

Kathryn Foxhall is a writer based in the Washington, D.C., area.