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Medco to use staff for MTM, charges R.Ph.

When an Ohio pharmacist recently called Medco Health Solutions to sign up to provide medication therapy management (MTM) services to Medicare beneficiaries, the giant pharmacy benefit manager basically told him to get lost.

A Medco pharmacist said that the firm would be using its own in-house staff to provide MTM services, said Allen Nichol, Pharm.D., director, Diabetes Management Program, Grandview Family Practice, in Columbus, Ohio. He said he was also told that the Centers for Medicare & Medicaid Services had agreed to the PBM's plan.

"Medco is going around the intent of the law," contended Nichol. "This means beneficiaries won't have face-to-face interactions. People will get zero service, and they will continue to have medical misadventures. Companies are not going to provide the MTM piece. This is a big lie. Someone has to go enjoin CMS from giving these contracts."

Medco does not have a signed contract with CMS, said Larry Kocot, senior adviser to administrator Mark McClellan. Neither does any other would-be prescription drug plan (PDP) sponsor. The agency had not completed its review of contract proposals as of early September. That review includes a close look at the PDP's proposed MTM program. He added, "I don't believe there's anything in the law to prohibit PDPs from using their own staff."

Since CMS was still reviewing proposed contracts, the competitive bid process was still open and Medco could not comment on whether its contract called for using in-house staff for MTM, according to a spokesman.

The American Pharmacists Association "feels Dr. Nichol's pain" over the Medco plan, said Kristina Lunner, director, federal government affairs. "We are very disappointed that Medco has decided to deny patients their choice of medication therapy management services providers," she said. "Part D includes some assurance that beneficiaries will have some choice of their pharmacist, but it does not appear to provide the choice of MTM provider. We will be seeking clarification to get CMS' official read on it."

Medco's decision is "not surprising at all," said John Rector, executive VP-general counsel, National Community Pharmacists Association. As an attorney, he doesn't see any legal issues raised by the firm's decision to use its own employees for MTM. He added that the Medicare reform law does not mandate the use of pharmacists for MTM services. In addition, drug plans will not get separate reimbursement for MTM, so it's economically advantageous for them to use their own employees instead of reimbursing outside pharmacists.

"Lots of PDPs are going to be minimalist as they view the MTM section because it's coming right out of their bottom line," said Rector, who feels that some in the profession have overblown the potential of MTM for pharmacists. "Remember what the law actually says. MTM doesn't have to be [provided by] a pharmacist; it doesn't have to be [provided by] a community pharmacist; and PDPs can pick and choose from the list of what goes into an MTM program. It's as loose as a goose in terms of the definition of the program. Nothing in [the law] incentivizes an entity to do what pharmacy people think ought to be done. CMS has said that it won't get involved in contractual matters. And there doesn't appear to be any way to change it."

Pharmacists shouldn't necessarily be discouraged if they haven't been contracted for MTM, said Kocot, who feels that most PDPs aren't going to use a broad network of providers to serve a subset of Medicare beneficiaries. "PDPs will structure their programs to meet the requirements of the law," he said. "I don't think anyone realistically thought that everyone would receive some sort of MTM program that's as robust as pharmacists would like it to be."

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