To amend part D of title XVIII of the Social Security Act to promote medication therapy management under the Medicare part D prescription drug program.

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Medication Therapy Management 
Benefits Act of 2011''.

SEC. 2. FINDINGS.

    Congress finds the following:
            (1) Medications are important to the management of chronic 
        diseases that require long-term or lifelong therapy. 
        Pharmacists are uniquely qualified as medication experts to 
        work with patients to manage their medications and chronic 
        conditions and play a key role in helping patients take their 
        medications as prescribed.
            (2) Nonadherence with medications is a significant problem. 
        According to a report by the World Health Organization, in 
        developed countries, only 50 percent of patients with chronic 
        diseases adhere to medication therapies. For example, in the 
        United States only 51 percent of patients taking blood pressure 
        medications are adherent; similarly, only 40 to 70 percent of 
        patients taking antidepressant medications adhere to prescribed 
        therapies.
            (3) Failure to take medications as prescribed costs over 
        $177 billion annually. The problem of nonadherence is 
        particularly important for patients with chronic diseases that 
        require use of medications; poor adherence leads to unnecessary 
        disease progression, reduced functional status, lower quality 
        of life, and premature death.
            (4) When patients adhere to, or comply with, their 
        medication therapy, it is possible to reduce higher-cost 
        medical attention, such as emergency department visits and 
        catastrophic care, and avoid the preventable human costs that 
        impact patients and those who care for them.
            (5) Studies have clearly demonstrated that community-based 
        medication therapy management (MTM) services provided by 
        pharmacists improve health care outcomes and reduce spending. 
        For example, the Asheville Project--a diabetes program designed 
        for city employees in Asheville, North Carolina, and delivered 
        by community pharmacists--resulted over a 5-year period in a 
        decrease in total direct medical costs ranging from $1,622 to 
        $3,356 per patient per year, a 50 percent decrease in the use 
        of sick days, and an increase in productivity accounting for an 
        estimated savings of $18,000 annually. Another project 
        involving pharmacist-provided care to patients with high 
        cholesterol increased compliance with medication to 90 percent 
        from a national average of 40 percent. In North Carolina, the 
        ChecKmeds NC program, which offers eligible seniors one-on-one 
        MTM consultations with pharmacists, saved an estimated 
        $10,000,000 in healthcare costs and avoided numerous health 
        problems in the first year of the program for the more than 
        15,000 seniors receiving MTM. Similar results have been 
        achieved in several other demonstrations using community 
        pharmacists.
            (6) Therefore, enhancement of the MTM benefit under part D 
        of the Medicare program should be a key component of the 
        national health care reform agenda.

SEC. 3. IMPROVEMENT IN PART D MEDICATION THERAPY MANAGEMENT (MTM) 
              PROGRAMS.

    (a) Improvements to Required Interventions.--Section 1860D-
4(c)(2)(C) of the Social Security Act (42 U.S.C. 1395w-104(c)(2)(C)) is 
amended--
            (1) by amending clause (i)(I) to read as follows:
                                    ``(I) shall include a review of the 
                                individual's medications, creation of a 
                                personal medication record, and a 
                                recommended medication action plan in 
                                consultation with the individual and 
                                the prescriber; and''; and
            (2) by redesignating clause (ii) as clause (iii) and 
        inserting after clause (i) the following new clause:
                            ``(ii) Targeted medication reviews 
                        furnished person-to-person by a licensed 
                        pharmacist offered no less frequently than once 
                        every quarter to assess medication use since 
                        the last annual comprehensive medication 
                        review, to monitor unresolved issues, to 
                        identify problems with new drug therapies or if 
                        the individual has experienced a transition in 
                        care.''.
    (b) Increase Availability of MTM Services to Beneficiaries and 
Increase Community Pharmacy Involvement in Provision of MTM Services.--
            (1) Increased beneficiary access to mtm services.--Section 
        1860D-4(c)(2) of such Act (42 U.S.C. 1395w-104(c)(2)) is 
        further amended--
                    (A) in subparagraph (A)(ii)(I), by inserting before 
                the semicolon at the end the following: ``or any 
                chronic disease that accounts for high spending in the 
                Medicare program including diabetes, hypertension, 
                heart failure, dyslipidemia, respiratory disease (such 
                as asthma, chronic obstructive pulmonary disease or 
                chronic lung disorders), bone disease-arthritis (such 
                as osteoporosis and osteoarthritis), rheumatoid 
                arthritis, and mental health (such as depression, 
                schizophrenia, or bipolar disorder)'';
                    (B) by adding at the end of subparagraph (A) the 
                following new clause:
                            ``(iii) Identification of individuals who 
                        may benefit from medication therapy 
                        management.--The prescription drug plan sponsor 
                        shall identify a process subject to the 
                        Secretary's approval that allows licensed 
                        pharmacists or other qualified providers to 
                        identify for medication therapy management 
                        interventions potential enrollees who are not 
                        described as targeted beneficiaries under 
                        clause (ii) or are not otherwise offered 
                        services described in subparagraph (C).'';
                    (C) by redesignating subparagraphs (F) and (G) as 
                subparagraphs (I) and (J), respectively;
                    (D) by redesignating the subparagraph (E), relating 
                to development of program in cooperation with licensed 
                pharmacists, as subparagraph (H);
                    (E) by redesignating subparagraph (D) and the 
                subparagraph (E), relating to automatic enrollment with 
                ability to opt-out, as subparagraphs (F) through (G), 
                respectively; and
                    (F) by inserting after subparagraph (C) the 
                following new subparagraph:
                    ``(D) Medication reviews for dual eligibles and 
                enrollees in transition of care.--Without regard to 
                whether an enrollee is a targeted beneficiary described 
                in subparagraph (A)(ii), the medication therapy 
                management program under this program shall offer--
                            ``(i) a comprehensive medication review 
                        described in subparagraph (C)(i) at the time of 
                        initial enrollment under the plan for an 
                        enrollee who is a full-benefit dual eligible 
                        individual (as defined in section 1935(c)(6)); 
                        and
                            ``(ii) a targeted medication review 
                        described in subparagraph (C)(ii) for any 
                        enrollee at the time of transition of care 
                        (such as being discharged from a hospital or 
                        another institutional setting) where new 
                        medications have been introduced to the 
                        individual's therapy.''.
            (2) Community pharmacy access.--Section 1840D-4(c)(2) of 
        such Act, as amended by paragraph (1), is further amended by 
        inserting after subparagraph (D) the following new 
        subparagraph:
                    ``(E) Pharmacy access requirements.--A prescription 
                drug plan sponsor shall offer any willing pharmacy in 
                its network the ability to provide medication therapy 
                management services to assure that enrollees have the 
                option of obtaining services under the medication 
                therapy management program from community-based retail 
                pharmacies.''.
    (c) Reimbursement and Incentives Based on Performance.--
            (1) Appropriate reimbursement for the provision of mtm 
        services.--Section 1860D-4(c)(2)(J) of such Act (42 U.S.C. 
        1395w-104(c)(2)(J)), as redesignated by subsection (b)(1)(C), 
        is amended by striking the first sentence and inserting the 
        following: ``The PDP sponsor shall reimburse pharmacists and 
        other entities furnishing medication therapy management 
        services under this paragraph based on the resources used and 
        the time required to provide such services.''.
            (2) Evaluation of performance for payment incentives.--
        Section 1860D-4(c)(2) of such Act (42 U.S.C. 1395w-104(c)(2)), 
        as amended by subsection (b), is further amended by adding at 
        the end the following new subparagraph:
                    ``(K) Evaluation of performance.--
                            ``(i) Data collection and provider 
                        measures.--The Secretary shall establish 
                        measures and standards for data collection by 
                        prescription drug plan sponsors to evaluate 
                        performance of pharmacies and other entities in 
                        furnishing medication therapy management 
                        services. Such measures and standards shall be 
                        developed by such date as to allow the 
                        application of such measures under this 
                        subparagraph beginning with the first plan year 
                        beginning after the date of the enactment of 
                        the Medication Therapy Management Benefits Act 
                        of 2011. Such measures shall be designed to 
                        help assess and improve overall quality of 
                        care, including a reduction in adverse 
                        medication reactions, improvements in adherence 
                        and persistence in chronic medication use, and 
                        a reduction in drug spending, where 
                        appropriate. Prescription drug plan sponsors 
                        shall use such measures to compare outcomes 
                        based on the type of entity offering such 
                        services and shall ensure broader participation 
                        of entities that achieve better outcomes with 
                        respect to such services. The measures 
                        established under this clause shall include 
                        measures developed by the Pharmacy Quality 
                        Alliance (PQA) in the case of pharmacist 
                        providers.
                            ``(ii) Continual development and 
                        incorporation of medication therapy management 
                        measures in broader health care outcomes 
                        measures.--The Secretary shall support the 
                        continual development and refinement of 
                        performance measures described in clause (i), 
                        including the incorporation of medication use 
                        measures as part of broader health care 
                        outcomes measures. The Secretary shall work 
                        with State Medicaid programs to incorporate 
                        similar performance-based measures into State 
                        drug use review programs provided pursuant to 
                        section 1927(g).
                            ``(iii) Incentive payments.--
                                    ``(I) In general.--Subject to 
                                subclause (II), for plan years 
                                beginning on or after the date that is 
                                1 year after the date the establishment 
                                of measures and standards under clause 
                                (i), pharmacies and other entities that 
                                furnish medication therapy management 
                                services under this part shall be 
                                provided (in a manner specified by the 
                                Secretary) with additional incentive 
                                payments based on the performance of 
                                such pharmacies and entities in meeting 
                                the such measures and standards. Such 
                                payments shall be made from the 
                                Medicare Prescription Drug Account 
                                except that such payments may be made 
                                from the Federal Hospital Insurance 
                                Trust Fund or the Federal Supplemental 
                                Medical Insurance Trust Fund if the 
                                Secretary determines, based on data 
                                under this part and parts A and B, that 
                                such services have resulted in a 
                                reduction in expenditures under part A 
                                or part B, respectively.
                                    ``(II) Limitation.--The total 
                                amount of additional incentive payments 
                                made under subclause (I) for a plan 
                                year may not exceed the amount by which 
                                the Secretary determines there are 
                                reductions in expenditures under this 
                                title during such plan year resulting 
                                from medication therapy management 
                                services furnished under this part.''.

Summary: Medication Therapy Management Benefits Act of 2011 - Amends part D (Voluntary Prescription Drug Benefit Program) of title XVIII (Medicare) of the Social Security Act (SSA) to require that the annual comprehensive medication review include creation of a personal medication record and a recommended medication action plan in consultation with the individual and the prescriber.

Requires medication therapy management (MTM) services to include targeted medication reviews furnished person-to-person by a licensed pharmacist offered at least once every quarter to: (1) assess medication use since the last annual comprehensive medication review, (2) monitor unresolved issues, or (3) identify problems with new drug therapies or if the individual has experienced a transition in care.

Increases the number of diseases and conditions for which beneficiaries may be targeted for medication therapy management (MTM) services.

Requires a prescription drug plan (PDP) sponsor to identify a process, subject to approval by the Secretary of Health and Human Services (HHS), that allows licensed pharmacists or other qualified providers to identify potential enrollees for MTM interventions where such individuals are not targeted beneficiaries or are not otherwise offered MTM services.

Requires any MTM program to offer both comprehensive and targeted medication reviews to individuals dually eligible for both Medicare and Medicaid (under SSA title XIX), regardless of whether they are MTM-targeted beneficiaries.

Requires a PDP sponsor to offer any willing pharmacy in its network the ability to provide MTM services.

Requires the PDP sponsor to reimburse pharmacists and other entities furnishing MTM services based on the resources used and the time required to provide such services.

Directs the Secretary to: (1) establish measures and standards for data collection by PDP sponsors to evaluate performance of pharmacies and other entities in furnishing MTM services; and (2) support the continued development and refinement of performance measures.

Provides pharmacies and other entities that furnish MTM services with additional incentive payments based on their performance in meeting quality measures established under this Act.