AHQA Supports Passage of a Medicare Outpatient Drug Benefit AHQA supports the goal of establishing a Medicare outpatient prescription drug benefit. Given the central role pharmaceuticals now play in treating and managing health conditions, it is critical that the seniors have affordable access to prescription drug coverage. Drug therapy needs improvement As Congress considers legislation, AHQA recommends that a quality improvement (QI) section be included. Rising pharmaceutical usage and costs require that any proposal include utilization and cost controls to prevent the over use of prescription drugs. However, drug utilization cost controls may encourage under use. Furthermore, as noted in the 1999 Institute of Medicine (IOM) report, To Err is Human, there is also a widespread problem of misuse of prescription drugs as well as often-avoidable adverse drug events (ADEs). The IOM reported that over 5% of hospital admissions are due to patients not faithfully following their drug regimen, amounting to 1.9 million admissions and $8.5 billion in hospital expenditures in 1986. In 1994, the nation paid about $76 billion for treatment of adverse drug events occurring in outpatient settings. (In March 2001 this figure was estimated at $177 billion in 2000. About 70% of the cost is due to hospitalizations to treat the unintended effects of drug therapy.) Core functions of a Medicare Rx quality improvement program: Identification, measurement and re-measurement of targeted clinical problem areas. The entity responsible for administering the new benefit, directly or through a contract with QIOs, should identify and prioritize patterns of over use, under use and misuse of prescription drugs. This requires the analysis of claims and the abstraction of medical records to establish a baseline measurement of the patterns of care. After interventions are put in place, ongoing re-measurement should be required to show that continual improvement is achieved. Quality improvement interventions with providers/practitioners to resolve targeted problems. The entity responsible for administering the new benefit, directly or through a contract with QIOs, should be required to demonstrate measurable clinical improvement in targeted clinical problem areas. This would require working directly with providers/practitioners to share best practices and institute systemic changes. Oversight of claims and appeals/formularies. QIOs should be assigned to review a sample of claims denials and appeals to ensure these processes are responsive to Medicare beneficiaries. QIOs are central to an effective Rx benefit quality program QIOs should be given a new mandate to monitor and alter patterns of over use, under use, and misuse of medications by Medicare beneficiaries. QIOs currently improve the quality of care delivered to Medicare beneficiaries in both inpatient and outpatient settings have the expertise to work with outpatient drug claims to improve clinical care. QIOs have established relationships with practitioners and providers nationwide. QIOs in several states already have used Medicaid drug claims in quality improvement projects.