S.Amdt. 3110

SA 3110. Mr. MENENDEZ submitted an amendment intended to be proposed
to amendment SA 2786 proposed by Mr. Reid (for himself, Mr. Baucus, Mr.
Dodd, and Mr. Harkin) to the bill H.R. 3590, to amend the Internal
Revenue Code of 1986 to modify the first-time homebuyers credit in the
case of members of the Armed Forces and certain other Federal
employees, and for other purposes; which was ordered to lie on the
table; as follows:

On page 974, between lines 9 and 10, insert the following:

SEC. 3316. PERFORMANCE BASED PHARMACY REIMBURSEMENT PROGRAM.

(a) In General.--Section 1860D-4 of the Social Security Act
(42 U.S.C. 1395w-104) is amended by adding at the end the
following new subsection:
``(m) Performance Based Pharmacy Reimbursement Program.--
``(1) In general.--The PDP sponsor shall have in place a
program that identifies omission gaps and adherence gaps (as
defined in paragraph (2)) for specified beneficiaries (as
described in paragraph (3)) and makes payments to
participating pharmacies (as described in paragraph (4)) that
close such gaps through clinical counseling.
``(2) Omission and adherence gaps defined.--In this
subsection:
``(A) Omission gaps.--The term `omission gaps' refers to
cases when the patient is not receiving a medication that
evidenced-based protocols or clinical practice standards
indicate is a best practice for treatment of their disease.
``(B) Adherence gaps.--The term `adherence gaps' refers to
cases when a patient is not taking their medication the way
it was prescribed, including failure to fill, failure to
renew, stopping or not starting medications, or not taking a
medication the way it was intended.
``(3) Specified beneficiaries described.--Beneficiaries
described in this paragraph are part D eligible individuals
taking medications for one of the following conditions:
``(A) Diabetes.
``(B) Cardiovascular disease.
``(C) Pulmonary disease.
``(4) Participating pharmacies.--The PDP sponsor shall
contract with any pharmacy that is willing to participate in
such program and meet the standard terms and conditions of
the PDP sponsor. To the extent practicable, the PDP sponsor
shall use a specified beneficiary's primary pharmacy to close
gaps in care. If such pharmacy does not participate in such
program or is unable to close a gap in care, the PDP sponsor
may use other participating pharmacies. The primary pharmacy
selected by the PDP sponsor shall advise the specified
beneficiary of his or her right to select another
participating pharmacy.
``(5) Gaps in medication adherence.--The Secretary shall
require PDP sponsors to follow uniform standards in
identifying gaps in medication adherence. The Secretary shall
develop such standards based on current treatment protocols
for the conditions described in paragraph (2).
``(6) Payments to pdp sponsors.--
``(A) In general.--The Secretary shall pay each PDP sponsor
a per member monthly amount to administer such program. Such
payments shall be for operational and administrative
activities only and shall not include the cost of any covered
part D drug. The per member monthly payment to a PDP sponsor
may not exceed an amount that equals $0.85 in 2012, increased
in subsequent years by the annual percentage increase in the
consumer price index (all items; U.S. city average) as of
September of the previous year.
``(B) Special rule.--The Secretary shall ensure that PDP
sponsors use greater than 50 percent of the aggregate amount
paid to the PDP sponsor under subparagraph (A) to compensate
pharmacies for counseling activities under such program.
``(C) Not in bids.--PDP sponsors shall not include the
payments described in subparagraph (A) in the bids submitted
by the PDP sponsor under section 1860D-11.
``(D) Source.--The payment described in subparagraph (A)
shall be made from the Federal Hospital Insurance Trust Fund
under section 1817 and the Federal Supplementary Medical
Insurance Trust Fund under section 1841, in such proportion
as the Secretary determines appropriate.
``(7) Payments to participating pharmacies from pdp
sponsors.--Under such program, PDP sponsors shall negotiate
payment structures with pharmacies, and pharmacists shall
receive remuneration based on success in closings gaps in
care. Payments under paragraph (6)(A) shall be made when it
is determined that the adherence and omission gaps have been
closed, or when billable activity by the pharmacy occurs, by
contract.
``(8) Bonuses and penalties for pdp sponsors based on
estimated changes in medical costs.--
``(A) Projected costs.--Beginning in 2012, the Secretary
shall, on an annual basis, project the anticipated costs for
individuals enrolled in the program under parts A and B for
the current year and the succeeding 2 years, based on risk-
adjusted historical costs under such parts.
``(B) Comparison.--
``(i) In general.--At the end of each 3-year period
described in subparagraph (A), for each PDP sponsor under the
program, the Secretary shall compare the actual spending for
such individuals to the costs projected under subparagraph
(A).
``(ii) Incentive payment.--For each year during the 3-year
period described in clause (i), to the extent the actual
costs are lower than the costs projected under subparagraph
(A), the Secretary will pay to the PDP sponsor an incentive
based on a graduated scale, under which the PDP sponsor
receives an incremental 10 percent of the per member monthly
amount paid to the PDP sponsor under paragraph (6) for every
10 percent of savings above the projection, not to exceed 50
percent of the aggregate amounts paid to the PDP sponsor
under such paragraph for the initial year of the 3-year
period.
``(iii) Penalties.--For each year during the 3-year period
described in clause (i), to the extent the actual costs are
higher than the costs projected under subparagraph (A), the
PDP sponsor shall make a payment to the Secretary in an
amount based on a graduated scale, under which the PDP
sponsor pays to the Secretary 10 percent of the per member
monthly amount paid to the PDP sponsor under paragraph (6)
for every 10 percent of costs above the projection, not to
exceed 50 percent of the aggregate amounts paid to the PDP
sponsor under such paragraph for the initial year of the 3-
year period.
``(C) Guidance on methodology used.--The Secretary shall
issue guidance on the methodology that the Secretary uses to
project costs as described in subparagraph (A), measure
actual costs for purposes of the comparison under
subparagraph (B), and calculate

[[Page S12832]]

incentive payment and penalties under clauses (ii) and (iii),
respectively, of such subparagraph.
``(D) Pharmacies not liable for fees.--A participating
pharmacy shall not be required to pay any penalties under
subparagraph (B)(iii).
``(E) Reconciliation.--Any financial reconciliation under
the program under this subsection shall be incorporated into
the annual reconciliation process under this part.
``(9) Limitation.--The requirements of this subsection
shall not apply to an MA-PD plan.
``(10) Construction.--The provisions of this subsection
shall not modify or relieve PDP sponsors of their
responsibilities under subsection (c)(2).''.
(b) Effective Date.--The amendment made by this section
shall take effect on January 1, 2012.
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