St Peter Wendy L
College of Pharmacy at the University of Minnesota, Minneapolis, MN 55404, USA.
J Manag Care Pharm. 2007 Dec;13(9 Suppl D):S13-8. doi: 10.18553/jmcp.2007.13.9-d.13.
Since 1972, Medicare has covered the cost of end-stage renal disease (ESRD). Consequently, Medicare pays a large proportion of ESRD's costs. However, before implementation of Medicare Part D, employer health plans paid most ESRD-associated prescription costs. The ESRD population faces significant hurdles when using the new Part D benefit. To understand those challenges, a basic understanding of Part D is needed.
Medicare Part D has unique implications for chronic kidney disease (CKD) populations (dialysis, kidney transplant, and CKD patients not on dialysis). Approximately 405,000 ESRD patients were eligible for Part D coverage in 2006. Drug coverage is available for many drugs via Medicare Part B or Part D; however, the Medicare Part B and Part D medication coverage divide is confusing to most clinicians, including pharmacists. Many ESRD patients fall into the dual-eligible category -- they are covered by both Medicare and Medicaid. These patients now receive their medications through Part D and must enroll in a prescription drug plan (PDP). However, many PDP plans may not have the drugs that were covered in state-sponsored Medicaid programs. Dialysis-specific issues also abound because of the high-cost, high-use medications needed to treat the numerous comorbid conditions (diabetes, hypertension, anemia, bone and mineral metabolism disorders, and cardiovascular disorders) that flourish in the ESRD population.
Managed care demonstration projects are underway to better understand if enrolling these patients into managed care plans with disease management models (i.e., special needs plans) can provide quality care in an effective and efficient manner. Screening patients at high risk for kidney disease, identifying patients with early kidney disease, preventing progression to ESRD, and effectively managing comorbid conditions may reduce long-term medical costs and maintain work productivity. Health care providers need to make an active effort to help CKD patients select kidney-friendly formularies. Medicare requires medication therapy management (MTM) services for certain beneficiaries (called "targeted beneficiaries") enrolled in PDP plans to improve medication optimization. Approximately 80% of the typical ESRD population has more than 2 targeted comorbidities. Thus, many ESRD patients should be targeted for MTM services, a task that represents an opportunity for pharmacists.
自1972年以来，医疗保险已涵盖终末期肾病（ESRD）的费用。因此，医疗保险支付了ESRD的大部分费用。然而，在医疗保险D部分实施之前，雇主健康计划支付了大多数与ESRD相关的处方药费用。ESRD患者在使用新的D部分福利时面临重大障碍。为了理解这些挑战，需要对D部分有基本的了解。
医疗保险D部分对慢性肾病（CKD）人群（透析患者、肾移植患者和未接受透析的CKD患者）有独特的影响。2006年约有40.5万名ESRD患者有资格获得D部分的保险。许多药物可通过医疗保险B部分或D部分获得药物保险；然而，医疗保险B部分和D部分的药物保险划分让包括药剂师在内的大多数临床医生感到困惑。许多ESRD患者属于双重资格类别——他们同时享有医疗保险和医疗补助。这些患者现在通过D部分获得药物，并必须加入处方药计划（PDP）。然而，许多PDP计划可能没有州资助的医疗补助计划所涵盖的药物。由于治疗ESRD人群中常见的多种合并症（糖尿病、高血压、贫血、骨和矿物质代谢紊乱以及心血管疾病）所需的高成本、高用量药物，透析特有的问题也比比皆是。
正在开展管理式医疗示范项目，以更好地了解将这些患者纳入采用疾病管理模式的管理式医疗计划（即特殊需求计划）是否能够有效且高效地提供优质护理。筛查肾病高危患者、识别早期肾病患者、预防进展为ESRD以及有效管理合并症可能会降低长期医疗成本并维持工作生产力。医疗保健提供者需要积极帮助CKD患者选择对肾脏友好的处方集。医疗保险要求为参加PDP计划的某些受益人（称为“目标受益人”）提供药物治疗管理（MTM）服务，以改善药物优化。典型的ESRD人群中约80%有两种以上的目标合并症。因此，许多ESRD患者应成为MTM服务的目标对象，这项任务对药剂师来说是一个机会。
