Streamlining data flow and accountability: The key to success for the Medicare drug price negotiation program

The Inflation Reduction Act's Medicare drug price negotiation program promises significant changes for payers, dispensers and manufacturers. A critical element of this program is the Medicare Transaction Facilitator (MTF). But its success hinges on overcoming a major hurdle: fragmented data.

The data challenge: Fragmented silos, streamlined needs

Currently, data critical to the program resides in isolated systems across payers (like Medicare Advantage plans), dispensers (pharmacies) and manufacturers. Imagine the challenge for each group – they need a holistic view of the program, but must cobble together data from various sources, wasting valuable time and resources.

The MTF aims to solve this. We recommend providing a central platform with a 360-degree view. This API-driven solution will allow each group to access the data they need, fostering transparency and streamlining workflows.

Change management: A new way of working

The MTF program introduces a significant change – direct communication between manufacturers and dispensers. Traditionally, this interaction flowed through plan sponsors, creating a single data pipeline. The MTF necessitates a new channel, requiring adjustments from all parties involved, including the Centers for Medicare and Medicaid Services (CMS).

Focus on dispensers: Making it easy for thousands

Dispensers, representing the numerous pharmacies participating in the program, present a unique challenge. The solution needs to be user-friendly and avoid creating an undue burden.

A solution with accountability at its core

Beyond data flow, accountability is paramount for CMS. Two key areas require focus:

• Verifying beneficiary payments: Ensuring beneficiaries pay the correct, discounted amount at the pharmacy.
• Tracking rebates: Verifying that manufacturers properly reimburse pharmacies for the price difference between what the pharmacy pays and the discounted beneficiary price.

Here's where CGI's expertise shines. Our proven solutions and system modernization work, like the Medicare Advantage plan verification system (HPMS) and All Payments platform, demonstrate our capabilities in these areas.

The MTF program has the potential to revolutionize drug price negotiation in Medicare. By focusing on data flow and accountability, and leveraging proven solutions like APIs and CGI's expertise, stakeholders can navigate the complexities of the program and ensure its success. This will ultimately benefit beneficiaries through lower drug costs.