Presentation Transcript

1. The ACA & Medicare: Changing Pharmacy

   Centers for Medicare & Medicaid Services CDR Gregory Dill Region V Associate Regional Administrator for Financial Management and Fee-for-Service Operations June 2011
2. Objectives Describe Medicare’s implementation of the Affordable Care Act and how it works to transform the delivery of health care and improve the health of the American public; List specific elements of the Affordable Care Act that impact pharmacy practice now and over the next several years; Identify changes to Medicare Part D (prescription drug coverage) and its impacts on pharmacy practice, medication therapy management, electronic health record systems.
3. CMS and The Affordable Care Act  The stakes are high for all of us. We have the most expensive health care system in the world, yet we are not getting the best results.  We have long recognized the problems with health care, yet we have not taken the responsibility to fix them. 
4. 2010 Federal Outlays
5. CMS FY 2012 Proposed Budget CMS FY2012 Budget Request
6. Nation’s Health Care Dollar 2010
7. Medicare Spending
8. Changing Demographics More people will be Medicare eligible
9. National Prescription Drug Spending by Source of Payment, 2005 and 2008 Private insurance and out of pocket spending as a share of all prescription drug spending decreased after the first year of the Part D drug benefit. Adapted from: Table 4, National Health Expenditures, by Source of Funds and Type of Expenditure: Calendar Years 2003-2008. http://www.cms.gov/NationalHealthExpendData/downloads/tables.pdf. Accessed 11/1/10.
10. A System of Coverage
11. A System of Coverage Medicaid/ CHIP Exchange Employer Coverage
12. Projected Changes in Coverage by 2019 -3m -5m Total new coverage = 32 million Source: Congressional Budget Office, March 2010
13. Sources of Coverage by 2019 51m 24m 22m 25m 159m (For All Individuals under 65) Source: Congressional Budget Office, March 2010
14. New Paradigm for Medicaid Not a “safety net” but a full partner in assuring coverage for all Eligible means enrolled; coverage is stable Necessary to achieve coverage, quality and cost containment objectives Need to rethink Medicaid/CHIP enrollment/renewal across the system Essential to make a system out of different components
15. A System of Coverage Medicaid/ CHIP Exchange Employer Coverage
16. Center for Consumer Information and Insurance Oversight New coverage options for previously uninsured Americans with pre-existing conditions; Pre-Existing Insurance Plan New competitive state-based health insurance markets that will operate through exchanges and provide millions of Americans with access to affordable coverage.
17. Medicare’s Approach
18. Overview: The Affordable Care Act The new law is a response to those Americans who want health to be, not just more available, but better—higher quality—for patients and families: It uses innovative and constructive forms of payment—payment on the basis of quality of care, payment for preventive care, and payment for new and bold demonstration projects. It works to appropriately price services and modernize Financing System.  The ACA contains some of the strongest anti-health care fraud provisions in American history and lays out a variety of new authorities under CMS for strengthening program integrity
19. Current Patient Physician Supplier Surgeon Hospital Pharmacy MEDICARE
20. Future Patient Physician Supplier Surgeon Hospital Pharmacy MEDICARE
21. Medicare Shared Savings Program Goals The Shared Savings Program is a new approach to the delivery of health care aimed at reducing fragmentation, improving population health, and lowering overall growth in expenditures by:  Promoting accountability for the care of Medicare fee-for-service beneficiaries Improving coordination of care for services provided under Medicare Parts A and B Encouraging investment in infrastructure and redesigned care processes
22. Electronic Health Records (EHR) and Meaningful Use Criteria
23. What are the Requirements/Meaningful Use? The Recovery Act specifies the following 3 components of Meaningful Use: Use of certified EHR in a meaningful manner (e.g., e-prescribing) Use of certified EHR technology for electronic exchange of health information to improve quality of health care Use of certified EHR technology to submit clinical quality measures (CQM) and other such measures selected by the Secretary
24. What are the Requirements/Meaningful Use? Eligible Professionals – 15 Core Objectives Computerized physician order entry (CPOE) E-Prescribing (eRx) Report ambulatory clinical quality measures to CMS/States Implement one clinical decision support rule Provide patients with an electronic copy of their health information, upon request Provide clinical summaries for patients for each office visit Drug-drug and drug-allergy interaction checks Record demographics
25. What are the Requirements/Meaningful Use? Eligible Professionals – 15 Core Objectives (cont.) Maintain an up-to-date problem list of current and active diagnoses Maintain active medication list Maintain active medication allergy list Record and chart changes in vital signs Record smoking status for patients 13 years or older Capability to exchange key clinical information among providers of care and patient-authorized entities electronically Protect electronic health information
26. What are the Requirements/Meaningful Use? Rule making was open to public comment Listened to many comments received Established 3 stages of meaningful use: 2011, 2013 and 2015 Improved outcomes Advanced clinical processes Data capture and sharing
27. Medication Therapy Management (MTM)
28. SSA 1860D-4(c)Cost and Utilization Management; Quality Assurance; MTMP 4(C)(2) Medication Therapy Management Program (MTMP) (A) A program of drug therapy management with respect to targeted beneficiaries may be furnished by a pharmacist designed to assure that covered part D drugs under the prescription drug plan are appropriately used to optimize therapeutic outcomes through improved medication use, and to reduce the risk of adverse events, including adverse drug interactions
29. 2005 Final Rule “Notwithstanding the lack of current MTMP standards and performance measures, we believe that MTMP must evolve and become a cornerstoneof the Medicare Prescription Drug Benefit.”
30. Regulatory Requirements MTM A beneficiary must meet ALL three criteria to be eligible for a Plan’s MTMP A beneficiary must have multiple chronic diseases; A beneficiary must have filled multiple covered Part D drugs; AND A beneficiary must be likely to incur annual costs for covered part D drugs that exceed a level specified by the Secretary.
31. Multiple Chronic Diseases Most programs (approx. 85% in 2009) require either a minimum of two or three chronic diseases.
32. 2010 Multiple Chronic Diseases “Sponsors cannot require more than 3 chronic diseasesas the minimum number of multiple chronic diseases” and “sponsors must target at least four of the seven core chronic conditions:” Hypertension Heart Failure Diabetes Dyslipidemia Respiratory Diseases (Asthma, COPD, Chronic Lung disorders) Bone Disease-Arthritis (Osteoporosis, RA, OA) Mental Health issues (Depression, Schizophrenia, Bipolar Disorder, others)
33. 2010 Disease Targets
34. Regulatory Requirements MTM A beneficiary must meet ALL three criteria to be eligible for a Plan’s MTMP A beneficiary must have multiple chronic diseases; A beneficiary must have filled multiple covered Part D drugs; AND A beneficiary must be likely to incur annual costs for covered part D drugs that exceed a level specified by the Secretary.
35. 2010 Dollar Cost Threshold The existing cost threshold will be revised to $3000. Therefore, sponsors must target beneficiaries who meet the other two criteria and who are likely to incur annual costsfor Part D drugs of at least $3000. This change will improve access to MTM.
36. Provider of MTM Services 2006-2009: (iii) May be furnished by a pharmacist or other qualified provider; 2010 No change
37. Provider of MTM Services Percent of plans utilizing each provider type
38. 2006-2009 MTM Interventions Delivery methods: face-to-face, via the phone, mail based, web based May distinguish between services in ambulatory and institutional settings Ten Most Common MTM Interventions: Face-to-face interaction Phone outreach Medication review Refill reminders Intervention letter Educational newsletters Drug interaction screenings Polypharmacy screenings Disease specific clinical initiatives Medication profile
39. MTM Services 2010 Offer a Comprehensive Medication Review (CMR) by a pharmacist or other qualified provider at least annually to all targeted beneficiaries enrolled in the MTM program A CMR is a review of a beneficiary’s medications, including prescription, over-the-counter (OTC) medications, herbal therapies and dietary supplements, that is intended to aid in assessing medication therapy and optimizing patient outcomes. CMS recognizes the importance of offering an interactive, person-to-person consultation with the beneficiary for a complete assessment of the beneficiary’s needs to improve medication use or outcomes.
40. MTM Services 2010 Interactive, person-to-person consultations An individualized, written summary of interactive consultation Medication reviews (targeted quarterly) Must target beneficiaries AND prescribers Approximately 90% of MTM programs in 2008 already target interventions to both beneficiaries and prescribers.
41. Written Summary of CMR Sponsors must implement a systematic process to summarize the interactive consultation and provide an individualized written or printed “take-away” to the beneficiary such as a personal medication record, reconciled medication list, action plan, recommendations for monitoring, education, or self-management.
42. Sec. 10328. Improvement in Part D MTM Programs The 2010 rules under Medicare Part D improved the standards for MTM services and access Sample Medicare Part D provisions annual comprehensive medication review person-to-person or using telehealth technologies licensed pharmacist or other qualified provider written or printed summary of the results Congress determined that the rules should be made into law and added Sec 10328 to amend the SSA and establish the Medicare rules under law Not required by law until plans for 2013
43. Conclusion: The Affordable Care Act It would have been easy to put these reforms off, as we’ve done in the past.  And we had an easy excuse in the recession.  We easily could have said, “We know our health care system isn’t working and we’ll fix those problems later.” We believe that fixing these problems is absolutely essential to putting our country back on the right path. That is our focus.  Thank you for your time, attention, and commitment.
44. Questions? Gdill@cms.hhs.gov