10th Annual Fall Meeting

1. 10th Annual Fall Meeting Callaway Gardens “A Decade of Dedication” November 13, 2009 Paul Moore, DPh 2008 President,National Rural Health AssociationRuralrx@att.net

2. What a difference a year makes!

3. Health care reform was just another campaign promise… Now…maybe…??? a possible reality???

4. CHANGE HAS COME TO WASHINGTON.

5. to the White House…

6. and to Congress.

7. CHANGE HAS COME TO WASHINGTON …. But you know what they say… the more things change… the more they stay the same!

8. Quick Recap • House conducted Floor debate Saturday • President made a visit to the Hill; • Stupak (D-MI) Amendment passed. • 14 hours debate - then House voted. • Bill passed 220-215 (1 Rep for, 39 Dems against)

9. HR 3962 Key Details • Require most Americans to purchase health insurance or pay a fine; • Expand coverage to 36 million more; • Require employers with payrolls > $500k to provide insurance or pay a fine; • Prohibit denial of pre-existing conditions;

10. HR 3962 Key Details • End gender premium disparities; • 5.4% Income Tax surcharge >$500K/$1M • Establish Govt. run insurance to compete with private insurers beginning 2013; • Cut Medicare spending by > $400 billion over 10 years. • Cost $1.2 Trillion over 10 years.

11. What’s next?Attention turns to Senate • " The Senate "won't run with" the House bill, because “the government health insurance plan included in the House bill is unacceptable to a few Democratic moderates who hold the balance of power in the Senate.” AP 11/8 • "the glow from a healthcare triumph faded quickly for President Barack Obama on Sunday as Democrats realized the bill they fought so hard to pass in the House has nowhere to go in the Senate." AP 11/9 • "The House bill is dead on arrival in the Senate. Just look at how it passed." Sen. Lindsey Graham (R-SC)

12. What’s next? • Senate bills are being blended, (Finance and HELP Committee) • Still waiting on final score from CBO. • Harry Reid (D-NV) announced public option will be a part of the blended Senate bill.

13. Reid’s Public Plan Option • Require the government plan to negotiate payments to providers, rather than base payments on Medicare rates. • States would have to choose to opt out of the public plan by 2014, a year after the plan would come into being. (No detail about how a state would do that.) • No trigger

14. Rep. counter-argument • Cost of the bill. ($1.2 Trillion over 10yrs) • Expansion of government • Employer insurance mandates. • Negative impact on small business.

15. Unclear in the Senate if Democratic votes are there. • President’s Desk by Christmas? • Now indicating possibly not ready for vote this year. • Democrats still do not have the 60 votes.

16. It’s still a heavy lift… • Several Senate moderate Democrats non-committal. • Two liberal Senators non-committal. • Lieberman (I-CT) – indicates he may support a filibuster. • Snowe (R-ME) now non-supportive. • Likely posturing. Expect the arm twisting to begin.

17. Sure enough…. • Tuesday-former President Bill Clinton became the arm-twister-in-chief. • Warned Democratic Senators that economy cannot withstand out-of-control health care spending. • Reminded Ds of 1994 midterm election cycle; Democrats lost both the House and the Senate.

18. Much work still needs to be done on behalf of rural folks… • Floor Amendment Strategy • Rural allies are strong • $$$ can be our enemy • Rural efforts continue

19. Healthcare Reform…Who Knows??? So..let’s look at what we do know…

20. ARRAAmerican Recovery and Reinvestment Act“Stimulus Bill” $787 billion package $87b for Medicaid $1.1b for comp. effect research HIT Investment Includes rural Rural broadband Rural water projects Workforce training Prevention/wellness

21. Meaningful Use Incentives Education regarding reimbursement of CAHs and PPS hospitals beyond the scope of this discussion…. As Presented by John Sheehan, CPA and Tim Wolters, CPA, BKD,LLP NRHA Critical Access Conference Portland, OR October 7, 2009

22. PPS Hospitals • (Medicare Payment) • Base amount = $2 million • Discharge amount = $200/discharge, discharges 1,150 - 23,000 • Sum of these amounts x Medicare percent = gross annual amount • Gross annual amount x transition factor = actual payment

23. PPS Hospital transition factors 1st Eligible→ 2011-2013 2014 2015 Year 1 1.00 0.75 0.50 Year 2 0.75 0.50 0.25 Year 3 0.50 0.25 0 Year 4 0.25 0 0 No payment if first year eligible is after 2015

24. CAHs • (Medicare payment) • CMS to define specifics in regulations? • First eligible for special funding for cost • reporting periods beginning in 2011 • Paid depreciable costs in year incurred x {Medicare % (same as PPS) +20%} • Medicare percent limited to 100% • CAH 1% add-on applies

25. CAHs • (Medicare payment) (continued) • Un-depreciated cost at start of first payment year is added to costs incurred in that year • Payment for up to 4 eligible years, but no payment after 2015 • Other allowable costs paid through cost report

26. Some of the Meaningful Use Objectives & Measures • 2011 Objectives: -10% of all orders (any type) directly entered by provider through CPOE. -Implement drug-drug, drug allergy, drug-formulary checks. -Medication reconciliation at transition of care. Measures: -% of orders entered electronically

27. More Meaningful Use Objectives & Measures • 2013 Objectives: -Use CPOE for all order types -Use evidence-based order sets -Medication reconciliation at transition of care. Measures: -% of orders entered by CPOE

28. Observations

29. The task at hand can seem “daunting”! (especially the more limited your resources.) • We did not have a lot to do with creating the current environment….but we can navigate it!

30. We are all in this together. • We must make evidence-based decisions. • Forward thinking will find the solution.

31. HAPPY ANNIVERSARY !!! Georgia Rural Remote Pharmacist Network

32. A brief history…. Georgia Rural Remote Pharmacist Initiative

33. Went “live”…November 2008 10 hospitals participated. -5 hospitals took the service “in-house” with their own RPh resources. -5 hospitals used the network RPh resources to provide the service. -2 hospitals dropped out of the initiative at end of grant funding. - 1 additional hospital joined the network.

34. 12 Month’s Data (Aggregate- 5 facilities w contracted service) Georgia Rural Remote Pharmacist Network Total Hours Pharmacist on duty: 2,700 Total Number of Orders Entered: 11,707 Total Number of Orders Reviewed: 44,384

35. Total Number of Interventions: 2,029 Breakdown: Medication Errors 520 Med error rate: (average) 0.93% Order clarifications 455 Therapeutic change recommendations 226 Therapeutic Monitoring recommendations 192 Dosing issues 499 Potential Drug Interactions communicated:137

36. Georgia Rural Remote Pharmacist Network A timely opportunity for small, rural hospitals to work together to initiate remote pharmacist services using current technology that can cost effectively address medication management and patient safety.

37. Georgia Rural Remote Pharmacist Network An Opportunity to • Reduce medication errors • Improve Patient Outcomes • Improve Quality of Care • Lead Instead of Follow • Demonstrate that “Rural does NOT mean “Second-Rate”

38. Georgia Rural Remote Pharmacist Network To learn more about this opportunity for your facility… ruralrx@att.net

39. A Year of Leadership in Improving Medication Management & Patient Safety in Georgia Hospitals!

40. 10th Annual Fall Meeting “A Decade of Dedication” Thank you! Paul Moore, DPh Ruralrx@att.net