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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 AFFORDABLE CARE ACT (ACA) 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. AFFORDABLE CARE ACT (ACA) 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. AFFORDABLE CARE ACT (ACA) 2010 Federal Outlays AFFORDABLE CARE ACT (ACA) CMS FY 2012 Proposed Budget CMS FY2012 Budget Request AFFORDABLE CARE ACT (ACA) Nation’s Health Care Dollar 2010 AFFORDABLE CARE ACT (ACA) Medicare Spending AFFORDABLE CARE ACT (ACA) Changing Demographics More people will be Medicare eligible AFFORDABLE CARE ACT (ACA) 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. AFFORDABLE CARE ACT (ACA) A System of Coverage AFFORDABLE CARE ACT (ACA) A System of Coverage Medicaid/ CHIP Employer Coverage Exchange AFFORDABLE CARE ACT (ACA) Projected Changes in Coverage by 2019 25 20 Exchanges 15 Medicaid & CHIP 10 Employer Nongroup & Other 5 0 -5 -3m -5m Total new coverage = 32 million Source: Congressional Budget Office, March 2010 AFFORDABLE CARE ACT (ACA) Sources of Coverage by 2019 22m 24m 51m 25m Medicaid & CHIP Employer Nongroup & Other Uninsured Exchanges 159m (For All Individuals under 65) Source: Congressional Budget Office, March 2010 AFFORDABLE CARE ACT (ACA) 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 AFFORDABLE CARE ACT (ACA) A System of Coverage Medicaid/ CHIP Employer Coverage Exchange AFFORDABLE CARE ACT (ACA) 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. AFFORDABLE CARE ACT (ACA) Medicare’s Approach AFFORDABLE CARE ACT (ACA) 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 antihealth care fraud provisions in American history and lays out a variety of new authorities under CMS for strengthening program integrity AFFORDABLE CARE ACT (ACA) Current Patient Physician Hospital Surgeon MEDICARE Supplier Pharmacy AFFORDABLE CARE ACT (ACA) Future Patient Physician Hospital Surgeon MEDICARE Supplier Pharmacy AFFORDABLE CARE ACT (ACA) 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 AFFORDABLE CARE ACT (ACA) Electronic Health Records (EHR) and Meaningful Use Criteria AFFORDABLE CARE ACT (ACA) What are the Requirements/Meaningful Use? • The Recovery Act specifies the following 3 components of Meaningful Use: 1. Use of certified EHR in a meaningful manner (e.g., e-prescribing) 2. Use of certified EHR technology for electronic exchange of health information to improve quality of health care 3. Use of certified EHR technology to submit clinical quality measures (CQM) and other such measures selected by the Secretary AFFORDABLE CARE ACT (ACA) What are the Requirements/Meaningful Use? • Eligible Professionals – 15 Core Objectives 1. Computerized physician order entry (CPOE) 2. E-Prescribing (eRx) 3. Report ambulatory clinical quality measures to CMS/States 4. Implement one clinical decision support rule 5. Provide patients with an electronic copy of their health information, upon request 6. Provide clinical summaries for patients for each office visit 7. Drug-drug and drug-allergy interaction checks 8. Record demographics AFFORDABLE CARE ACT (ACA) What are the Requirements/Meaningful Use? • Eligible Professionals – 15 Core Objectives (cont.) 9. Maintain an up-to-date problem list of current and active diagnoses 10. Maintain active medication list 11. Maintain active medication allergy list 12. Record and chart changes in vital signs 13. Record smoking status for patients 13 years or older 14. Capability to exchange key clinical information among providers of care and patient-authorized entities electronically 15. Protect electronic health information AFFORDABLE CARE ACT (ACA) 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 Data capture and sharing Advanced clinical processes Improved outcomes AFFORDABLE CARE ACT (ACA) Medication Therapy Management (MTM) AFFORDABLE CARE ACT (ACA) 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 AFFORDABLE CARE ACT (ACA) 2005 Final Rule “Notwithstanding the lack of current MTMP standards and performance measures, we believe that MTMP must evolve and become a cornerstone of the Medicare Prescription Drug Benefit.” AFFORDABLE CARE ACT (ACA) Regulatory Requirements MTM • A beneficiary must meet ALL three criteria to be eligible for a Plan’s MTMP 1. A beneficiary must have multiple chronic diseases; 2. A beneficiary must have filled multiple covered Part D drugs; AND 3. A beneficiary must be likely to incur annual costs for covered part D drugs that exceed a level specified by the Secretary. AFFORDABLE CARE ACT (ACA) Multiple Chronic Diseases • Most programs (approx. 85% in 2009) require either a minimum of two or three chronic diseases. AFFORDABLE CARE ACT (ACA) 2010 Multiple Chronic Diseases • “Sponsors cannot require more than 3 chronic diseases as the minimum number of multiple chronic diseases” and “sponsors must target at least four of the seven core chronic conditions:” 1. 2. 3. 4. 5. Hypertension Heart Failure Diabetes Dyslipidemia Respiratory Diseases (Asthma, COPD, Chronic Lung disorders) 6. Bone Disease-Arthritis (Osteoporosis, RA, OA) 7. Mental Health issues (Depression, Schizophrenia, Bipolar Disorder, others) AFFORDABLE CARE ACT (ACA) 2010 Disease Targets AFFORDABLE CARE ACT (ACA) Regulatory Requirements MTM • A beneficiary must meet ALL three criteria to be eligible for a Plan’s MTMP 1. A beneficiary must have multiple chronic diseases; 2. A beneficiary must have filled multiple covered Part D drugs; AND 3. A beneficiary must be likely to incur annual costs for covered part D drugs that exceed a level specified by the Secretary. AFFORDABLE CARE ACT (ACA) 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 costs for Part D drugs of at least $3000. This change will improve access to MTM. AFFORDABLE CARE ACT (ACA) Provider of MTM Services • 2006-2009: – (iii) May be furnished by a pharmacist or other qualified provider; • 2010 – No change AFFORDABLE CARE ACT (ACA) Provider of MTM Services Percent of plans utilizing each provider type AFFORDABLE CARE ACT (ACA) 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 AFFORDABLE CARE ACT (ACA) 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. AFFORDABLE CARE ACT (ACA) 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. AFFORDABLE CARE ACT (ACA) 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. AFFORDABLE CARE ACT (ACA) 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 AFFORDABLE CARE ACT (ACA) 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. AFFORDABLE CARE ACT (ACA) Questions? [email protected]