Download CMS and The Affordable Care Act

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]