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The Changing Landscape of Health Care:Cultivating Leadership in Health‐System Pharmacy
The Changing Landscape of Health Care:Cultivating Leadership in Health‐System Pharmacy
Health Care Reform for Health System Pharmacy:
Recommendations and A l iAnalysis
Kevin Colgan, M.A., B.S.Pharm., FASHPCorporate Director of PharmacyRush University Medical Center
Chicago, IL
Learning Objectives
• Describe the components of health care reform and their impact on health systems.
• Identify strategies that pharmacy leaders can employ to positively influence their institution's ability to thrive within the new health careability to thrive within the new health care environment.
• List new strategies and tools that will be needed in order to lead health system pharmacy into the next decade.
• Describe what is on the "must‐do" list for pharmacy leaders.
HC Reform Quiz
1. Will the health reform law require nearly all Americans to have health insurance by 2014 or else pay a fine? (64%)
Yes the law will do thisYes, the law will do this
No, the law will not do this
Don’t know
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HC Reform Quiz
2. Will the health reform law expand the existing Medicaid program to cover low‐income, uninsured adults regardless of whether they have children? (62%)whether they have children? (62%)
Yes, the law will do this
No, the law will not do this
Don’t know
Patient Protection & Affordability Act
Coverage: 22.9 M Newly Insured!2014
• Insurer Rules– Coverage must be offered to everyone – no exclusions for pre‐existing
diticonditions
– Requires coverage of essential benefits as determined by the Secretary
– Bars plans from basing premiums on health status, gender & other factors – premium based on age – also limits on annual cost sharing
– Permits employers to offer employees rewards of up to 30‐50% for participating in wellness programs and maintaining certain health‐related standards
Health Care Overhaul Suffers Setback in Latest Court Test
Wall Street Journal August 13‐14, 2011
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HC Reform Quiz
3. Will the health reform law allow a government panel to make decisions about end‐of‐life care for people on Medicare? (45%)(45%)
Yes, the law will do this
No, the law will not do this
Don’t know
HC Reform Quiz
4. Will the health reform law cut benefits that were previously provided to all people on Medicare? (40%)
Yes, the law will do this
No, the law will not do this
Don’t know
HC Reform Quiz
5. Will the health reform law provide financial help to low and moderate income Americans who don’t get insurance through their jobs to help them purchase coverage? (72%)help them purchase coverage? (72%)
Yes, the law will do this
No, the law will not do this
Don’t know
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HC Reform Quiz
6. Will the health reform law prohibit insurance companies from denying coverage because of a person’s medical history or health condition? (67%)condition? (67%)
Yes, the law will do this
No, the law will not do this
Don’t know
Patient Protection & Affordability Act
Coverage: Additional 32M uninsured2010
• Expand limit on Medicaid to 133% FPL & ↓ DSH payments by 75% 20.3% increase in Medicaid Spending by 2014
• Dependent coverage for adult children up to age 26
• Prohibit lifetime limits annual limits determined by the Secretary• Prohibit lifetime limits – annual limits determined by the Secretary HHS
• Provides grants to states for reviewing health plan increases
• Medical loss ratio 85% in large group market
• Reinsurance for employers providing insurance to retirees > 55 not receiving Medicare
• Bans co‐pays for preventative care and immunizations
HC Reform Quiz
7. Will the health care reform law require all businesses, even the smallest ones, to provide health insurance for their employees? (25%)employees? (25%)
Yes, the law will do this
No, the law will not do this
Don’t know
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HC Reform Quiz
8. Will the health reform law provide tax credits to small businesses that offer coverage to their employees? (65%)
Yes, the law will do this
No, the law will not do this
Don’t know
HC Reform Quiz
9. Will the health reform law create a new government run insurance plan to be offered along with private plans? (27%)
h l ill d hiYes, the law will do this
No, the law will not do this
Don’t know
Patient Protection & Affordability Act
Funding: Health Insurers
1. Annual Fees of $58.8B through 2018
2. RestructuringMedicare Advantage – Cut Subsidies of $132B over 10 years2. Restructuring Medicare Advantage Cut Subsidies of $132B over 10 years– 22% of beneficiaries are enrolled in MA Plans nationally
– Illinois 9% of beneficiaries enrolled in MA Plans
Coverage: 9.4% increase in Health Insurance Spending by 2014
1. Consumer Operated and Oriented Plan Program (CO‐OP)Non‐profit, member‐run health insurance companiesProfits used to lower premiums, improve benefits, and improve quality
2. Health Insurance Exchanges
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HC Reform Quiz
10.Will the health reform law allow undocumented immigrants to receive financial help from the government to buy health insurance? (42%)health insurance? (42%)
Yes, the law will do this
No, the law will not do this
Don’t know
Economics of the Current Law
Spending GrowthAverage Annual Growth from Prior Year
Sector 2010 2014 2020
Hospital 9.5% 9.8% 10.3%
(Billions) $794 $985 $1410
Sector 2010 2014 2020
Hospital 4.6% 7.2% 6.2%
(Billions) $794 $985 $1410
MD/Clin Svcs 6.2% 6.2% 6.3%
(Billions) $518 $624 $868
Rx Drugs 3.1% 3.4% 3.7%
(Billions) $259 $338 $513
Reflects 29.4% ↓ in MD payment rate
MD/Clin Svcs 2.4% 8.9% 5.6%
Rx Drugs 3.5% 10.7% 7.2%
Population 310.3 321.6 338.4
1% ↑ growth for hospitals than w/out ACA5.1% ↑ growth in Rx than w/out ACA
Adapted from Health Affairs, August, 2011 30:8; 1‐12
Economic Balance
National Debt
Government Policy50%
Federal, State, & Local health spending will increase to just under
50% by 2020
National Health care Expenditures
Economy
50%
Employment50%
Health Affairs, August 2011
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Economic Balance
National Debt
Government Policy50%
Federal, State, & Local health spending will increase to just under
50% by 2020
Up
National Healthcare Expenditures
Economy
50%
Employment50%
Health Affairs, August 2011
Down Down
Economic Balance
National Debt
Government Policy50%
Federal, State, & Local health spending will increase to just under
50% by 2020
Downif spending flat
National Healthcare Expenditures
Economy
50%
Employment50%
Health Affairs, August 2011
Up Up
Bonus Questions
11.What is each citizen’s share of the national debt?
$104,000
$47,000
Don’t know
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Bonus Questions
12.What is each taxpayer’s share of the national debt?
$69,000
$104,000
Don’t know
U.S. Government Budget
U.S. Government Budget
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What effect will deficit reduction have on health care?
• Medicare trust fund runs out of money in 2024!• 5 deficit & debt reduction reports have suggested changes in Medicare & Medicaid1. Debt Reduction Task Force – Restoring America’s
FutureFuture2. The Administration’s National Commission on Fiscal
Responsibility and Reform – The Moment of Truth3. House Budget Committee Budget Resolutions4. The President’s Framework for Shared Prosperity and
Shared Fiscal Responsibility5. The Senate “Gang of Six” Proposal
Common Themes
1. Hold health care spending to the GDP + 1%
Common Themes
2. Require the Senate Finance Committee to identify savings of $298 B to replace the Sustainable Growth Rate Formula (SGR)
• Enacted in 1997 – physician reimbursement tied• Enacted in 1997 – physician reimbursement tied to general economy
• Congress has blocked annual payment reductions each year
• To fix it, physicians would have to take a 29.4% pay cut in 2012.
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Common Themes
3. Cap annual growth – shift from a “defined benefit” program to a “defined contribution program”
4. Cost Sharing – Annual Deductable $560; i 20% M t f k t $5 250coinsurance 20%; Max out‐of‐pocket $5,250
5. Raise premiums if costs rise faster than established limits
6. Raise Medicare Part B premiums from 25% to 35%
Defined Contribution PlanAKA Premium Support System
Part B Premiums
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Common Themes7. Repeal the CLASS Act – save $70 B
• Added HC disability/ outpatient long term care insurance – Part of ACA
8. Increase Medicare age from 65 to 679.Require rebates for single source drugs as a
diti f ti i ti i P t Dcondition of participating in Part D10. Change Medicaid to a capped payment program.
11. Allow Medicaid waivers12. Fraud and Abuse – more audits
Important Questions
• What strategies pharmacy leaders can employ to positively influence their institution’s ability to thrive within the new HC environment?
• What strategies and tools that will be needed• What strategies and tools that will be needed in order to lead health system pharmacy into the next decade?
• Present what is on the “must‐do” list for pharmacy leaders?
Helping Your Institution Thrive
1. Value‐based purchasing
2 Readmissions2. Readmissions
3. Appropriate drug policy and drug utilization
4. Accountable Care Organization ‐Wild Card!
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Opportunities for Pharmacists in HC Reform
Value‐based Purchasing Program for Medicare
• Section 3001 – Hospital Value‐Based Purchasing Program– Applies to payments made on discharges on or after October 1, 2012
– 2013 includes:
• 5 conditions/procedures (AMI, HF, Pneumonia, Surgeries though SCIP, HC‐associated infections)
• Hospital Consumer Assessment of Health Care Providers and Systems Survey – HCAHPS
– 1% of Medicare reimbursement growing to 2% by 2017
• 2014 added measures include:– Outcome measures of 30‐day mortality for AMI, HF, and Pneumonia
– AHRQ Patient Safety Indicators (PSIs) & Inpatient Quality Indicators (IQIs) composite scores
– Hospital Acquired Condition Measures
Measure ID 2013 Measure Description
AMI‐7a Fibrinolytic therapy received within 30 minutes of hospital arrival.
AMI‐8a Primary PCI received within 90 minutes of hospital arrival.
HF‐1 Discharge instructions.
PN‐3b Blood cultures performed in the ED prior to initial antibiotic received.
PN‐6 Initial antibiotic selection for CAP in immunocompetent patient.
SCIP‐Inf‐1 Prophylactic antibiotic received within 1 hour prior to surgical incision.
SCIP‐Inf‐2 Prophylactic antibiotic selection for surgical patients.
SCIP‐Inf‐3 Prophylactic antibiotics discontinued within 24 hours after surgery end.
SCIP‐Inf‐4 Cardiac surgery patients with controlled 6AM postoperative glucose.
SCIP‐Card‐2 Patients on a beta‐blocker PTA received a beta‐blocker perioperatively.
SCIP‐VTE‐1 Surgery patients with recommended VTE prophylaxis ordered.
SCIP‐VTE‐2 VTE prophylaxis within 24 hrs prior to surgery to 24 hours after surgery.
HCAHPS ‐ Hospital Consumer Assessment of Healthcare Providers and Systems.
Communication with nurses. Communication with doctors
Responsiveness of house staff. Pain management.
Communication about medicines. Cleanliness & Quietness of environment.
Discharge information. Overall rating of hospital.
Hospital Scoring
Achievement: 0‐10 points based on national percentile– 10: at or above 95th percentile
– 1‐9: 50th – 95th percentiles
– 0: below 50th percentile
Improvement 0 9 i t b d tilImprovement: 0‐9 points based on percentile improvement
All improvement points will be rounded to the nearest whole number.
Clinical process of care makes up 70%
Patient experience of care makes up 30%
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Implementation Timeline
BaselineBaselineperiodperiodBaselineBaselineperiodperiod
PerformancePerformanceperiodperiod
PerformancePerformanceperiodperiod
ImprovementImprovementperiodperiod
ImprovementImprovementperiodperiod
VBP program VBP program reimbursement reimbursement
beginsbegins
VBP program VBP program reimbursement reimbursement
beginsbegins
Hospital Scoring Ex. PNA‐6
Achievement Threshold Benchmark
0.9277 0.9958
Achievement Range
Hospital Score
Hospital earns: 10 points for achievement performance exceeding the benchmark
0.9995
Hospital Scoring Ex. PNA‐6
Achievement Threshold Benchmark
0.9277 0.9958
Achievement Range
Hospital Score
0.8200
0.9099
1 2 3 4 5 6 7 8 9 1 0
0 1 2 3 4 5 6 7 8 9
Hospital earns: 0 points for achievement4 points for improvement
Hospital earns 4 points
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Study of 100 Random DischargesFindings for May – October, 2009
• 12.8% RUSH Readmission Rate
Complete Med Rec
• 32% RUSH Readmission Rate
Incomplete
p 0.002
Readmissions
Readmission RateMed Rec
Patient Protection and Affordability Act
Section 3025 Hospital Readmission Reduction Program – Adjustment Factor
0.99
(2013)
0.98
(2014)
0.97
(2015)
ReferenceBell CM, et al. Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases, JAMA, August 24,2011 306:840‐7
Appropriate Drug Policy and Drug Utilization
Key Drug Utilization Variances from UHC Average for Leukemia and Lymphoma
Accountable Care Organization (ACO) s
1. Triple Aim goals:a) to focus on better care; b) better health for populations; and c) lower cost per capita
2 L l tit ( ti t hi LLC f d ti ) i d2. Legal entity (corporation, partnership, LLC, foundation) recognized and authorized under applicable state law and composed of certified Medicare providers and suppliers. Eligible providers include:a) Professionals in group practice arrangementsb) Networks of individual practicesc) Joint venture arrangements between hospitals and
professionalsd) Hospitals employing professionals
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3. Must have a tax ID number that will become the basis for identifying all ACO participants
4. Governing body must have 75% control by providers & include beneficiaries served by the ACO and community stakeholders
Accountable Care Organization
stakeholders
5. Management of ACO operations by an executive
6. Clinical management by a senior‐level medical director
7. Meaningful commitment for clinical integration
Accountable Care Organization
8. An ongoing QA and PI program overseen by a physician‐directed committee
9. A technology infrastructure that enables it to collect data and provide feedback to providers
10. Enough primary care physicians (general practice, family practice, internal medicine, geriatric medicine) sufficient for at least 5000 FFS Medicare beneficiaries
• Application must include a description of plans to
1. Promote evidence‐based medicine (EBM) (Rx)
2. Promote beneficiary engagement (Rx)
3. Report internally on quality & cost metrics (Rx)
Accountable Care Organization
3. Report internally on quality & cost metrics (Rx)
4. Coordinate care (Rx)
• Applications must also exhibit a strong element of patient‐centeredness (e.g. individualized care plans, transitions of care) (Rx)Rx Note: All of these are opportunities for pharmacists and pharmacy
services participating in an ACO
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• Must have – a beneficiary experience survey (Consumer Assessment of
Healthcare Providers – CAHPS Survey)
– systems to identify high‐risk individuals and develop individualized care plans for targeted patient
Accountable Care Organization
individualized care plans for targeted patient populations. (Rx)
– a mechanism for coordinating care (Rx)
– “Patient engagement” ‐ a means for communicating clinical knowledge and EBM to beneficiaries (Rx)
– Process for measuring clinical and service performance by physicians across practices
1. Patient/Caregiver Experience (7 measures)
•Health Promotion and Education‐‐‐CAHPS Survey
2. Care Coordination (16 measures)
•Medication Reconciliation after discharge from an inpatient facility (within 60 days)
•Care Transition Measure – medication management
ACO Measures that Pharmacy Can Impact
CMS‐1345‐PNCQA, 2011
g•Disease specific (e.g. diabetes) ambulatory admissions
3. Patient Safety (2 Measures)
•Health Care Acquired Conditions‐‐‐Fall and Trauma (medications)
4. Preventative Health (9 Measures)
•Influenza & pneumococcal vaccination•Cholesterol management, Tobacco cessation
One‐Sided Risk Model
• Shared savings in year 1
• Shared risk in year 3
• 50% of shared savings
Two‐Sided Risk Model
• Shared savings in year 1
• Shared risk in year 1
• 60% of shared savings
ACO Payment Based on Quality & Savings
• 50% of shared savings
• Up to 2.5% additional for FQHP or RHC
• MSR = 2.0 – 3.9%
• Shared savings net of 2% threshold
• 60% of shared savings
• Up to 5.0% additional for FQHP or RHC
• MSR = 2%
• Shared savings on first $ basis once MSR exceeded
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New Tools and Strategies to Lead HS Pharmacy into the Next Decade
• Department organizational structure that focuses on improving national quality measures – both inpatient and ambulatory
• Aggressive drug usage evaluation program• Electronic health record ‐ use of clinical decision support, expansion to ambulatory care
• Effective medication reconciliation & medication adherence program – post discharge calls & great transitions of care
• Alignment with primary care and multispecialty groups for chronic disease management – become primary care extenders
“Must Do” List
• Ambulatory
• Specialty pharmaceuticalsSpecialty pharmaceuticals
• Utilization
• Research
Summary
• Deficit reduction is going to drive changes in Medicare and Medicaid
• If ruling to mandate healthcare coverage is unconstitutional expect turmoilunconstitutional, expect turmoil
• Value‐based purchasing is here to stay
• Greater movement in both public and private sector for shared risk
• Pharmacy needs to carve out it’s role
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