MEDICARE PART D FROM THE MEDICAL DIRECTOR PERSPECTIVE. Daniel Haimowitz, MD, FACP, CMD
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1 MEDICARE PART D FROM THE MEDICAL DIRECTOR PERSPECTIVE Daniel Haimowitz, MD, FACP, CMD
2 History of Medical Directors in LTC OBRA (1987) required for all NFs by October, 1990 Medical Directors met in 1988: described 4 major roles, 9 broad functions & over 100 tasks
3 Federal Regulations OBRA 87 The Medical Director shall ensure that residents receive necessary nursing, medical & other services to maintain the highest possible levels of mental & physical function & well-being, as defined by the comprehensive care plan.
4 MEDICAL DIRECTOR RESPONSIBILITIES Physician leadership Patient care Clinical leadership Quality of Care Education, Information, and Communication
5 Roles and Responsibilities of Medical Directors Physician Leadership Quality of Care Education,Information, Communication Clinical Leadership
6 Medical Director Administrator DON
7 MEDICAL DIRECTORS AND MEDICARE PART D Patient Care- Clinical Leadership Participate in administrative decisionmaking and the development of policies and procedures related to patient care Education, Information, Communication Maintain knowledge of the changing social, regulatory, political, and economic factors that affect medical and health services of LTC patients
8 TYPES OF MEDICAL DIRECTORS Full time Part time Corporate Rural, etc.
9 Who is the average medical director? 62% part time 80% serve as attending in their facility 71% have practices outside the facility Most serve more than one facility Average number of hours/month = 18
10 F-501 TAG Issued June 2005 (effective November) Clarifies requirements, defines medical director s essential responsibilities Ensures that facilities have licensed physician medical director to provide clinical guidance and oversight regarding quality standards of practice Coordination of medical care and implementation of resident care policies
11 WORKING DAY OF A MEDICAL DIRECTOR Facility responsibilities (meetings, survey issues, physician coverage, etc.) Direct patient care concerns in facility Private practice (office, hospital, assisted living, house calls, etc.) Hundreds to thousands of calls, forms, e- mails, faxes, mail, paperwork
12 CONSULTANT PHARMACIST/MEDICAL DIRECTOR INTERACTIONS Quarterly meetings Pharmacy reports Collegial, respectful, in an atmosphere of mutual trust and admiration! Suspicions of conflict of interest
13 PHYSICIAN AWARENESS OF MEDICARE PART D Earlier than community-based American Medical Directors Association (AMDA) Concerns about time and effort
14 PART D TIMELINE Late 2005: Physician education, meeting with administration, talking to families January 3, 2006: Calm! Spring 2006: Real problems begin
15 WHAT MEDICARE PART D IN LTC REALLY IS saving money? ability to prescribe medications? way to ensure quality? FORMULARY!!
16 PROBLEMS FROM PHYSICIAN Time PERSPECTIVE 38% AMDA members spend 4-7 uncompensated hours/week 13% spend 8+ hours/week Frequent or very frequent problems with prior authorizations (70%) and exceptions (55%)
17 Timeframe for Coverage Determinations plan Enrollee or physician requests exception 72hr Request granted: receive coverage Request normal review Decision in 72 hrs Request denied Expedited review rejected Request denied Request expedited review In 24 hrs Decision 24hr Request granted: receive coverage Redetermination Request denied 7 days std 72 hrs exp Request granted: receive coverage Appeal leaves plan
18 Timeframe for Coverage Determinations beyond the plan Independent Review Entity (IRE) Request denied 72 hrs Request granted: receive coverage Administrative Law Judge (ALJ) Request granted: receive coverage Request denied Medicare Appeals Committee (MAC) Judicial Review
19 PROBLEMS FROM PHYSICIAN PERSPECTIVE (con t) Particular drugs or types of drugs --Alzheimer s disease (23%) --non-generics ( almost anything a problem ) --inexpensive drugs --emergency meds (influenza outbreaks)
20 PROBLEMS FROM PHYSICIAN PERSPECTIVE (con t) Lack of standardized forms No access to chart Patient history often unknown Requirement for personal contact to plan Seem designed to deter physicians from requesting prior approvals or exceptions
21
22 DRUG PLAN CALL CENTER PERFORMANCE CMS: 92% answered within 5 minutes GAO: accurate/complete info 1/3 of time different answers to same question CMS took issue with the report, faulting it for asking the wrong questions or not phrasing the questions more precisely
23 PROBLEMS FROM PHYSICIAN PERSPECTIVE (con t) Myriad drug plans and drug plan options Requiring a form to get a form Lack of critical information about the PDP (formulary alternatives) Omission of all forms and doses (liquid, ODTs) Formulary choices inappropriate for the elderly Surveyor concerns (unnecessary medications, F329 tag)
24 CASE STUDY Mrs. Casper The hurdles created are resulting in a lower level of care being provided for nursing home patients. They are now less likely to be prescribed uncovered medicines because it takes too much time and effort for everyone involved.
25 BROADER PROBLEMS LTC input to PDP formularies Evidence-based/data driven decisions Physician knowledge of drug availability CMS responsiveness to concerns Long term effect on quality and patient care
26 ASSISTED LIVING (AL) More AL than nursing home beds Increasing acuity of care for AL residents Not typically a medical director in an AL facility No mandated pharmacist review Regarded as same as community-dwelling Problem with dual-eligibles required to make Part D co-payments
27 NF & ALF Projections Number of Residents 2,000,000 1,800,000 1,600,000 1,400,000 1,200,000 1,000, , , , , Est 2006 Est Assisted Living Skilled Nursing Source HSG, 7/02
28
29 A comparison of ADL dependency among ALF and SNF residents % of ALF residents who need assistance % of SNF residents who need assistance Eating 23% 47% Transferring 36% 73% ADL Toileting 41% 78% Dressing 57% 86% Bathing 72% 94% Source: Natl. Center for Assisted Living, 2001
30 CENTER FOR EXCELLENCE IN ASSISTED LIVING (CEAL) 2006 Quality Summit November 30 to December 1, 2006 Arlington, VA
31 AMDA Represents more than 7000 medical directors, attending physicians and others in LTC Average physician sees 100 NH patients per month (42% of total in 2000) Majority of members maintain a private practice outside of their LTC responsibilities
32 AMDA (con t) Has been part of weekly CMS conference calls and frequent s Part D task force Susan Pettey AL involvement (AL workgroup, CEAL Advisory board)
33 SOLUTIONS SIMPLIFICATION! Mandate uniform procedure and forms for exceptions, prior authorizations and appeals Prohibit prior authorization requirements for all meds in a class Greater CMS oversight with quarterly public reports, prompt sanctions against non-compliant PDPs
34 WORKING WITH THE MEDICAL DIRECTOR Discuss use of problem medications Develop protocols Educate staff about automatic substitutions (PPIs, cholesterol meds) Educate physician staff (medical staff meetings)
35 WORKING WITH THE MEDICAL DIRECTOR (con t) Use of common CMS exception form Use medical director as a resource (?pharmaceutical companies) Improve communications (discourage fax as be-all and end-all) Develop strategy to identify common Part D problems
36 DEALING WITH THE NON- COMPLIANT PHYSICIAN Education Communication Use of the medical director as a resource
37 STRENGTH IN NUMBERS Develop relationships with interested organizations (ASCP, AMDA, Alzheimer s Assoc., etc.), and tell them specific problems Put political pressure on CMS
38
39 Sources of Additional Information Governmental Medicare MEDICARE & Social Security Administration v State Medicaid State Health Insurance Assistance Programs (SHIPs) National Senior Care Associations American Society of Consultant Pharmacist American Geriatrics Society rg American Medical Directors Association American Health Care Association Non-governmental Organizations Kaiser Family Foundation Medicare Rx Matters rg Medicare Today Access to Benefits
40 Region V Chicago (IL,IN,MI,MN,OH,WI) Centers for Medicare and Medicaid Services ROCHIDMO@cms.hhs.gov Social Security Administration
41 RESOURCES American Medical Directors Association Susan Pettey Richard Stefanacci
42 CONTACT ME 1 Gardenia Road Levittown PA Phone geridoc1@comcast.net
43 THANK YOU! QUESTIONS?
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