The Impact of Healthcare Reform on Pharmacy Practice. Disclosure

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1 The Impact of Healthcare Reform on Pharmacy Practice Thomas Buckley, MPH, RPh Assistant Clinical Professor University of Connecticut School of Pharmacy Disclosure Thomas Buckley has nothing to disclose for this presentation 1

2 Objectives 1. Describe the emerging opportunities for pharmacy practice as a result of healthcare reform 2. Discuss the opportunities for expanded insurance eligibility as a result of the new insurance exchange. 3. List ways pharmacists and technicians can assist patients with insurance choices. What was Health Care Reform About? 1.Access 2.Cost 3. Quality gets short end of the stick... 2

3 Optimizing Medication Management: Are we truly at a paradigm shift? Convergence of factors suggest timing is NOW: Federal health reform initiatives: Improved access more patients insured with comprehensive coverages Healthcare delivery reform new models of care (ACO, PCMH) Healthcare payment reform provider status changes, shift from FFS to global payment State health reform initiatives: State Innovation Model (SIM) $45 million; health neighborhoods; MTM delivery Pharmacy profession shift to payment for service No other profession has literature base to substantiate value of pharmacist services Provider status changes state & federal recognition impact on reimbursement Medicare Part D vs Part B Pharmacists impacted by these health reform initiatives: New care delivery models: Medical homes Accountable Care Organizations (ACOs) Coordinated Care Organizations (CCOs) New payment structures: FFS, capitated payments, quality incentives, shared savings CT specific reforms impacting pharmacists: MTM Medicaid reimbursement Dual eligibles SIM (State Innovation Model) enhanced care teams 3

4 The New Health Delivery System Federal reform delivery models: Pharmacist Opportunities Medication Therapy Management grants Medical Homes Accountable Care Organizations Independence At Home CMS Innovations Center grants 4

5 Will Pharmacy Provisions Impact Health Reform Goals? ACCESS COST QUALITY Health Reform Opportunities Pharmacy was not left behind in the ACA and other health reform initiatives (27 mentions) Appears recognition of medication use has occurred for policymakers Still have obstacles to overcome, but questions are not whether pharmacists should be involved but how 5

6 Improved Access Reduction of uninsured (projected 95% covered) Expanded Medicaid Insurance reform Individual mandate: insurance pools, federal subsidies, employer credits More coverage = more opportunities for pharmacist MTM services Prevention & health promotion funds Largest allocation to preventive care in history $5B/yr thru 2014, then $2B/yr for prevention & PH programs Health plans required to provide preventive services Reduced costs Delivery system reforms pilot projects and payment reform mechanisms Prevention & Public Health Fund ($15 billion) New council to coordinate federal prevention, wellness, and public health activities 3 year Medicaid grants for health lifestyle programs Employer wellness programs 5 year grants Medicaid incentives to improve immunizations & preventive services rated A or B by U.S. Preventive Services Task Force State receives 1% increase in federal matching payment How will pharmacists participate? 6

7 Reduced Cost through Improved Quality Can pharmacists reduce costs through MTM services ability to improve outcomes? Can pharmacists improve incentives for payfor performance? Shared savings? Aligned incentives? Integration of systems?... end/reduction of fee for service????? 7

8 Which of the following was NOT a reason for health care reform? a. Poor access to care b. Rationing of care c. High cost of care d. Better quality of care ACA Impact: State Innovation Model (SIM) CT one of 16 model design grant states 4 Work groups: Care delivery, payment reform, HIT, workforce Will include 80% state lives within 5 years Medicare, Medicaid, private insurers Providers responsible for quality & outcomes Payment from volume based to value based 8

9 Steps to Achieving Transformation CMS 3 part aim Better care for individuals: safety, effectiveness, patient centeredness, timeliness, efficiency and equity; Better health for populations: public health education on causal factors for poor health and the influence of preventative services; Lower growth in expenditures: eliminating waste and inefficiencies while not withholding any needed care that helps beneficiaries 9

10 System Options for 3 part aim (As defined by CT DSS) Accountable Care Organizations group of providers and suppliers of services (e.g., hospitals, physicians, and others involved in patient care) work together to coordinate care for the Medicare FFS patients they serve. Integrated Care Organization group of providers and suppliers of service that has as its hub either a primary care center or a small group practice; and also includes APRNs, specialists, hospitals, pharmacists, behavioral health practitioners, and providers of long term care; that will work together to coordinate care for individuals who are dually eligible for Medicare and Medicaid Comprehensive Primary Care Initiative "practice transformation and multi payer payment reform enhanced Medicare and Medicaid PMPM payments for primary care practices to underwrite the costs of coordinating and integrating care. Connecticut vision for SIM (parallel track with federal ACA) Establish whole person centered health system Integrate primary care, behavioral health, population health, oral health, consumer engagement Pharmacists included in value based payment models hiring pharmacists to help with medication management to improve consumer access, satisfaction and outcomes Creation of health neighborhoods shared savings Dual eligible s: pharmacists paid for med management CMS funding expected early 2014: $45 million 10

11 ACA impact: ACOs & PCMH 8 ACOs in CT currently MD practices affiliated w/hospital systems Care coordination key to success FFS slowly converting to global (capitated) payment PCMH: outpatient setting under ACO umbrella NCQA accreditation & core element evaluation MTM & CDTM key to pharmacist involvement CDTM open to all practice settings & conditions in CT was key PCMH operated by health system CDTM clinic Goal: prevent reimbursement challenges from hospital readmissions, inadequate care coordination Billing: hospital outpatient PPS, incident to, MTM codes New Medicare G codes for transitional care (med rec) Shift from FFS to Global Payments Reimbursement shift issues Source of funding: FFS to global or capitated payment (who is at risk?) Is everyone subject to PMPM allocation? Who receives funding: PCP, specialists, allied health professionals Payment incentives as a result of cost savings Global, bundled or shared savings model How is the pie divided???? 11

12 Incentives to improve medication adherence How shifting to paying for QUALITY instead of quantity affects your adherence initiatives: Medicare Part D Star Ratings impacted by patient adherence to oral diabetes meds, ACEIs or ARBs, and statins Targeted, comprehensive MTM services includes safety, effectiveness & appropriateness Medication synchronization improves adherence, approved this year by CT legislature Payers cannot refuse payment to synch refills UCONN Pharmacy voice in health policy 12

13 Provider status: State vs Federal CT provider status since 1997 Has it been utilized & accepted by payers??? Medicaid has MTM codes, not implemented California provider status: 10/1/13 Created Advanced Practice Pharmacist (APP): can perform pt assessments, refer to other providers, CDTM in outpatient settings APP has 2 yr renewal (additional 10 hrs CE), need 2 of 3: certification, residency, 1 yr CDTM experience Impact on other states with & without provider status will credentialing be required? Payers require credentialing varies by payer Federal provider status: Still awaiting Congressional action Non physician provider status (section 1861 of the Social Security Act) would allow pharmacists to be reimbursed directly from Medicare Part B for providing cognitive services to patients Domino effect with commercial payers to reimburse pharmacists Medicare Part D reimburses pharmacies for pharmacists providing some cognitive services, including medication therapy management (MTM) to a select subset of patients, the program is restrictive and encompasses only a small set of the services pharmacists are capable of undertaking Will federal provider status extend to all pharmacists? Will there be specific credentialing requirements? 13

14 Federal provider status: Still awaiting Congressional action Current non MD providers recognized: audiologists, certified nurse midwives, certified registered nurse practitioners, certified registered nurse anesthetists, physicians assistance, licensed clinical psychologists, licensed clinical social workers, physical and occupational therapists, and registered dieticians/nutrition professional Do pharmacists have at least as much training/expertise? Advocacy is key: National pharmacy organizations coordinated efforts, also need consumer groups, other health organizations USPHS report to Surgeon General Change.org petition started by Arizona pharmacist White House We the People petition started by St. John s student 14

15 MTM aspects of ACA include all but: a. Provide more MTM opportunities because of more access to insurance b. May allow MTM services within new care delivery models c. May provide reimbursement through shared savings models d. Provides reimbursement through Medicare Part B Patient Protection and Affordable Care Act (2010) Overall Approach Goal: Insurance access to 95% of population From 83% 32 million more covered Maintains private insurance system Employer based employer mandates Individual mandates with certain provisions (e.g., mandatory coverage, limits pre existing conditions, etc.) Expands and changes Medicare and Medicaid 15

16 Patient Protection and Affordable Care Act Changes to Private Insurance Must provide dependent coverage for children up to age 26 Prohibit pre existing condition exclusions for children Pre existing conditions & uninsured 6 mos, fall into high risk pool Prohibit lifetime limits for individuals Limit deductibles to $2,000 for individuals and $4,000 for families Patient Protection and Affordable Care Act Insurance Mandate Individuals required to get health insurance Penalties ($95 $695 or 1 2% of total income) Exemptions: those who fall below the income level that requires filing a tax return, those who cannot find a policy that costs less than 8% of their total income IRS can only collect penalty by subtracting it from any annual tax refund due if no refund, there is no mechanism to collect it Mandate date extended to 3/31/14 16

17 Patient Protection and Affordable Care Act Insurance Exchanges State or federally managed Currently only 15 states manage their own exchanges Small businesses can shop for health insurance Restricts illegal immigrants Allows non profit Consumer Operated and Oriented Plan (CO OP) in CT, called HealthyCT Profits returned in reduced premiums or additional services Federal site: CT site: Patient Protection and Affordable Care Act Tax Credits Families between 133 and 400% of the FPL Those between % of FPL will receive cost sharing subsidies up to 90% of the cost of the premiums. Small businesses with <50 employees that average <$50k/yr salaries eligible for premium tax credits. 17

18 Kaiser Family Foundation 18

19 Patient Protection and Affordable Care Act Medicaid Expansion Families with income up to 133% of FPL eligible + 5% disregard = 138% FPL ($15,400 indiv; $32,000 family 4) : Fed pays 100% of difference between state s eligibility level and ACA requirement : Fed contributions 95%, 90% after 2020 Impacted by Supreme Court decision: Ruled Fed could not withhold Medicaid funding for states choosing not to expand program Gave states option to expand eligibility or opt out Ohio changed to opt in 10/21/13, now 29 states Pharmacists/technicians helping patients access health insurance Utilizing Assisters & AccessHealthCT 9 UCONN students certified in person assisters Conduct educational outreach & insurance enrollments in community Similar to Medicare Part D roll out Community service provided by high access provider 19

20 Will ACA create MORE health outcome disparity between the states? The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid Will ACA survive? Will pharmacists thrive? 3 unexpected events made ACA vulnerable: Supreme Court: Medicaid optional (21 states out) 35 states have federally managed exchange... Creates botched online enrollment process Barriers for pharmacists to thrive: Stratifying patients for highest value Standardizing med management services Pharmacist training & credentialing True team based collaborations (CDTM, PCMH, ACO) Sustainable payment models shared savings? 20

21 The ACA will increase access to insurance by all of the following EXCEPT: a. Individual mandate b. Expanded Medicaid eligibility c. A public option insurance plan d. Employer mandate 21

22 It is not the strongest of the species that survives, nor the most intelligent, but the one most responsive to change. Charles Darwin 22

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