Transcript Million Hearts - Food Marketing Institute

Million Hearts: The Role of Pharmacy, Pharmacy Benefit
Design, and Improving Medication Adherence
John Michael O’Brien, PharmD, MPH
Senior Advisor
U.S. Department of Health & Human Services
CMS Innovation Center
Objectives
1. Describe the Million Hearts initiative.
2. List the baseline measures of the ABCS.
3. Explain the importance of medication adherence to
better health, better health care, and lower costs
through improvement.
4. Describe forthcoming opportunities for pharmacy and
pharmacy benefit design to improve adherence, and to
support Million Hearts and other HHS initiatives.
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The “Three-Part Aim”
Better Health for
the Population
Better Care
for Individuals
Lower Cost
Through
Improvement
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Innovation Will Transform
American Health Care
Current State
Producer-Centered
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Fragmented delivery systems
with variable quality
Costs rising at twice the inflation
rate
17 year lag between best
practice discovery and
widespread adoption
Clinicians dissatisfied
Patients often passive and
unengaged
PRIVATE
SECTOR
PUBLIC
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Fragmented payment systems
(IPPS, OPPS, RBRVRS)
Fee-for-service payment model
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All Americans receive the right
care, in the right setting, at the
right time, all the time
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Health dollars spent efficiently;
rate of growth slowed significantly
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Clinical and delivery system best
practices diffused rapidly
SECTOR
CMS part of the
solution…
Current payments –
part of the problem…
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Future State
People-Centered
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INNOVATION
CENTER
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Episode-based payments
Value-based purchasing
Accountable Care Organizations
Patient Centered Medical Homes
Resource Utilization Reporting
Innovation Center
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The Innovation Center
Our charge: Identify, Test, Evaluate, Scale
“The purpose of the Center is to test innovative payment and
service delivery models to reduce program expenditures under
Medicare, Medicaid, and CHIP…while preserving or enhancing
the quality of care furnished.”
– “preference to models that improve the coordination, quality, and
efficiency of health care services.”
• Resources: $10 billion funding for FY2011 through 2019
• Opportunity to “scale up”: The HHS Secretary has the authority
to expand successful models to the national level
Innovation Center Menu of
Model Options
• ACO Suite
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Shared Savings (3022)
Pioneer ACO
Advanced Payment ACO
Accelerated Development and
Learning Sessions
• Primary Care Suite
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MAPCP
Comprehensive Primary Care
FQHC Medical Home
Independence at Home
Medicaid Home Health
• Bundled Payment Suite
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Gainsharing Acute Care
Retrospective Acute Care Episode
Retrospective Post-Acute Care
Prospective Acute Care
• Dual Eligible Suite
– Capitated Integrated
– FFS Integrated
– Nursing Facility Model
• Diffusion & Scale Suite
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Partnership for Patients
Million Hearts
Innovation Advisors
Innovation Challenge
Innovation Center Menu of
Model Options
• ACO Suite
– Shared Savings (3022)
– Pioneer ACO
• Primary Care Suite
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–
–
MAPCP
Comprehensive Primary Care
FQHC Medical Home
Independence at Home
Medicaid Home Health
• Diffusion & Scale Suite
– Partnership for Patients
– Million Hearts
– Innovation Advisors
Medicare Shared Savings Program
• Accountable Care Organizations (ACOs) are groups of
doctors, hospitals, and other health care providers, who
come together voluntarily to give coordinated high quality
care to their Medicare patients
• When an ACO succeeds both in both delivering highquality care and spending health care dollars more wisely,
it may share in the savings it achieves for the Medicare
program
– 50% one-sided risk, 60% two-sided risk
Medicare Shared Savings Program
Quality is defined by 33 pay-for-reporting or pay-forperformance measures, including:
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Patient/caregiver experience (7 measures)
Care coordination/patient safety (6 measures)
Preventive health (8 measures)
At-risk population: Diabetes, Hypertension, Ischemic
Vascular Disease, Heart Failure, Coronary Artery Disease
Expenditures are defined as Part A & B spending
The Pioneer ACO Model
• Designed for more advanced organizations
• Alternative payment models possible
• Partnership with Part D plans encouraged
• 32 sites listed at http://innovations.cms.gov
Comprehensive Primary Care
initiative (CPCi)
• CMS-led, multi-payer approach to improving and strengthening our
primary care system
• Enhanced payment strategy to provide Primary Care Providers with
resources to:
– Manage Care for Patients with High Health Care Needs
– Ensure Access to Care
– Deliver Preventive Care
– Engage Patients and Caregivers
– Coordinate Care Across the Medical Neighborhood
• Medicare will pay approximately $20 per beneficiary per month to start,
then move towards smaller PBPM to be combined with shared savings
opportunity
Partnership for Patients:
Better Care, Lower Costs
40% Reduction in Preventable Hospital Acquired
Conditions over three years
• 1.8 Million Fewer Injuries
• 60,000 Lives Saves
• A reduction in HACs from 137/1000 to 111/1000
20% Reduction in 30-Day Readmissions in Three Years
• 1.6 Million Patients Recover Without Readmission
• An 11.5% readmissions rate vs. a 14.4% readmission rate
Potential to Save $35 Billion in Three Years
Million Hearts™ Initiative
A national initiative, co-led by
CDC & CMS
Supported by many federal
and state agencies and
private-sector organizations
Goal: Prevent 1 million heart attacks
and strokes in 5 years
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Heart Disease and Strokes
Leading Killers in the United States
 Cause 1 of every 3 deaths
 Over 2 million heart attacks and strokes each year
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800,000 deaths
Leading cause of preventable death in people <65
$444 B in health care costs and lost productivity
Treatment costs are ~$1 for every $6 spent
 Greatest contributor to racial disparities in life
expectancy
Roger VL, et al. Circulation 2012;125:e2-e220
Heidenriech PA, et al. Circulation 2011;123:933–4
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Status of the ABCS
Aspirin
B
People at increased risk
of cardiovascular events
who are taking aspirin
People with hypertension
lood pressure who have adequately
controlled blood pressure
47%
46%
Cholesterol
People with high cholesterol
who are effectively managed
33%
Smoking
People trying to quit smoking
who get help
23%
MMWR: Million Hearts: Strategies to Reduce the Prevalence of Leading Cardiovascular Disease Risk Factors — United States, 2011,
Early Release, Vol. 60
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Key Components of Million Hearts
CLINICAL
PREVENTION
Optimizing care
COMMUNITY
PREVENTION
Changing the context
Focus on
ABCS
Health
information
technology
Clinical
innovations
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TRANS
FAT
Clinical Prevention
Optimizing Quality, Access, and Outcomes
 Focus on the ABCS
 Fully deploy health information technology
 Innovate in care delivery
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Clinical Prevention
Optimizing Quality, Access, and Outcomes
 Focus on the ABCS
 Simple, uniform set of measures
 Measures with a lifelong impact
 Data collected or extracted in the workflow of care
 Link performance to incentives
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Clinical Prevention
Optimizing Quality, Access, and Outcomes
 Fully deploy health information technology (HIT)
 Registries for population management
 Point-of-care tools for assessment of risk for cardiovascular
disease
 Timely and smart clinical decision support
 Reminders and other health-reinforcing messages
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Clinical Prevention
Optimizing Quality, Access, and Outcomes
Innovate in care delivery
 Embed ABCS and incentives in new models
 Health Homes, Accountable Care Organizations,
bundled payments
 Interventions that lead to healthy behaviors
 Mobilize a full complement of effective team members
 Pharmacists, cardiac rehabilitation teams
 Health coaches, lay workers, peer wellness
specialists
 Improve adherence wherever possible
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Why Adherence?
 Patients adhere to 50-70% of chronic essential meds
 Leads to excess morbidity, mortality and costs
 Results in 11% of all hospitalizations
 Estimated costs from $150-290 billion a year in U.S.
 In cardiovascular disease, more adherent patients are about
20% less likely to die of a heart attack and have 20% lower
healthcare costs
“Drugs do not work in patients who do not use them”
(C. Everett Koop, MD)
Part D and Medicare A and B are NOT aligned
Part D plans & pharmacies do not have sufficient
clinical data on their beneficiaries
Unable to determine when their patients are
hospitalized
Part D plans & pharmacies do not benefit when their
patients experience better health
Private firms have no incentive to invest in better
adherence because the averted hospitalization
costs are accrued by A and B
Medicare Part C/D & Adherence
True adherence & quality
improvement
Five-Star Ratings and
Quality Bonuses
Traditional MTM
Medicare Part C/D & Adherence
 Plans below 3 stars get no bonus and beneficiaries are
warned of their low performance during enrollment
 Plans with a 3-5 stars receive bonuses
 Plans with a 5 star rating receive a 5% bonus and an
icon reading “this plan got Medicare’s highest rating.”
Also, MA & PDP beneficiaries may now leave their plan
to join a 5-star plan at any time.
 The MA-PD bonus associated with moving from 3 to 5 stars
is approximately $16 PMPM (but varies by county).
 This is one way to increase attention to medication
adherence, and, ultimately, plan sponsor investment in
interventions to promote adherence
Adherence at CMMI
 Chronic medication therapy will be central to any
model developed by CMMI
 All the care coordination will not help if patients do
not take their medications at home
 Align interests & incentives (e.g., pharma, insurers,
pharmacies, patients, doctors)
 Role of adherence to existing programs?
 A specific focus on adherence?
2013 Call Letter
 We are very interested in Part D sponsors of stand-alone
prescription drug plans (PDPs) playing a greater role in
managing the care of our beneficiaries in Original
Medicare and contributing to overall health outcomes.
 One possible strategy under consideration to further this
goal would be to enable business arrangements between
the new Medicare Shared Savings Program Accountable
Care Organizations (ACOs) or Pioneer ACOs and Part D
sponsors for improved coordination of pharmacy care.
2013 Call Letter
 We would like to receive information on specific
activities that such coordination could consist of and on
the benefits that could accrue to beneficiaries and the
Medicare program from such interventions.
 Finally, we are also interested in seeking feedback
from Part D sponsors on innovative payment or service
delivery models that promote improved medication
adherence.
Simple Interventions Can Help…
 Multi-factorial interventions substantially more effective than simple
mailing or educational efforts (Kriplani, Archives of Int Med, 2006)
 Physicians are not particularly effective at improving their patients’
adherence (Cutrona, Shrank, AJMC, 2010)
 Pharmacists in face-to-face setting and nurses at hospital
discharge are most effective at intervening to improve
adherence (Cutrona, Shrank, AJMC, 2010)
 Health IT simple reminder systems are effective, but little evidence
exists regarding systems that more fully engage patients (Misono, Shrank,
AJMC, 2010)
 Most effective interventions use real-time data to identify and target
those who do not adhere (Cutrona, Shrank, JAPhA, in press)
 Simplification of therapy can improve adherence (Choudhry, Shrank Archives
of Int Med, 2011)
How Could Part D Plans & ACOs invest?
 Value-based insurance design
 Pharmacist Coaches – Motivational Interviewing
 HIT – reminders
 Smarter packaging
 Patient incentives
 Shared decision-making, education, communication
 Health Literacy
 Pharmacy Home
Should patients receive secondary prevention
medications for free after a myocardial infarction?
Providing 3 years of full coverage for
combination pharmacotherapy to currently
insured post-MI patients will on average:
COST AN ADDITIONAL
 $1,149 per beneficiary
in drug costs
Choudhry, Shrank. Health Affairs 2008
SAVE AN ADDITIONAL
 $5,096 per beneficiary in
event-related costs
 1.1 lives and 13 nonfatal re-infarctions per
100 patients
Incentives Under the ACO Rule
ACOs in good standing and their suppliers may
provide items for free or at less than market value if:
 There is a reasonable connection between the items or
services and the medical care of the beneficiary.
 The items or services are in-kind and either are
preventive care items or services or advance one or
more of the following clinical goals: adherence to a
treatment regime; adherence to a drug regime;
adherence to a follow-up care plan; or management of
a chronic disease or condition.
Million Hearts™: Pharmacist Outreach Project
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Million Hearts™: Getting to the Goal
Intervention
Baseline
Target
Clinical
target
Aspirin for those at high risk
47%
65%
70%
Blood pressure control
46%
65%
70%
Cholesterol management
33%
65%
70%
Smoking cessation
23%
65%
70%
Sodium reduction
~ 3.5 g/day
20% reduction
Trans fat reduction
~ 1% of calories
50% reduction
Unpublished estimates from Prevention Impacts Simulation Model (PRISM)
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Everyone Can Make a Difference to
Prevent 1 Million Heart Attacks and Strokes
Clinicians
Pharmacies, pharmacists
Individuals
Foundations
Insurers
Healthcare systems
Government
Retailers
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Consumer groups
Public-Sector Support
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Administration on Aging
Agency for Healthcare Research and Quality
Centers for Disease Control and Prevention
Centers for Medicare and Medicaid Services
Food and Drug Administration
Health Resources and Services Administration
Indian Health Service
National Heart, Lung, and Blood Institute
National Prevention Strategy
National Quality Strategy
Office of the Assistant Secretary for Health
Substance Abuse and Mental Health Services
Administration
 U.S. Department of Veterans Affairs
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Private-Sector Support
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Academy of Nutrition and Dietetics
Alliance for Patient Medication Safety
America’s Health Insurance Plans
American College of Cardiology
American Heart Association
American Medical Association
American Nurses Association
American Pharmacists’ Association
American Pharmacists Association
Foundation
Association of Black Cardiologists
Georgetown University School of
Medicine
Kaiser Permanente
Medstar Health System
 National Alliance of State Pharmacy
Associations
 National Committee for Quality
Assurance
 National Community Pharmacists
Association
 Samford McWhorter School of Pharmacy
 SUPERVALU
 The Ohio State University
 UnitedHealthcare
 University of Maryland School of
Pharmacy
 Walgreens
 WomenHeart
 YMCA of America
Action-Oriented and Results-Focused State Nodes:
Harvesting, Spreading, and Providing Technical Assistance
on Quality Improvement in the ABCS
State Medical,
Pharmacy,
Nursing, etc
Associations
Schools of
Patient & Science
Medicine
Advocacy Groups
Pharmacy,Nursing,
(WomenHeart,
Public Health, etc
AHA)
Employers &
Insurers
Corporate
Partners
Five Ways Every Pharmacy or Pharmacist Can
Support Million Hearts
1. Sign the Million Hearts pledge at
http://millionhearts.hhs.gov and let me know when you do!
2. Contact your state Heart Disease and Stroke Program,
QIO, and state health professionals associations and ask what
they are doing and offer to get involved.
3. Let us know ASAP about any Novel Policies, Care
Innovations, Quality Improvement work (e.g., toolkits, etc), on
blood pressure and reporting you have, or any networks in
which you are participating.
4. Identify potential tests of change in blood pressure and
measurement/reporting
5. Become a Pharmacy Outreach Project Partner!
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What the Future Could Look Like
 Lower sodium foods are abundant and inexpensive
 Blood pressure monitoring starts at home and
ends with successful control
 Data flows seamlessly between settings
 Professional advice when, where, and how you need it
 No or low co-pays for medications
Adding web-based pharmacist care
to home blood pressure monitoring
increases control by >50%
Green BB, et al. JAMA 2008;299:2857-67
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Take the Pledge & Please Stay in Touch!
http://millionhearts.hhs.gov
John Michael O’Brien, PharmD MPH
Senior Advisor
John.O’[email protected]
443-821-4183
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