Transcript Changing Pharmacy Landscape of the Post

Changing Pharmacy Landscape of the
Post-Acute Care Stay
Todd King, PharmD, Senior Director
Clinical Services, Omnicare, A CVS Health Company
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Agenda
1. Growth and Costs of Post-Acute Care
2. Strategies to Help Improve Quality and Lower Costs
3. Discussion
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Post-Acute Care (PAC) Patients Represent a Significant
and Growing Portion of Health Care Costs
27M people will need long-term care
services and support by 2050 – an
increase of 80% since 20001
Medicare’s payments to PAC providers
totaled $59B in 2013 – more than
double than in 20012
1. “Long-Term Care Services in the United States: 2013 Overview,” U.S. Department of Health and Human Services, December 2013.
2. “Medicare Post-Acute Care Reforms,” Medicare Payment Advisory Commission (MEDPAC) Testimony, April 2016.
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Growth in Medicare Fee-For-Service Spending on PAC has
Outpaced Inpatient Hospital Spending1
Total Percent Change in Spending from 2003 - 20122
80%
70%
60%
50%
40%
30%
20%
10%
0%
PAC
Hosp IP
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Home health care and skilled nursing facilities have significantly contributed to the growth in
Medicare post-acute care expenditures.
1. “Delivering Value Through Post-Acute Care: What it Means for Health Systems,” October 2014.
2. Chart based on Chartis Analysis of MedPAC Data Boo, Charts 1-1 and 8-2 (2014).
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More than 40% of Fee-for-Service Medicare Beneficiaries
Transition from an Acute Care Hospital to PAC1
Skilled Nursing Facility
Home Health
20%
17%
Inpatient Rehab Facility
4%
1%
Long-term Acute
Care Hospital
1. Report to the Congress: Medicare Payment Policy, March 2015.
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58%
Home/Other
One Patient May Require Several Transitions of Care Between
the Hospital, PAC Facilities and Home
Patient with
congestive
heart failure
and
dementia
Receives care at home
from a home health aid
Admitted to short-term
acute hospital
Transferred to
nursing home
Falls at home
Admitted to shortterm acute hospital
Falls at
home again
Transitions to
skilled nursing
facility
Condition worsens; needs
more care support 24/7
Transition of care
Patient story is represented for illustrative purposes only and is not based on an actual patient.
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Hospital Readmissions Due to Poor Patient Care Transitions
Can Add Significant Costs for Medicare and Health Plans
READMISSIONS CAN MORE THAN DOUBLE THE CARE EPISODE COST AND ARE OFTEN PREVENTABLE1, 2
$29,803
$23,844
$19,243
$18,128
$14,977
Non-Readmission
Readmission
$12,075
$8,492
$5,514
Chronic obstructive pulmonary
disease
Pneumonia and pleurisy
Heart failure and shock
Major Joint replacement or
attachment
1 in 5 patients are readmitted within 5 days3 – impacting both patient outcomes and payor costs
1. “Issue Brief: Moving Towards Bundled Payment,” American Hospital Association, 2013.
2. “Medicare Payment Bundling: Insights from Claims Data and Policy Implications,” Dobson DaVanzo & Associates (2012).
3. “Rehospitalizations Among Patients in the Medicare Fee-for-Service Program,” The New England Journal of Medicine, April 2, 2009.
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High Readmission Rate – All Discharges
Diagnoses with the highest readmission rate (% readmitted)
Congestive Heart Failure CHF (31%) –MDS item: I0600
Urinary Tract Infection (28%) - MDS item I2300
Renal Failure (acute volume depletion) (27%)- MDS item I1500
Pneumonia (23%) –MDS item I2000
Chronic Obstructive Pulmonary Disease (23%)- MDS item I6200
Ouslander JG, et al. J Am Med Dir Assoc 2011; 12: 195-203.
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Avoiding Rehospitalization Program
Omnicare, Inc. 2013
©
High Readmission Rate – Preventable from SNFs
Top 5 diagnoses of preventable SNF rehospitalizations
1) Electrolyte imbalance
2) Respiratory infection/pneumonia
3) CHF exacerbation
4) Urinary tract infection (UTI)
5) Sepsis
Ouslander JG, et al. J Am Med Dir Assoc 2011; 12: 195-203.
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What Causes Poor PAC Transitions?
Medication
management
issues
Lack of
effective care
coordination
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Incomplete
transfer of
information
Inadequate
patient and
caregiver
education
Limited
access to
essential
services
Manual environment leads to lengthy medication delays at
admission
Acute care hospital
Reinvented
admission
experience
Skilled nursing
12:00
1
Patient
discharge
2
Patient
transport
3
Arrive at
facility
4
Physician
review
5
Telephone
orders
6
Nurse
order entry
8:00
7
Electronic
order
8 Pharmacy order entry,
fulfillment
9
Delivery
Current process entails manual workflows and delays in patient care
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Strategies to Help Improve PAC Transitions Which Helps Lead
to Better Health Outcomes and Lower Costs
CONSULTANT PHARMACISTS
Serve as an integral part of
the PAC patient’s care team
QUALITY INITIATIVES
Incentivize all members
of the care team to
provide more
accountable care
TECHNOLOGY ADVANCEMENTS
Support prescription
accuracy and clear
communication among
providers
High-quality transitional care is essential, helping to ensure optimal health
outcomes and lower costs
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Consultant Pharmacists Play a Critical Role in Helping Patients
and Caregivers Successfully Transition to PAC Effectively
Conduct medication
reviews; help identify and
address potential issues in
a timely manner
Serve as patient advocates to
help ensure therapy regimens
are accurately transferred and
understood by all
Source: American Pharmacist’s Association: Improving Care Transitions: Optimizing Medication Reconciliation, 2012.
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Educate patients and caregivers
on therapy regimens, adherence,
potential drug side effects
and more
Work with providers and
health plans to better
connect all members of the
patient’s health care team
New CMS Quality Initiatives Should Positively Impact PAC
Outcomes and Accountable Care
BUNDLED
PAYMENTS FOR
HIP AND KNEE
REPLACEMENTS
Holds hospitals accountable for the quality of care
they deliver from surgery through recovery
QUALITY
MEASURES ADDED
TO NURSING HOME
COMPARISON TOOL
Holds skilled nursing facilities accountable for the
quality of care delivered to both short- and longstay patients
Choosing providers with consistently high quality metrics may help reduce readmissions and costs.
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Nursing Home Compare Five Star Quality Rating System- 6 New
Quality Measures
MEDICARE CLAIMS BASED
MDS DATA BASED
• Percentage of short-stay residents who were
successfully discharged to the community
• Percentage of short-stay residents who made
improvements in function
• Percentage of short-stay residents who have
had an outpatient emergency department visit
• Percentage of long-stay residents whose ability
to move independently worsened
• Percentage of short-stay residents who were rehospitalized after a nursing home admission
• Percentage of long-stay residents who received
an antianxiety or hypnotic medication
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Selected Quality Measures for Medicare Part D Star Ratings
Related to Drug Therapy for 2017
Comprehensive Medication Review (CMR) Completion Rate
•
% of patients enrolled in a Medication Therapy Management (MTM) Program who received a CMR
Adherence to non-insulin diabetes medications, statins, ACEIs and ARBs
Appropriate Use of High-Risk Medications in patients 65 years and older
•
Note this measure will count for 2017 Star Ratings but will move to a display measure for 2018. This change was made because
drugs considered high-risk are not necessarily contraindicated. The risks and benefits must be weighed for each patient
Ensuring Statin use in patients with diabetes age 40 to 75 years
•
This will be a display measure for 2017 and 2018 and a full measure in 2019
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Future Display Measures for Medicare Part D and Medicare
Advantage Plans for 2017
MEDICARE PART D
Rate of Chronic Use of Atypical Antipsychotics by
Residents in Nursing Homes
MEDICARE ADVANTAGE
Medication Reconciliation Post Discharge
planned to be included for 2018 Star Ratings- expanded focus on
care coordination
Avoidance of Drug-Drug Interactions
Statin Therapy for Patients with Cardiovascular
Disease
Avoidance of Excessive Doses of Oral Diabetes
Medications
Drug Treatment of COPD with brochodilators or
systemic corticosteriods
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Automated Medication Dispensing Cabinets Help Reduce
Delivery Time to the Customer’s Location
AUTOMATED DISPENSING DEVICES SUPPORT THE NURSING STAFF’S WORKFLOW
Clinicians can:
• Access medications for newly-admitted
patients or for patients who need an
emergency dose
• Select items for each patient via touch
screen
• Confirm correct item with barcode
scanning
Interface with pharmacy receives admission, transfer, discharge and prescription data
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Increasing Use of EHR to Help Improve PAC Transitions,
Improve Outcomes, Reduce Costs
A COMMON DATA ELEMENT IS CRITICAL
• The HITECH Act requires eligible providers
to send care summaries during transitions
of care
– May help significantly shorten
turnaround for new PAC patients to get
prescriptions
– Could be transformative for the industry
As many as 70% of patients may have an
unintentional medication discrepancy at hospital
discharge with the potential for harm1
EHR (Electronic health record). HITECH (Health Information Technology for Economic and Clinical Health). EMR (Electronic medical record).
1. “Improving Medication Safety During Hospital-based Transitions of Care,” Cleveland Clinic Journal of Medicine, June 2015.
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Facility and Pharmacy Web Tools to Help Enhance Medication
Management and Help Expedite Patient Care
TECHNOLOGY MAKES DELIVERING
BETTER CARE EASIER
• Order medication with handheld
scanners
• Quickly assess medication needs
and costs for incoming residents
• View the fulfillment status of each
resident's medications
Omniview
• Secure applications for mobile
devices
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Improving Medicare Post-Acute Care Transformation (IMPACT) Act of
2014
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DRAFT For Internal Use Only
2
Quality Reporting Program
PAC providers must report data within the following
five domains (categories), under a new Quality Reporting Program (QRP):
1.
Skin integrity
2.
Functional status and cognitive function
3.
Medication reconciliation
4.
Incidence of major falls
5.
Transfer of health information and care preferences
when an individual transitions
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QRP: Measure Domain Effective Dates
Quality Measure Domain
LTCH
IRF
SNF
HHA
Functional status/cognitive
function
10/1/18
10/1/16
10/1/16
1/1/19
Skin integrity
10/1/16
10/1/16
10/1/16
1/1/17
Medication reconciliation
10/1/18
10/1/18
10/1/18
1/1/17
Incidence of major falls
10/1/16
10/1/16
10/1/16
1/1/19
Transfer of health information
and care preferences
10/1/18
10/1/18
10/1/18
1/1/19
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SNF Quality Measures Mapped to IMPACT Act
“Domain”
Quality Measure Title
Effective Date for SNFs
Source
Functional status
and cognitive
function
Percent of Patients with an Admission and
Discharge Functional Assessment & a Care Plan
that Addresses Function
Initial reporting Oct – Dec 2016
then CY reporting. First reporting period
will determine if payment adjustment in
FY 2018
MDS
Skin integrity
Percent of Residents with Pressure Ulcers that
are New or Worsened
(Short Stay)
(Same as above)
MDS
Incidence of
major falls
Percent of Residents Experiencing One or More
Falls with Major Injury (Long Stay)
(Same as above)
MDS
Medication
reconciliation
Drug Regimen Review Conducted with Follow up
for Identified Issues
Initial Reporting Oct – Dec 2018 for FY
2020 payment adjustment, followed by
CY reporting, with subsequent year
adjustments
MDS
Transfer of
information and
care preferences
during
transitions
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Initial Reporting Oct – Dec 2018 for FY
2020 payment adjustment, followed by
CY reporting, with subsequent year
adjustments
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Discussion
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