Health Care Reform: Practical Implications for Pharmacy Staff

1
Health Care Reform Practical Implications for
Pharmacy Staff

• Rachel Kruer
• University of Cincinnati
• PharmD Candidate 2010
• August 2009

2
Goals of Health Care Reform

• Increasing value for patients
• Improved patient health outcomes per dollar spent
• Coverage for all patients
• Improve access to primary care and preventative
  medicine

Porter, M.E. Health Care 2009 A Strategy for
Health Care Reform Toward a Value Based
System. N Engl J Med. 3612 9 July 2009.
www.nejm.org. 4 August 2009.
3
Status of Health Care Reform Legislation

• Two health care reform bills
• Americas Affordable Health Choices Act of
  2009, (HR 3200)
• Proposed by the House Tri-Committee composed of
  the Committee on Energy and Commerce, the
  Committee on Education and Labor, and the
  Committee on Ways and Means
• A draft bill from the Senate Health Education
  Labor and Pensions (HELP) Committee
• The Senate Finance Committee is expected to
  release a proposal by mid-September, which will
  be fused with the HELP Committee version
• The legislation is likely to be voted upon in
  both chambers in September

Status Report Health Care Reform Legislation,
Where Health-System Pharmacy Stands. August
2009. American Society of Health-System
Pharmacists.
4
The Kaiser Family Foundation

• A non-profit, non-partisan, private operating
  foundation focusing on the major health care
  issues facing the U.S., as well as the U.S. role
  in global health policy.
• The Kaiser Family Foundation is not associated
  with Kaiser Permanente or Kaiser Industries.
• Kaiser develops and runs its own research and
  communications programs, sometimes in partnership
  with other non-profit research organizations or
  major media companies.
• The information in this presentation was obtained
  from Focus on Health Reform Side-by-side
  Comparison of Major Health Care Reform
  Proposals. The Kaiser Family Foundation. 7
  August 2009. http//www.kff.org/healthreform/sideb
  yside.cfm.

About the Kaiser Family Foundation.
http//www.kff.org/about/index2.cfm. 12 August.
2009.
5
President Obamas Principles for Health Reform

• Reduce long-term growth of health care costs for
  businesses and government
• Protect families from bankruptcy or debt due to
  health care costs
• Guarantee choice of doctors and health plans
• Invest in prevention and wellness
• Improve patient safety and quality care
• Assure affordable, quality health coverage for
  all Americans
• Maintain coverage through job loss or changes
• End barriers to coverage for those with
  pre-existing medical conditions

6
Overall Approach to Expanding Access to Coverage

• Require individuals to have health insurance
• HR 3200
• Create a Health Insurance Exchange
• Require employers to provide coverage OR pay into
  Health Insurance Exchange Trust Fund, some
  exceptions for small employers
• New regulations for plans partaking in the
  Exchange and in the small group insurance markets
• Expand Medicaid
• Senate HELP Committee
• Create state-based American Health Benefit
  Gateways
• Require employers to provide coverage for
  employees or pay a fee, with some exceptions for
  small employers
• New regulations for non-group and small group
  insurance markets
• Expand Medicaid
• Senate Finance Committee
• Create a Health Insurance Exchange
• New regulations for non-group and small group
  insurance markets
• Expand Medicaid and CHIP, offer temporary
  Medicare buy-in for those not yet qualified for
  Medicare

Explaining Health Care Reform What Are Health
Insurance Exchanges? The Kaiser Family
Foundation, Health Care Marketplace Project.
7908. 20 May 2009. http//www.kff.org/healthreform
/7908.cfm. 12 August 2009.
7
Individual Mandate

• Require all individuals to have health insurance
  that meets minimum qualifying standards
• HR 3200
• Penalty required for those without adequate
  coverage, 2.5 of modified adjusted gross income
  up to the average cost of a national premium for
  a basic plan in the Health Insurance Exchange
  some exceptions apply
• Senate HELP Committee
• Annual tax penalty required for those without
  adequate coverage up to 750 per year some
  exceptions apply
• Senate Finance Committee
• Excise tax for those without adequate coverage
  equal to a percentage of the lowest cost national
  premium for a basic plan in the Health Insurance
  Exchange, some exceptions apply

8
Employer Requirements

• HR 3200
• Employers required to offer insurance coverage to
  employees AND contribute a percentage of premium
  cost of the lowest cost, qualifying plan
• Minimum of 72.5 for single coverage
• Minimum of 65 for family coverage
• OR employers can contribute to the Health
  Insurance Exchange Trust Fund at a rate of 8 of
  the payroll, some exceptions apply
• Senate HELP Committee
• Employers required to offer insurance coverage to
  employees AND contribute a percentage of premium
  costs
• Minimum of 60 of premium cost contributed by
  employer
• OR pay a fee for each uninsured employee not
  offered coverage, some exceptions apply
• 750 fee for each uninsured full time employee,
  and 375 for part time

9
Employer Requirements

• Senate Finance Committee
• Option A Employers with a total payroll per
  year greater than 500,000 required to contribute
  a minimum of 50 of the premium or play
  assessment and pay a fee
• Option B No pay or play requirement
• Pay or Play health reform proposals that
  would require employers to offer coverage or pay
  to help finance subsidies for those without
  access to affordable coverage

Explaining Health Care Reform What Are Health
Insurance Exchanges? The Kaiser Family
Foundation, Health Care Marketplace Project.
7907. 20 May 2009. http//www.kff.org/healthreform
/7907.cfm. 12 August 2009.
10
Expansion of Public Programs

• HR 3200
• Medicaid
• Include all individuals with income up to 133
  FPL
• Include all newborns lacking qualifying coverage
• Optional coverage for patients with HIV and for
  family planning services for low-income women
• Increase Medicaid reimbursement rates to 100 of
  Medicare rates for primary care providers
• Expansions that are not optional will be financed
  with federal funds
• CHIP participants will be required to gain
  coverage through the Health Insurance Exchange,
  provided it can be done without coverage
  interruption

11
Expansion of Public Programs

• Senate HELP Committee
• Medicaid
• Include all individuals with income up to 150
  FPL
• If eligible, patients will be covered by State
  Medicaid Programs and will not be eligible to
  purchase coverage through American Health Benefit
  Gateways
• Those eligible for CHIP will have the option to
  enroll in CHIP or in an adequate Gateway plan

12
Expansion of Public Programs

• Senate Finance Committee
• Medicaid
• Include all individuals with income up to 115
  FPL
• There is an option to include everyone except
  childless adults, who are instead given tax
  credits to purchase Exchange coverage or buy into
  Medicaid
• CHIP
• Expand eligibility to 275 FPL following 9/30/13
• CHIP participants would then be required to
  obtain coverage through the Exchange, once it is
  fully established
• States would subsequently be responsible for
  covering any preventative care not covered by the
  Exchange

13
Expansion of Public Plans

• Senate Finance Committee Continued
• Medicare
• Individuals 55-64 years of age would be allowed
  to buy-in to Medicare at full-cost until the
  Exchange is fully established
• Waiting period for Medicare eligibility would be
  decreased for those with disabilities
• Public Health Insurance Options
• Proposed Option A Creation of a new public
  plan, subject to the rating and assessment of
  private plans, offered through the Exchange and
  administered by either the federal government,
  the States, or multiple third-parties
• Proposed Option B No public plan option

14
Premium Subsidies to Individuals and Employers

• Individuals
• HR 3200 and The Senate HELP Committee
• Provide premium credits to individuals and
  families with income 100-400 FPL for the
  Exchange (HR 3200) or Gateway (HELP)
• Senate Finance Committee
• Provide refundable tax credits for individuals
  and families with income 100-400 FPL
• Employers
• HR 3200 and The Senate Finance Committee
• Provide qualifying small employers with a tax
  credit
• Senate HELP Committee
• Provide health options credit to small employers
  who qualify

15
Creation of Insurance Pooling Mechanisms

• HR 3200
• Implement a National Health Insurance Exchange
• Include private plans and a public health
  insurance option that meet qualifying
  requirements regarding benefit levels, provider
  networks, consumer protections, cost sharing,
  renewability, insurance rating rules, network
  adequacy, and information transparency
• Require state licensure of plans participating in
  the exchange
• Restrict access to those who are not already
  eligible for enrollment in employer or individual
  coverage or another public program (i.e.
  Medicare, Medicaid (some exceptions apply),
  TRICARE, and VA coverage (some exceptions apply))

16
Creation of Pooling Mechanisms

• Senate HELP Committee
• Generate state-based American Health Benefit
  Gateways
• Gateways would be administered by a government
  agency or a non-profit
• There may be multiple Gateways in a state OR
  multiple states may form regional Gateways, as
  long as the Gateway corresponds to a geographic
  region
• Access to coverage through the Gateway would be
  restricted to those who are not incarcerated,
  enrolled in an employer-sponsored program (that
  meets all qualifications of adequate coverage),
  Medicare, Medicaid, TRICARE, or the Federal
  Employee Health Benefits Program
• Require all plans participating in the Gateway to
  meet minimum requirements with regard to
  renewability and inclusion of essential benefits
• Require Gateways to certify participating plans,
  and ensure consumers have access to information
  that allows them to make informed decisions
  regarding plan selection

17
Creation of Pooling Mechanisms

• Senate Finance Committee
• Implement one national OR multiple regional
  Health Insurance Exchanges
• Standardize format for presentation and
  distribution of coverage options
• Require participation by all state-licensed
  non-group and small group markets
• Require plans to meet minimum renewability
  requirements

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Benefit Design

• HR 3200
• Generate a package of essential benefits to be
  covered at 70 of the actual value of the
  benefits
• Limit annual cost incurred by 5,000/individual
  or 10,000/family
• No annual or lifetime limits of coverage
• Health Benefits Council to determine precise
  services covered

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Benefit Design

• Senate HELP Committee
• Create essential benefits package
• No lifetime limit on benefits
• Outline minimum qualifying coverage criteria and
  affordability standard
• Senate Finance Committee
• Create four categories of benefits (lowest, low,
  medium, high)
• No lifetime limit on benefits
• Insure compliance with one of the four benefit
  categories

20
Changes to Private Insurance

• HR 3200
• Prohibit the purchase of coverage though the
  individual market unless it is grandfathered
  coverage
• Qualifying health benefit plans can be acquired
  through the Exchange
• Establish standards that at least meet the
  minimum requirements required by the Exchange
• Senate HELP Committee
• Require compliance with the same insurance market
  regulations as the plans participating in the
  Gateways
• Allow licensed private health insurers to sell
  plans outside of the Gateway, as long as they are
  regulated by the state
• Senate Finance Committee
• State-licensed insurers required to participate
  in the Exchange
• All insurers must offer policies in each of the
  four proposed benefit categories

21
Cost Containment

• HR 3200
• Simplify administration of health insurance
  including increasing electronic transactions
• Medicaid Increase prescription drug rebate
  percentage and expand prescription drug rebate to
  include Medicaid managed care plans
• Require drug manufacturers to provide rebates for
  those who are dual eligible and enrolled in Part
  D plans
• Require the reporting of all health care
  associated infections obtained in hospitals and
  surgical centers to the Centers for Disease
  Control and Prevention
• Allow provider screening, enhanced oversight
  periods, and enrollment freezes in areas
  identified as at risk for fraud in an attempt to
  reduce waste, fraud, and abuse in public programs

22
Cost Containment

• HR 3200
• Amendments offered by the Committee on Energy and
  Commerce
• Require negotiations with pharmaceutical
  manufacturers to obtain lower drug prices for
  Medicare Part D and Medicare Part D advantage
  plans
• Authorize FDA to approve generic biologics
  biosimilars grant biologic manufacturers 12
  years exclusivity before allowing the development
  of generics

23
Cost Containment

• Senate HELP Committee
• Establish a council to oversee policy and program
  development
• Simplify administration of health insurance
  including increasing electronic transactions
• Senate Finance Committee
• Expand incentives in the American Recovery and
  Reinvestment Act to encourage the use of health
  information technology
• Improve information transparency on skilled
  nursing floors
• Allow intensive provider screening in an attempt
  to reduce waste, fraud, and abuse in public
  programs
• Require the disclosure of payment and incentives
  given to providers by drug or device
  manufacturers and physician investment interests

24
Improving Quality/Health System Performance

• HR 3200
• Establish a Center for Comparative Effectiveness
  Research to encourage research on outcomes,
  effectiveness, and appropriateness of health care
  services
• Improve coordination of primary care services by
  increasing Medicaid payments and Medicare bonus
  payments to primary care practitioners
• Implement Medicare pilot programs testing payment
  incentives for accountable care organizations and
  payment bundling for post-acute care
• Implement Medicare and Medicaid pilot programs to
  determine the feasibility of reimbursing medical
  homes

25
Improving Quality/Health System Performance

• HR 3200 continued
• Amendment, Ways and Means Committee
• Require the Institute of Health to research
  geographic variations in health care spending and
  recommend ways in which this variation can be
  addressed
• Require disclosure of financial interests between
  health entities including physicians, hospitals,
  pharmacists, and manufacturers and distributors
  of drugs, devices, biologics, and medical
  supplies
• Decrease health disparities due to race and
  ethnicity by conducting a study on the
  feasibility of implementing Medicare payment for
  language services

26
Improving Quality/Health System Performance

• Senate HELP Committee
• Create a Center for Health Outcomes Research
• Develop quality measures involving multiple
  stakeholders to assess health outcomes,
  continuity of care, safety and efficacy,
  timeliness, health disparities, and appropriate
  delegation of resources
• Implement a national strategy to improve health
  care delivery, patient outcomes, and population
  health that includes an annual publication of the
  national health care quality report card
• Provide grants to improve the efficiency of
  health systems including the establishment of a
  medical home model, to implement medication
  management services, and to design and implement
  regional emergency care and trauma systems
• Require the reporting of preventable readmission
  rates by hospitals
• Design a Patient Safety Research Center to
  identify, evaluate, and distribute information
  regarding best practices
• Provide incentives and grants for implementing
  the use of health information technology

27
Improving Quality/Health System Performance

• Senate Finance Committee
• Improve primary care and the management of
  chronic care by providing payment bonuses to
  primary care providers
• Institute a framework to establish national
  priorities for comparative clinical effectiveness
  research
• Bundle payments for hospital stays and post-acute
  care services
• Establish a value-based purchasing program in
  hospitals to pay based on quality performance
  measures
• Develop strategies for the development of quality
  measures involving multiple stakeholders
• Require improved collection and data reporting
  regarding race, ethnicity, and primary language
  as well as access and treatment data for
  individuals with disabilities

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Prevention/Wellness

• HR 3200
• Develop a strategy to improve the nations
  wellness by implementing community based
  preventative medicine
• Senate HELP Committee
• Develop a national strategy to increase
  prevention and health promotion
• Provide incentives such as grant programs to
  state and local governments as well as community
  organizations to implement and evaluate
  preventative health activities
• Encourage employer provided wellness programs
• Create a temporary Right Choices Program to cover
  preventative services for the uninsured
• Senate Finance Committee
• Provide incentives such as grant programs to
  states implementing innovative prevention and
  wellness activities

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Other Investments

• HR 3200
• Eliminate the Medicare Part D coverage gap (in
  phases) and require a 50 discount provided my
  manufacturers on brand name prescriptions filled
  during the gap
• Reform Graduate Medical Education to increase
  training of primary care providers by
  redistributing residency positions
• Encourage the training of health professionals,
  including advanced education nurses, who will
  practice in underserved areas promote a diverse
  work force and provide cultural competence for
  health care professionals
• Senate HELP Committee
• Reform Graduate Medical Education to increase the
  education and training of doctors, nurses, and
  other health care workers, especially in the
  areas of pediatrics, geriatrics, and primary care
• Senate Finance Committee
• Reform Graduate Medical Education to increase
  training of primary care providers and increase
  the availability of residency programs in rural
  and underserved areas

30
Financing

• President Obama dedicated 630 billion over 10
  years to the Health Reform Reserve Fund in his
  February budget outline
• HR 3200
• 1.042 trillion over 10 years (approximately ½ of
  the cost is financed through savings from
  Medicare and Medicaid)
• Senate HELP Committee
• 615 billion over 10 years the Senate HELP
  Committee has no jurisdiction over Medicaid and
  Medicare programs, financing will be developed by
  the Senate Finance Committee

31
Implications for Pharmacy Staff

• Changes for your patients
• Expansion of Medicaid coverage
• Increased provider screening and enhanced
  oversight may come with delays
• Health Insurance will be entirely restructured
  and regulated by the federal government
• Health insurance entities will be required to
  comply with quality and affordability standards
• Eventually all patients will be covered by a
  health insurance entity
• Will there be a need for disproportionate share
  hospitals? Compassionate care programs provided
  by pharmaceutical companies? Patient assistance
  programs?
• Primary care, wellness, and prevention services
  will be expanded
• With the current shortage of primary care
  providers, can the current system handle a vast
  influx in patients?
• Reform will prohibit discrimination against
  individuals with regard to disability,
  pre-existing conditions, health status, and
  gender
• Patients may be confused and frustrated
• Pharmacy staff must be a source for information
  as well as patience and compassion

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Important Issues for Pharmacists

• HR 3200
• Includes
• MTM grant program, administered by the Agency for
  Health Care Research and Quality
• Loan forgiveness for pharmacy graduates who
  commit to practice in underserved areas, separate
  from the National Health Service Corps
• Does not include
• Restoration of funding for PGY2 residencies under
  the GME reform
• Recognition of pharmacists as providers

Status Report Health Care Reform Legislation.
August 2009. American Society of Health-System
Pharmacists.
33
Important Issues for Pharmacists

• Senate HELP Committee
• Includes
• Grants for pharmacist-provided MTM, through the
  formation of a patient safety research center
• Requirement for MTM services in the medical home
  model
• Does not include
• Expanded loan forgiveness program for pharmacists
• PGY2 funding restoration
• The Senate Finance Committee does have
  jurisdiction over this issue through its dealings
  with Medicare funding
• Recognition for pharmacists as providers

Status Report Health Care Reform Legislation.
August 2009. American Society of Health-System
Pharmacists.
34
Sources for Additional Information

• http//finance.senate.gov
• http//help.senate.gov
• http//wayandmeans.house.gov
• http//energycommerce.house.gov
• http//edlabor.house.gov
• http//www.whitehouse.gov/omb/budget/
• http//www.HealthReform.gov
• http//www.healthreform.gov/reports/statehealthref
  orm/kentucky.html

35
What You Can Do

• Write a letter to your legislators
• Log in to ASHPs online advocacy center to
  contact your two senators and representative.
• Work with your Director of Pharmacy to invite
  them to visit your practice site, or schedule an
  appointment at their district office.
•  Attend a town hall meeting.

36
References

• About the Kaiser Family Foundation.
  http//www.kff.org/about/index2.cfm. 12 August.
  2009.
• Focus on Health Reform Side-by-side Comparison
  of Major Health Care Reform Proposals. The
  Kaiser Family Foundation. 7 August 2009.
  http//www.kff.org/healthreform/sidebyside.cfm.
• Explaining Health Care Reform What Are Health
  Insurance Exchanges? The Kaiser Family
  Foundation, Health Care Marketplace Project.
  7907. 20 May 2009. http//www.kff.org/healthreform
  /7908.cfm. 12 August 2009.
• Explaining Health Care Reform What Are Health
  Insurance Exchanges? The Kaiser Family
  Foundation, Health Care Marketplace Project.
  7908. 20 May 2009. http//www.kff.org/healthreform
  /7907.cfm. 12 August 2009.
• Porter, M.E. Health Care 2009 A Strategy for
  Health Care Reform Toward a Value Based
  System. N Engl J Med. 3612 9 July 2009.
  www.nejm.org. 4 August 2009.
• Status Report Health Care Reform Legislation.
  August 2009. American Society of Health-System
  Pharmacists.