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Pharmacy Liaison Committee Preparing for the Future Ideas for Pharmacists adding quality and control

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Examine MTM under the Medicare ... Expenditure distribution based on CBO data that includes only ... Woodwork effect will add low-income Medicare ... – PowerPoint PPT presentation

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Title: Pharmacy Liaison Committee Preparing for the Future Ideas for Pharmacists adding quality and control


1
Pharmacy Liaison CommitteePreparing for the
FutureIdeas for Pharmacists adding quality and
controlling expendituresNovember 16, 2004
2
Overview
  • Briefly recap current environment
  • Examine MTM under the Medicare Modernization Act
    2003
  • Identify innovative programs in other states
  • Present areas for future focus

3
Medicaid Enrollees and Expendituresby Enrollment
Group, 2003
Elderly 9
Elderly 26
Disabled 16
Adults 27
Disabled 43
Children 48
Adults 12
Children 19
Total 52.4 million
Total 235 billion
Expenditure distribution based on CBO data that
includes only federal spending on services and
excludes DSH, supplemental provider payments,
vaccines for children, administration, and the
temporary FMAP increase. Total expenditures
assume a state share of 43 of total program
spending. SOURCE Kaiser Commission estimates
based on CBO and OMB data, 2004.
4
Sources of Increasing Pressure on State Medicaid
Programs
  • Increasing enrollment, especially of elderly and
    disabled
  • Increasing urgency to slow growth of Medicaid
    spending
  • Loss of one-time enhanced federal match in 2004
  • New responsibilities and costs from Medicare Part
    D prescription drug benefit
  • Intensified CMS scrutiny
  • Likelihood of Medicaid reform or restructuring

5
The Medicare Part D Prescription Drug Benefit
Adds to Medicaid Stress
  • Fiscal implications
  • Clawback will erode hope for savings
  • Woodwork effect will add low-income Medicare
    enrollees to Medicaid
  • States are feeling pressure already to wrap
    around the Medicare benefit
  • Administrative implications
  • Preparation for eligibility determinations for
    low-income subsidies
  • System changes

6
The Medicare Part D Prescription Drug Benefit Is
Better at Low Incomes
7
States Undertaking New Medicaid Cost Containment
Strategies FY 2002 FY 2005
SOURCE KCMU survey of Medicaid officials in 50
states and DC conducted by Health Management
Associates, September and December 2003 and
October 2004.
8
Medicaid Prescription Drug Policy Changes FY 2004
and FY 2005
SOURCE KCMU survey of Medicaid officials in 50
states and DC conducted by Health Management
Associates, October 2004.
9
Underlying Growth in State Tax Revenue Compared
with Average Medicaid Spending Growth, 1997-2004
NOTE State Tax Revenue data is adjusted for
inflation and legislative changes. 2004 is a
preliminary estimate. SOURCE Analysis by the
Rockefeller Institute of Government of data from
the Bureau of the Census, Bureau of Economic
Analysis and the National Association of State
Budget Officers.
10
The Outlook for Medicaid All Signs Point to
Continued Cost Growth for States
  • Medicaid enrollment Growth is shifting toward
    more costly elderly and disabled
  • Medicaid spending Projected to grow 8 to 9 per
    year over the next decade (CBO, March 2004)
  • Federal financial help Doesnt appear
    likelyfederal fiscal relief ended and Medicare
    prescription drug financing adds to the state
    financing challenge
  • Result State Medicaid program growthoutpacing
    revenue growthwill continue to drive Medicaid
    politics and policy decisions

11
Re-Structuring Medicaid Expect
Proposals
  • State-based organizations are developing
    proposals for federal re-structuring of Medicaid
  • National Conference of State Legislatures (NCSL)
  • National Academy for State Health Policy (NASHP)
  • Chances of any significant changes being
    adopted?????

12
MMA Comprehensive Benefit 2006Law Sec.
1860D4 (c) - MTM
  • ..that covered part D drugs under the
    prescription drug plan are appropriately used to
    optimize therapeutic outcomes through improved
    medication use, and
  • to reduce the risk of adverse events, including
    adverse drug interactions. Such a program may
    distinguish between services in ambulatory and
    institutional settings.

13
MMA Comprehensive Benefit 2006Law Sec.
1860D4 (c) - MTM
  • Targeted beneficiaries described in this clause
    are part D eligible individuals who
  • (I) have multiple chronic diseases (such as
    diabetes, asthma, hypertension, hyperlipidemia,
    and congestive heart failure) (II) are taking
    multiple covered part D drugs and (III) are
    identified as likely to incur annual costs for
    covered part D drugs that exceed a level
    specified by the Secretary.

14
MMA Comprehensive Benefit 2006Law Sec.
1860D4 (c) - MT
  • (B) ELEMENTS.Such program may include elements
    that promote
  • (i) enhanced enrollee understanding to promote
    the appropriate use of medications by enrollees
    and to reduce the risk of potential adverse
    events associated with medications, through
    beneficiary education, counseling, and other
    appropriate means

15
MMA Comprehensive Benefit 2006Law Sec.
1860D4 (c) - MTM
  • (B) ELEMENTS.Such program may include elements
    that promote
  • (ii) increased enrollee adherence with
    prescription medication regimens through
    medication refill reminders, special packaging,
    and other compliance programs and other
    appropriate means and

16
MMA Comprehensive Benefit 2006Law Sec.
1860D4 (c) - MTM
  • (B) ELEMENTS.Such program may include elements
    that promote
  • (iii) detection of adverse drug events and
    patterns of overuse and underuse of prescription
    drugs.

17
MTM Consensus Definition
  • Services include but are not limited to
  • Assessment of health status
  • Formulating a medication treatment plan
  • Selecting, initiating, modifying, or
    administering medication therapy
  • Performing a comprehensive medication review to
    identify, resolve and prevent medication-related
    problems, including adverse drug events
  • Documenting the care delivered and communicating
    essential information to the patients other
    primary care providers

18
MTM Consensus Definition
  • Services include but are not limited to
  • Providing verbal education and training designed
    to enhance patient understanding and appropriate
    use of his/her medications
  • Providing information, support services and
    resources designed to enhance patient adherence
    with his/her therapeutic regimens
  • Coordinating and integrating medication therapy
    management services within the broader health
    care-management services being provided to the
    patient

19
Cognitive Services
  • AL Clozaril case management fee of 3.00
  • MN, VA Clozaril monitoring fee
  • FL Pays for DUR and disease management
    counseling for HIV, mental health, diabetes, and
    htn services
  • MS Pays for DM for diabetes, hyperlipidemia,
    asthma, and coagulatory disorders. Pays 20 for
    average 30 minute encounter

20
Cognitive Services
  • MO Payment is provided to qualified pharmacies
    who enroll to provide asthma, diabetes,
    heartfailure, and depression education
  • WA Pays for cognitive services under the
    Emergency Contraceptive Program
  • WI proves an expanded dispensing fee for
    cognitive services

21
Pilot PCM Iowa
  • Program Details
  • Funds were initially appropriated during the 2000
    Iowa Legislative session
  • Obtained State Plan Amendment from CMS
  • Reimburse physicians and pharmacists separately
    for their participation
  • 75 - initial assessment
  • 40 - new problem assessment and follow-up
    assessment
  • 25 - preventative assessment

22
Pilot PCM Iowa
  • Focuses on patients who are identified as being
    at high-risk for difficulty taking their
    medications safely and effectively
  • A research team from the University of Iowa
    Colleges of Public Health, Pharmacy, and Medicine
    evaluated the program, funded from pharmacy
    organizations, not the state.
  • An advisory committee composed of members of IPA
    and the three state medical associations assisted
    the Iowa Department of Human Services in
    formulating the program and the research

23
Pilot PCM Iowa
  • Eligible patients must
  • Be receiving 4 or more chronic medications
  • Not be in a nursing facility and
  • Be receiving treatment for at least one of twelve
    specified disease states CHF, asthma, diabetes,
    hyperlipidemia, hypertension, GERD, peptic ulcer
    disease, depression, osteoarthritis, ischemic
    heart disease, atrial fibrillation, and COPD.

24
Pilot PCM Iowa
  • Both pharmacists and pharmacies must become
    eligible to provide PCM. Pharmacists are given a
    PCM pharmacist provider number.
  • Pharmacists must meet special criteria to
    participate completion of professional training
    regarding patient-oriented care and submission of
    patient care plans for evaluation.
  • Pharmacies must have a private patient
    consultation area and an appropriate patient care
    documentation system.

25
Florida Medicaid QRE Project
  • Since July 2003, Florida Medicaid in certain
    counties have participating pharmacies offering
    quality related events project.
  • Online training/tracking provided by Outcomes an
    Iowa based company

26
Others initiatives
  • NC - program where the Managed Care Docs are
    educated on ProductCosts to MEDICAID
  • From Florida The Gold Standard Program and the
    Pilot to Minimize ERutilization

27
Others initiatives
  • Florida press release - October 8, 2004
  • Governor's Health Advisory Board Recommends Bold
    Initiative To Bring Electronic Health Records To
    Floridians
  • recommended Florida be a lead state in
    establishing community pilot initiatives to
    transition to an electronic records system.

28
Virginia Cost/Quality Tools
  • PDL
  • Threshold/Polypharmacy Program
  • 34 day supply limit
  • Tierd co-pay
  • Generic utilization
  • Brand medically necessary could be enhanced
  • MAC
  • DUR
  • Pro DUR
  • Retro DUR

29
Virginia Cost/Quality Tools
  • Retro - DUR
  • Beers criteria
  • Atypical Antipsychotic TD
  • Sedative hypnotic Benzodiazepines greater 35 days
  • APAP greater than 4gm/day

30
Virginia Cost/Quality Tools
  • Upcoming Retro- DUR
  • Asthmatics using beta-agonist inhalers and not on
    an anti-inflammatory inhaler
  • Medication and ER admission review of migraine
    patients addition of prophylactic treatments
  • Meds that lower seizure threshold
  • Synagis Review pts less 3yo who got Synagis
  • Use of treatment guidelines

31
Future Focus
  • Health Literacy Compliance aids
  • E-Prescribing
  • Health lifestyles
  • OTC pharmacist initiated
  • Smoking cessation
  • HIV mgmt
  • STD counseling
  • Prenatal Care
  • Evidence Based Medicine Initiatives
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