 |
Long-Term Care Pharmacy State of the Industry
Douglas A. Present
Chief Executive Officer
Managed Health Care Associates, Inc. View selected slides with audio>
Mr. Present started his presentation by discussing the 2010 Health Care Reform Act and aspects of the Act that will have
greatest relevance to long-term care pharmacy. In regards to Medicare, the Act will incur the following changes:
• Restructures payments to Medicare Advantage plans
• Freezes the threshold for Medicare Part B payments from 2011-2019 for people with
incomes over 85K per year (170K per couple)
• Establishes an Independent Payment Advisory Board |
• Allows for the creation of Accountable Care
Organizations (ACOs)
• Creates an “Innovation Center” within CMS
• Closes the donut hole
• Requires no co-insurance or deductibles for
preventive services |
Mr. Present went on to highlight those issues currently of greatest importance to long-term care pharmacy owners and operators, including the increased use of generics and erosion of profit margins related to generic dispensing, short cycle
dispensing, audits that are being mandated by prescription drug plans (PDPs), dispensing of controlled substances from long-term care pharmacies into skilled nursing facilities, and increased federal and state compliance. Mr. Present emphasized
that long-term care pharmacy owners and operators must take a proactive role in shaping, managing, and implementing these changes. Actions that pharmacies can take include getting involved in legislative activities at federal and
state levels and maximizing pharmacy efficiency.
Mr. Present closed by emphasizing the active role MHA has in helping long-term care pharmacies with these changes.
MHA has been working with Prescription Drug Plans, federal and state governments, and pharmacy and long-term care
associations such as the Long-Term Care Pharmacy Alliance and the American Society of Consultant Pharmacists to
ensure that independent long-term care pharmacies have a “voice” with key decision-makers.
|
 |
|
Overview of the Health Care Reform Act
The Honorable William H. Frist, MD
18th Majority Leader, U.S. Senate, 2003-2007
U.S. Senator from Tennessee, 1995-2007
Heart-Lung Transplant Surgeon
Co-Chair, Partnership for a Healthier America
Leading Voice in the Healthcare Debate
View selected slides with audio
View slide presentation
The Honorable Dr. Frist initiated his presentation with a history and background of the Patient
Protection and Affordable Care Act (PPACA) that was signed on March 23, 2010 and the follow-up
Health Care and Education Reconciliation Act of 2010 that was signed on March 30, 2010. He discussed
the role the 2008 recession had on health care reform and how this may shape future health
care trends.
The Honorable Dr. Frist then presented his view on the future of the Health Care Reform Act and
noted that it is his belief that the Act may be ruled unconstitutional in the courts. He emphasized
concerns about how the Health Care Reform Act will be paid for and the debt that will be incurred
with this Act: “The single largest threat to the greatness of America is the skyrocketing DEBT … driven
by explosive, accelerating entitlement spending.” This exploding debt will impact productivity within
the United States. The question is—how will these entitlements be paid for?
Next, the Honorable Dr. Frist presented his thoughts on how the federal government could manage
healthcare. One example he provided was to move toward “defined contribution” tax support in all
three main insurance coverage platforms:
• Medicare—premium support
• Medicaid (for the non-disabled)—per capita federal payments to the states
• Employer-sponsored insurance with refundable tax credits
One idea for Medicare Part D is partial prototype: Medicare Part D enrollees select the insurance and care delivery model they
would like to have. The more expensive options would be paid out-of-pocket by the enrollee. The federal government would provide
oversight of the marketplace as the new healthcare agenda is being implemented. One example would be starting in 2021,
people who turn 65 would receive vouchers to purchase private Medicare-certified health insurance plans in a new “Medicare
Exchange.”
The Honorable Dr. Frist closed by noting that the real action in health care reform is at the state level. States are responsible for
most of the new legislation due to Medicaid restrictions and state budget pressures that are only worsening. |
|
|
Short Cycle Implementation and Market Impact 
Michael J. Sicilian
President
Managed Health Care Associates, Inc. View selected slides with audio
Mr. Sicilian started his presentation by providing the background and potential reasons why short cycle dispensing may
have been included in the 2010 Health Care Reform Act. Mr. Sicilian emphasized that the initial intent of the federal
government was to reduce unused medications associated with 30-day fills, thereby reducing costs, protecting the environment,
and discouraging diversion. The original intention of this guidance was to include all medications dispensed
by a long-term care pharmacy to almost all long-term care settings. This Act was to be implemented January 1, 2012 and to include the following:
• How to service assisted living facilities (ALFs) and rural
pharmacies within the requirements
• How to repackage non-oral medications such as eye drops,
ear drops, and ointments |
• The dispensing fee model based on initial inclusion of brand
and generics and that each prescription would require
4
dispenses at the same cost each month
• The need for PDPs to have network adequacy in future bids
and the costs associated with this additional dispensing would
need to be accounted for in future bids |
Financial analysts believed that short cycle would result in a net increase in healthcare costs because the cost of additional dispensing fees and
beneficiary premium increases would be greater than waste savings.
These issues were presented by pharmacy associations, organizations, and MHA
to the Centers for Medicare and Medicaid Services (CMS) in 2010.
Final guidance was published in April 2011. This guidance included only branded medications, excluded all non-oral medications, and delayed the
implementation date to January 1, 2013.
|
|
Never, Never, Never Quit:
Lessons From an
Entrepreneur
John F. Crowley
Biotech Entrepreneur
Inspiration for the
major motion picture
Extraordinary
Measures
When the Crowleys discovered that
their two young children could die
from a rare disease with no
known cure, they didn’t give up even
though they were frustrated and terrified. Crowley recounted the
impetuousness of his and his wife’s decision to take the lead in
finding a treatment for Pompe disease.
Mr. Crowley noted in his presentation that “I remember looking at
[my daughter] Megan and looking into those big brown eyes and...I think those eyes told me that she wanted to fight, that she
didn’t want to quit, that she wanted to fight...So we would, too.”
Mr. Crowley shared with the audience the virtues of investing your
entire life in something, and finding the strength to overcome challenges
and potential heartbreak. He also discussed how he set a
vision and made the decision to reach for a seemingly impossible
goal, and never quit. |
|
|
 Overview of Current MHA Activities
Lou Livolsi
Senior Vice President,
Long-Term Care
Managed Health Care
Associates, Inc.
View selected slides with audio
Mr. Livolsi provided background on
current activities ongoing at MHA, including potential and future legislative
activities, PDP activities, pharmaceutical contracting, and
other initiatives to support long-term care pharmacy owners and operators.
Mr. Livolsi focused on the Net-Rx™Suite, RxPertise Consulting
Software, and Pharma Data Services and its value to MHA members.
He also provided an overview of the current MHA LTC Managed
Care Network, which has more than 700 independent long-term care
pharmacies in more than 1,100 locations.
Mr. Livolsi highlighted two recent acquisitions by MHA—the
Navigator Purchasing Group, which provides food, medical/surgical supplies, and capital equipment to nursing facilities, and The MED
Group, which supplies mobility, complex rehabilitation equipment,
respiratory and sleep supplies and equipment, durable medical equipment,
and patient supplies to health providers and facilities. He closed
by emphasizing that MHA has evolved from being strictly a pharmacy
group purchasing organization into a full-service health care company. |
|
|
Missed Reimbursement Opportunities:
What Are You Leaving on the Table?
Elizabeth H. DeMeo
Vice President, Strategic Accounts
Chad Hammerstrom
Vice President, Net-Rx
Managed Health Care Associates, Inc.
View selected slides with audio
Ms. DeMeo and Mr. Hammerstrom discussed the
possible missed reimbursement opportunities that
may exist for MHA members. Member pharmacies
have claim adjudication volumes of 230 to 185,000 claims per month and adjudicate claims with an average of 10-22 PDPs each month. For a long-term care pharmacy that is responsible for fewer than 5,000 beds, this can result in a loss of approximately $2,700 per month and $32,400 annually. For a long-term care pharmacy that services more than 25,000 beds, this can result in a loss of approximately $42,000 per month or $504,000 annually! Significant monies are being “left on the table!”
One option to maximize reimbursement opportunities is the Net-Rx™ Reimbursement Suite. This program offers users access to reconcile
third party claims information through a secure web portal. The illustration
below provides an overview of the services offered in the Net-Rx™ Reimbursement Suite.
Features include:
• Reconciliation—reimbursements are verified
electronically
to ensure pharmacies are paid according
to the agreed amount from adjudication. Discrepancies
are viewable online so you know exactly what you
are owed and from whom
• Contract Assurance—a value-added service that takes
the reconciliation process one step further by
identifying third party claims not reimbursed at the
MHA contracted rate
• AWP Verification—An enhanced claims analysis tool
that uses proprietary analytics to detect billing
and database errors
• U&C Reports—Edit-Rx provides detailed payment
reports highlighting variances in Usual and Customary
to ensure the pharmacy is billing the correct amount
Ms. DeMeo and Mr. Hammerstrom closed by presenting some examples
of how long-term care pharmacies improved their reimbursement
process through the use of these tools. |
|
|
 Beyond Long-Term Care: Opportunities
in Specialty Pharmacy
Lois Ann Murray, RPh
Executive Director, Specialty
Contracting
Managed Health Care
Associates, Inc.
View selected slides with audio
Ms. Murray started her presentation by defining
specialty pharmacy as pharmaceuticals
with the following attributes:
• Complex large molecule and biologic drugs
• Requires special handling and expanded clinical services
• Used to treat rare and chronic diseases, often with small populations
• High cost /unit results generally results in reimbursement challenges
Ms. Murray discussed the growth of specialty pharmacy and why long-term care pharmacies are looking at specialty pharmacy as an option to grow their business. Ms. Murray noted that in 2009, Express Scripts reported that the spending trend for specialty pharmaceuticals increased at a rate 5 times that of traditional drugs and that specialty pharmaceuticals is forecasted for double digit growth in the coming years! The growth seen in the general marketplace is mirrored in long-term care findings as well with MHA reporting 17% growth in drugs to treat Multiple Sclerosis and 27% growth in drugs to treat inflammatory conditions such as Rheumatoid Arthritis, Crohns, and Psoriasis.
 Three significant drivers for this growth in spending trend include the increased prevalence of specialty therapies being used to manage chronic disease states, the increased cost of specialty pharmaceuticals, and the rapid growth of new drug entrants. Currently there are 287 specialty pharmaceuticals in Phase III clinical studies; almost 50% are oncology medications. This allows new treatment choices for patients with chronic illnesses. Ms. Murray emphasized the fact that specialty pharmacy is a growth center of the future.
Ms. Murray reviewed the services that pharmacies must provide to meet the standards set by health plans for specialty pharmacy as well as to meet the expectations of manufacturer for specialty contracting.
Ms. Murray closed her presentation by providing an overview of MHA Specialty Pharmacy Solutions, which
provides a comprehensive program of solutions and services
for members. This graphic provides an overview of these programs and services. |
|
MHA Blackjack Tournament Raises $5,000
to Support the Mark Baldinger Student
Leadership
Award!
At the Business Summit, MHA hosted a blackjack tournament
on Thursday, March 17th to benefit the Mark
Baldinger Student Leadership Award. There were 47 total
participants with a total of $5,000 raised! |
|
An Update on the MHA Long-Term Care Member Study 
Michelle L. Templin
Vice President
Managed Health Care Associates, Inc. View selected slides with audio
Ms. Templin provided an update on the MHA
Independent Long Term Care Member Study. This
presentation on study results was from data collected October 2009 through September 2010.
Data for this study came from two main sources:
• The quantitative data was obtained from MHA’s Pharmaceutical Data
Services (PDS) and SDI, one of
the country’s leading healthcare analytics
organizations. A total of 893 closed door pharmacies representing
2.8
million patient profiles were used in the study. Respondents were
from all regions of the United States
• The qualitative data was derived from 155 surveys developed by MHA
and administered by Cooper Research. This research
was conducted
online between October and December 2010. Respondents were from all
regions of the United States
Some key highlights from this research are:
• There was a 5% decrease in pharmacies servicing 2,000 or fewer residents
and 5% increase in pharmacies servicing
3,001-6,000 residents
• Most pharmacies operate 6 days a week, are open 9-10 hours per day,
service 1 state, and service 25 or fewer facilities
• For pharmacies that service more than skilled nursing facilities (SNFs),
44% of SNF residents are responsible for 48% of
total prescriptions, while
31% of ALF residents are responsible for 29% of total prescriptions
• The “typical” resident receives 4 branded prescriptions, 5
generic prescriptions, and 3-5 over-the-counter prescriptions
The data supported the statement made by Lois Ann that specialty pharmacy
has seen double digit growth among long-term care pharmacy providers. Even
with increased growth in other avenues of business, Medicare Part D continues
to be the biggest payor in this market.
Ms. Templin closed by noting that the 2011 MHA Independent Long-Term Care
Member Study is available to MHA members by contacting their National
Account Manager.
|
|
An Update on
Operational Issues:
Short Cycle
Implications on
Operation Systems,
Audits,
and DEA
This panel discussion focused on three
issues that are “top of mind” with pharmacy
owners and operators—implementing
the short cycle guidance, the
increased use of pharmacy audits by
PDPs and how to prepare for these, and
the current status of long-term care
pharmacies dispensing controlled substances
to nursing facilities.
Mr. Weiss started the panel by providing a
more detailed discussion regarding coding
for branded medications and what information would be
required to receive reimbursement
for a claim. He also noted
that pharmacies will be required to indicate what type of packaging
was dispensed along with the dispensing cycle (eg, daily,
every 2-3 days, every 7 days, etc.). Other items and information
that the long-term care pharmacy will need to track and may be
able to bill for include:
|
|
|
• Dispensing fees (“costs associated with acquiring
and maintaining technology....”)
• Excluded drugs
• Copays (once per month and up front)
“Most recently, in October 2010 the DEA issued a “policy
statement” giving some guidance on who can be the
agent of the prescriber within the skilled nursing facility.
Unfortunately, the DEA has not defined details of how
this should be implemented.”
Mr. Weiss recommended that exceptions such as emergency
fills be billed separately to the PDP.
He closed by telling participants that more information will be
available in the coming months.
Next, Dr. McCall discussed pharmacy audits. His presentation
focused on:
• Fraud, waste, and abuse (FWA) training
• Monitoring of staff for OIG Exclusion
• CMS PDE/DIR Audits
• Using the correct Prescriber Identification
• Proper submission of compounds
• Records retention
Dr. McCall emphasized that CMS has an annual requirement
that all pharmacy personnel complete FWA training
and that PBMs may require a specific training or
allow attestation of other training materials to be utilized.
He noted that
compliance training should include fundamental compliance areas
such as those areas at risk for fraud, waste and abuse; employee
responsible for reporting issues; and training on how to report potential
compliance and fraud, waste, and abuse issues. |
|
Dr. McCall closed his presentation with a discussion on the proper
submission of compounds. He noted that under CMS rules, Part D plan
sponsors cannot cover Part D drugs prescribed for off-label uses
unless those drugs appear in one of three Medicare-approved drug
compendia — the United States Pharmacopeia Drug Information, the
American Hospital Formulary Service Drug Information, or the
Drugdex® System.
Dr. Hilliard provided a history and overview of the current situation regarding dispensing of controlled substances by a long-term care pharmacy to a skilled nursing facility. She noted that in 1995 the Drug Enforcement Agency (DEA) recognized the nurse in the facility as an agent for the prescriber but in 2001 the nurse was “unrecognized” as an agent for the prescriber. In general, 2009 was the year that the DEA started enforcement of this issue and started going after long-term care pharmacies that dispensed controlled substances into the skilled nursing facility without an actual prescription.
Most recently, in October 2010 the DEA issued a “policy statement” giving some guidance on who can be the agent of the prescriber within the skilled nursing facility. Unfortunately, the DEA has not defined details of how this should be implemented. In addition, this statement covered only Schedule III-V medications, not Schedule II. At the time of this meeting the issue had not been resolved.
Dr. Hilliard closed by indicating she thought this matter eventually will be settled through legislative action, which would be necessary to permit nurse-as-agent with respect to Schedule II medications. |
|
|
/**/
 |
