Million Hearts: The Role of Pharmacy, Pharmacy Benefit Desi - PowerPoint Presentation

Slide1

Million Hearts: The Role of Pharmacy, Pharmacy Benefit Design, and Improving Medication Adherence

John Michael O’Brien, PharmD, MPHSenior AdvisorU.S. Department of Health & Human Services CMS Innovation CenterSlide2

Objectives

2Describe the Million Hearts initiative.List the baseline measures of the ABCS.Explain the importance of medication adherence to better health, better health care, and lower costs through improvement.Describe forthcoming opportunities for pharmacy and pharmacy benefit design to improve adherence, and to support Million Hearts and other HHS initiatives.Slide3

Better Health for

the Population

Better Care

for Individuals

Lower Cost

Through

Improvement

The “Three-Part Aim”

3Slide4

Innovation Will Transform American Health Care

All Americans receive the right care, in the right setting, at the right time, all the timeHealth dollars spent efficiently; rate of growth slowed significantlyClinical and delivery system best practices diffused rapidly 4

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

Current payments – part of the problem…

Future State

People-Centered

Current State

Producer-Centered

Episode-based payments

Value-based purchasing

Accountable Care Organizations

Patient Centered Medical Homes

Resource Utilization Reporting

Innovation Center

Fragmented payment systems (IPPS, OPPS, RBRVRS)

Fee-for-service payment model

CMS part of the solution…Slide5

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 levelSlide6

Innovation Center Menu of Model Options

ACO SuiteShared Savings (3022)Pioneer ACOAdvanced Payment ACOAccelerated Development and Learning SessionsPrimary Care SuiteMAPCPComprehensive Primary CareFQHC Medical HomeIndependence at HomeMedicaid Home Health

Bundled Payment Suite

Gainsharing Acute Care

Retrospective Acute Care EpisodeRetrospective Post-Acute Care

Prospective Acute Care

Dual Eligible Suite

Capitated

Integrated

FFS Integrated

Nursing Facility Model

Diffusion & Scale Suite

Partnership for Patients

Million Hearts

Innovation

Advisors

Innovation ChallengeSlide7

Innovation Center Menu of Model Options

ACO SuiteShared Savings (3022)Pioneer ACOPrimary Care SuiteMAPCPComprehensive Primary CareFQHC Medical HomeIndependence at HomeMedicaid Home Health

Diffusion & Scale SuitePartnership for PatientsMillion Hearts

Innovation AdvisorsSlide8

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 high-quality care and spending health care dollars more wisely, it may share in the savings it achieves for the Medicare program50% one-sided risk, 60% two-sided riskMedicare Shared Savings ProgramSlide9

Quality is defined by 33 pay-for-reporting or pay-for-performance measures, including:

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 DiseaseExpenditures are defined as Part A & B spendingMedicare Shared Savings ProgramSlide10

The Pioneer ACO Model

Designed for more advanced organizationsAlternative payment models possiblePartnership with Part D plans encouraged32 sites listed at http://innovations.cms.govSlide11

Comprehensive Primary Care initiative (CPCi)

CMS-led, multi-payer approach to improving and strengthening our primary care systemEnhanced payment strategy to provide Primary Care Providers with resources to:Manage Care for Patients with High Health Care Needs  Ensure Access to CareDeliver Preventive CareEngage Patients and CaregiversCoordinate Care Across the Medical NeighborhoodMedicare will pay approximately $20 per beneficiary per month to start, then move towards smaller PBPM to be combined with shared savings opportunitySlide12

Partnership for Patients:Better Care, Lower Costs

40% Reduction in Preventable Hospital Acquired Conditions over three years1.8 Million Fewer Injuries60,000 Lives SavesA reduction in HACs from 137/1000 to 111/100020% Reduction in 30-Day Readmissions in Three Years

1.6 Million Patients Recover Without ReadmissionAn 11.5% readmissions rate vs. a 14.4% readmission rate

Potential to Save $35 Billion in Three YearsSlide13

Million Hearts™ Initiative

A national initiative, co-led by CDC & CMSSupported by many federal and state agencies and private-sector organizations

13

Goal: Prevent 1 million heart attacks

and strokes in 5 years Slide14

Heart Disease and Strokes Leading Killers in the United States

Cause 1 of every 3 deathsOver 2 million heart attacks and strokes each year800,000 deathsLeading cause of preventable death in people <65 $444 B in health care costs and lost productivityTreatment costs are ~$1 for every $6 spentGreatest 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

AspirinPeople at increased risk

of cardiovascular events

who are taking aspirin

47%

B

lood

pressure

People with hypertension who have adequately controlled blood pressure

46%

C

holesterol

People with high cholesterol who are effectively managed

33%

S

moking

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

COMMUNITYPREVENTIONChanging the context

CLINICAL

PREVENTION

Optimizing care

Focus on ABCS

Health information technology

Clinical innovations

TRANS

FAT

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Clinical PreventionOptimizing Quality, Access, and Outcomes

Focus on the ABCS

Fully deploy health information

t

echnology

Innovate in care

delivery

17Slide18

Focus on the ABCS Simple, uniform set of measures

Measures with a lifelong impactData collected or extracted in the workflow of careLink performance to incentives Clinical PreventionOptimizing Quality, Access, and Outcomes

ABCS

18Slide19

Fully deploy health

information technology (HIT)Registries for population managementPoint-of-care tools for assessment of risk for cardiovascular diseaseTimely and smart clinical decision supportReminders and other health-reinforcing messages

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Clinical Prevention

Optimizing Quality, Access, and Outcomes Slide20

Innovate in care delivery

Embed ABCS and incentives in new models Health Homes, Accountable Care Organizations, bundled paymentsInterventions that lead to healthy behaviorsMobilize a full complement of effective team membersPharmacists, cardiac rehabilitation teamsHealth coaches, lay workers, peer wellness specialists Improve adherence wherever possible

20

Clinical Prevention

Optimizing Quality, Access, and Outcomes Slide21

Why Adherence?

Patients adhere to 50-70% of chronic essential medsLeads to excess morbidity, mortality and costsResults in 11% of all hospitalizationsEstimated 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

)Slide22

Part D and Medicare A and B are NOT alignedPart D plans & pharmacies

do not have sufficient clinical data on their beneficiariesUnable to determine when their patients are hospitalizedPart 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 BSlide23

Medicare Part C/D & AdherenceSlide24

Plans below 3 stars get no bonus and beneficiaries are warned of their low performance during enrollmentPlans with a 3-5 stars receive bonusesPlans 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 adherenceMedicare Part C/D & AdherenceSlide25

Adherence at CMMIChronic 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 homeAlign interests & incentives (e.g., pharma, insurers, pharmacies, patients, doctors)Role of adherence to existing programs?A specific focus on adherence?Slide26

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.Slide27

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.Slide28

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)

Slide29

How Could Part D Plans & ACOs invest?Value-based insurance designPharmacist Coaches – Motivational Interviewing

HIT – remindersSmarter packagingPatient incentivesShared decision-making, education, communicationHealth LiteracyPharmacy HomeSlide30

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 costsSAVE AN ADDITIONAL

$5,096 per beneficiary in event-related costs

1.1 lives and 13 non-fatal re-infarctions per 100 patients

Choudhry, Shrank. Health Affairs 2008

Should patients receive secondary prevention medications for free after a myocardial infarction?Slide31

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.Slide32

Million Hearts™: Pharmacist Outreach Project

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Intervention

BaselineTargetClinical target

A

spirin for those at high risk

47%

65%

70%

B

lood pressure c

ontrol

46%

65%

70%

C

holesterol management

33%

65%

70%

S

moking cessation

23%

65%

70%

Sodium reduction

~ 3.5 g/day

20% reduction

Trans fat reduction

~ 1% of calories

50% reduction

Million Hearts™: Getting to the Goal

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

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Pharmacies, pharmacists

Insurers

Retailers

Clinicians

Individuals

Healthcare systems

Foundations

Consumer groups

GovernmentSlide35

Public-Sector Support

Administration on AgingAgency for Healthcare Research and QualityCenters for Disease Control and Prevention Centers for Medicare and Medicaid ServicesFood and Drug AdministrationHealth Resources and Services AdministrationIndian Health ServiceNational Heart, Lung, and Blood InstituteNational Prevention Strategy

National Quality StrategyOffice of the Assistant Secretary for HealthSubstance Abuse and Mental Health Services Administration

U.S. Department of Veterans Affairs

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Academy of Nutrition and DieteticsAlliance for Patient Medication

SafetyAmerica’s Health Insurance Plans American College of CardiologyAmerican Heart Association American Medical AssociationAmerican Nurses AssociationAmerican Pharmacists’ Association American Pharmacists Association Foundation Association of Black Cardiologists

Georgetown University School of MedicineKaiser Permanente

Medstar Health System

Private-Sector Support

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

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State Medical, Pharmacy, Nursing, etc Associations

Schools of Medicine

Pharmacy,Nursing

, Public Health, etc

Patient & Science Advocacy Groups

(

WomenHeart

, AHA)

Employers & Insurers

Action-Oriented and Results-Focused State Nodes: Harvesting, Spreading, and Providing Technical Assistance on Quality Improvement in the ABCS

Corporate PartnersSlide38

Five Ways Every Pharmacy or Pharmacist Can Support Million Hearts

38Sign the Million Hearts pledge at http://millionhearts.hhs.gov and let me know when you do!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.

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.

Identify potential tests of change in blood pressure and measurement/reportingBecome a Pharmacy Outreach Project Partner!Slide39

What the Future Could Look Like

Lower sodium foods are abundant and inexpensiveBlood pressure monitoring starts at home and ends with successful controlData flows seamlessly between settingsProfessional advice when, where, and how you need it

No or low co-pays for medications

Green

BB,

et al. JAMA 2008;299:2857-67

Adding web-based pharmacist care

to

home

blood pressure monitoring

increases

control by >50%

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Take the

Pledge & Please Stay in Touch!

40

http://millionhearts.hhs.gov

John Michael O’Brien,

PharmD

MPH

Senior Advisor

John.O

’

Brien@cms.hhs.gov

443-821-4183