LTC Pharmacy News
January 2018
The healthcare industry is in the beginning of massive change and the long term care pharmacy industry will be affected by this change. is your guide to understanding this process, the legislation and regulation that will implement this change and the key to adjusting your approach to succeeding in this new environment. We will try to not just tell you the "what" of this change, but the "how" as well.
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MedPAC Calls it a Wrap!
Elise reports on the January meeting and finalizes its recommendations to Congress for payment policy in 2019. This is the annual ritual where the Commission assembles its mountain of data and tells Congress which providers, in its estimation, are being overpaid, underpaid and how payments could be improved.

As usual, MedPAC thinks nursing homes get paid too much under Medicare and has some recommendations. I won't spoil the story, so if you want to know what they think, read more.

CMS Final Rule: Knee Replacement No Longer Inpatient Only
Elise reported earlier on the CMS proposed rule to remove total knee replacement from the list of "inpatient only" procedures under the Medicare Outpatient Payment System. The agency has finalized the rule, which means that recipients undergoing outpatient knee replacement will not have a 72-hour hospital stay in order to qualify for Medicare Part A rehabilitation in a SNF.  See more here.

Recent MedPAC actions on Nursing Home Quality
Elise reviews recent MedPAC research on why Medicare beneficiaries continue to choose lower quality nursing facilities. MedPAC staff point to statutory prohibitions against allowing hospitals to recommend SNFs for patients being discharged. How could changes affect nursing home quality initiatives and how can LTC pharmacies engage? See more here

Proposed Changes to the Inpatient Only Rule Could Impact SNFs
CMS recently published a proposed rule on Hospital Outpatient Payment System updates and asked for comments on allowing hip and knee replacements to be performed in outpatient settings. Elise discusses the implications on nursing facilities if Medicare beneficiaries stop using SNFs for rehabilitation. See more here.

Getting to a Unified Post-Acute Care Payment System
Various Federal agencies have been working for years to come up with a unified payment system for post-acute care (PAC). In this paper, Elise gives us a much-needed history of the policy and its development, featuring the star players CMS and MedPAC. 

Why should you care? Your PAC customers have a lot riding on how the drama finally resolves. They care about this, and so should we. See more here.

CMS Reverses Its 2016 Position on Pre-Dispute Arbitration
On June 8, 2017, CMS issued a proposed rule that reversed its position prohibiting pre-dispute arbitration agreements in long term care facilities. This was the culmination of policy making and unmaking that, with respect to the latest clash on Skilled Nursing Facility/ Nursing Facility arbitration practice, started on October 4, 2016. See more here

More Elise Smith Insights
The list of Elise's publications was getting too lengthy to continue listing on the newsletter, so we have created her own page on the LTC Pharmacy News site. See it all now.

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Legislative Highlights

Will Congress Turn to Drug Price Reform?
With tax reform passed, members of Congress turn their attention You will recall from your high school civics class that the House of Representatives and a third of the Senate faces the voters in even-numbered years, 2018 being one of them. 

Speaker of the House, Paul Ryan (R-WI), hinted at making a move on entitlement reform, which almost certainly means Medicaid. Other entitlements (Social Security and Medicare) appear to be off limits (remember, it's 2018).

Efforts on controlling drug prices would seem to be a popular topic. As prices for prescriptions increase the popularity of the drug industry hovers just above that of Congress. The Energy and Commerce Subcommittee on Health recently held a hearing billed as Examining the Drug Supply Chain. Witnesses included representatives from manufacturers, PBMs, pharmacy, health insurers, hospitals and consumer advocacy groups. Is this a prelude to definitive legislative action?

Perhaps we should take a deep breath and remind ourselves that it's 2018. 

Ways and Means Committee Announces New Members and Subcommittee Chairmen
Rep. Kevin Brady (R-TX) announced the makeup of the House Ways and Means Committee's Republican membership and subcommittee leadership. Peter Roskam (R-IL) will take the helm as chairman of the Health Subcommittee. See full committee membership.

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Federal Agency News
CMS Issues Final Rule on Bundled Payments
CMS published a final rule that reduced the number of geographic areas affected by the comprehensive care for joint replacement model from 67 to 34 and made participation voluntary for low-volume and rural hospitals. The program appears to have achieved its objective of lowering costs, but most of the savings came from reductions in payments to skilled nursing facilities. Analysts believe this move to scale back the program will be mostly positive for SNFs.

AHRQ Update: Adverse Drug Events in US Hospitals
The Agency for Healthcare Research and Quality has updated its popular Healthcare Cost and Utilization Project (HCUP) series with a report on the change in adverse drug events in hospitals between 2010 and 2014. The evidence shows that adverse events originating during the hospital stay declined dramatically, while adverse drug events present on admission increased.

National Health Expenditures
The much-anticipated report from the CMS Office of the Actuary reveals that US healthcare spending in 2016 reached $3.3 trillion, nearly 20 percent of the national GDP. Among the bright spots, cost increases were the lowest in recent years, but remain well above the rate of inflation.

Nursing Care Facilities and Continuing Care Retirement Communities consumed $167 billion, representing a 2.9 percent increase over 2015.

CMS Announces Voluntary Bundled Payment Initiative
The CMS Innovation Center unveiled its first Advanced Alternative Payment Model. Billed as the Bundled Payments for Care Improvement Advanced, the model is voluntary and will focus on 32 clinical conditions. 

The model will officially start operations in October 2018 with the performance period running through 2023.

CMS Publishes MFP Rebalancing Report
The Money Follows the Person Rebalancing Program was created to assist states in transitioning Medicaid recipients in nursing homes to home and community-based care settings. This report is a required report to Congress and details the progress states have made in moving LTC residents away from institutional care to community-based care.

CMS Updates Market Saturation Tool
Have you ever wondered about the nursing home density in your county or in your state? CMS has a great tool for finding out this and lots of other important information. It's called the Market Saturation and Data Utilization Tool. It includes data on the number and concentration of several different varieties of healthcare providers and services and identifies areas where CMS has imposed a moratorium on new providers. Great tool for your market research.

MACPAC Publishes Data Book
The Medicaid and CHIP Payment and Access Commission (MACPAC) announced the publication of its annual data book containing comprehensive information on the Medicaid and CHIP programs, including eligibility and service utilization. 
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Go to the LTC Pharmacy website for regular updates on what's coming from CMS, including proposed and final rules, new programs, news from Medicare and Medicaid and updated Medicare Learning resources. Go there now.

The FDA often updates its website with drug safety information, news about drug approvals and implementation information on laws, such as the Drug Quality and Security Act. Keep checking our site for the latest news from FDA.

THE HHS Office of Inspector General publishes audit reports and results of investigations on federal health programs, such as Medicare and Medicaid. Congress frequently looks at these reports when deciding where to focus on oversight and legislation. Keep in touch here.

The Government Accountability Office is the official investigative arm of Congress and publishes important reports that often guide the national conversation. We keep track of announcements coming out of GAO, so you don't have to. All you need to do is click here.
News Items of Interest
Avalere 2018 Healthcare Forecast
Healthcare consultancy Avalere Health held its annual Healthcare Industry Outlook event and has made slides from the presentation available for download. Avalere is a recognized leader in healthcare data and analysis.

NIC Issues Q3 SNF Report
The National Investment Center for Seniors Housing & Care (NIC) published its third quarter 2017 Skilled Nursing Data Report. The report confirms the continuing slide in SNF occupancy and declining percentage of Medicare stays. It also notes the trend of decreasing payments by managed care organization and the increased reliance on Medicaid for nursing home revenue.

Kaiser: Epidemic of Unnecessary Drugs in Elderly
Kaiser Health News reports on the rising problem of polypharmacy in the elderly population. It estimates that 25 percent of seniors, aged 65-69, take five or more drugs, a number that has steadily increased over time. 

Health Affairs Blog: A Study of Family Caregiver Burden
The cost of caregiving for a person with dementia may be as much as 80 percent higher than for a person with cardiovascular or cancer. This blog post discusses the imperative of understanding this burden and helping to mitigate the burden on caregivers is a critical part of a comprehensive strategy in the age of value-based payment systems.

States Increase Oversight of Assisted Living
McKnights reports that states have been steadily increasing scrutiny of assisted living facilities (ALFs). With 47 percent of ALFs qualifying to be Home and Community-based Service providers and with 15 percent of residents qualifying for Medicaid, state governments are taking a more active interest in regulation.

Advocates Speak Out Against DIR Fees
Specialty Pharmacy Times reports that more than 115 advocacy groups have sent comments to CMS in response to its notice of proposed rulemaking supporting a proposal to require PBMs to include DIR fees at point of sale. DIR fees have long been a point of contention in pharmacy, and CMS has solicited feedback on requiring PBMs to include these fees at point of sale.

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