LTC Pharmacy News
March 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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Medicare Bundled Payments and SNFs
CMS' Bundled Payments for Care Improvement seems to have left nursing homes out of the driver's seat on managing care for Medicare patients. In this comprehensive overview of the latest policy moves by CMS on bundled payments, Elise 
patiently takes us through the history of bundled payments in Medicare and how SNFs have been positioned and why, as well as how the industry has responded.

The Policy Issues Ahead for SNFs in 2018
Nursing homes are faced with a dizzying mix of pending and likely regulatory activity that could cause us to throw our hands in the air in defeat. Unless, of course, you have Elise Smith to guide you through the quagmire.

Read what Elise sees as the major public policy issues facing the industry we serve and what we can do to lend a hand.

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.

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

House Readies Opioids Legislation
The House Energy and Commerce Committee is preparing a list of more than 20 separate bill taking aim at taming the scourge of opioid addiction. The Subcommittee on Health will consider these bills in a two-day session beginning March 21. 

House Fails to Pass Right-to-Try Legislation
The House of Representatives voted on legislation allowing patients with terminal conditions to access unapproved therapies. The bill was defeated, primarily because it was considered under a rule that required three-fourths of members to vote in favor. The vote was 259-140. The concept is controversial, with more than 40 consumer health organizations opposed, on the grounds that FDA's current compassionate use program is sufficient to make unapproved drugs available to patients in need. Energy and Commerce leaders have worked to overcome objections but failed . A bill similar to this has already passed the Senate by unanimous consent. See Energy and Commerce Release

Republicans Trying to Roll Back Donut Hole Legislation
The pharmaceutical industry is working overtime to persuade Republicans to roll back a provision in the last spending bill that requires manufacturers to pay 70 percent of the costs of drugs when a Medicare beneficiary reaches the coverage limit (donut hole). The provision would take effect in October. See story in BioCentury

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Federal Agency News
AHRQ: Electronic Prescribing Hides Information
The Agency for Healthcare Quality and Research reports on a study that showed that 10 percent of prescriptions included instructions from the provider that were not visible to the pharmacist through the electronic prescribing platform, resulting in potential harm to the patient.

Health Spending to Continue Growth
The CMS Office of the Actuary has issued its latest report on National Health Expenditures for 2017-2026, predicting an annual rate of increase of 5.5 percent. One of the major cost drivers will the aging of the population. Under current projections, we can expect healthcare to consume nearly 20 percent of the gross domestic product in the next 8 years.

CMS Administrator Focus on Interoperability of EHRs
The CMS Administrator announced an initiative to ensure that Medicare enrollees have access to medical records. The MyHealthEData initiative will focus on providing beneficiary access to claims data and encourage health plans to make health record information available to enrollees.

MedPAC March Meeting
The Medicare Payment Advisory Commission held its March meeting on March 1-2 in Washington, DC. Among the issues discussed were Encouraging Medicare beneficiaries to use higher-quality post-acute care providers, and An update on CMS’s financial alignment demonstration for dual-eligible beneficiaries. See presentations here.

FDA Generic Drugs Office Issues Report
The Food and Drug Administration's Office of Pharmaceutical Quality has released its initial annual report, detailing the group's activities across all aspects of the FDA's regulatory portfolio.

MedPAC March 2018 Report to the Congress: Medicare Payment Policy
The report includes MedPAC’s analyses of payment adequacy in fee-for-service (FFS) Medicare and reviews the status of Medicare Advantage (MA) and the prescription drug benefit, Part D. MedPAC also recommends changing the way Medicare pays for clinician services in FFS by moving beyond the Merit-based Incentive Payment System (MIPS), recommends changes to MA and Part D to improve the equity and efficiency of those programs, and responds to a Congressional mandate on telehealth in Medicare. In the Bipartisan Budget Act of 2018, Congress enacted several policies that are similar to recommendations contained in this report.

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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
NIC Reports Continuing Nursing Home Woes
National Investment Center for Seniors Housing & Care (NIC) has published its fourth quarter 2017 Skilled Nursing Data Report. The results paint a picture of continuing reduction in census, higher Medicaid occupancy and the erosion of payments driven by managed care. 

United Healthcare to Share Rebates with Consumers
The latest development over PBM practices is the announcement that United Healthcare will begin passing drug rebates negotiated with manufacturers on to consumers at the point of sale. Retail pharmacies have raised concerns that PBMs routinely hide discounts until much later in the process, often resulting in retroactive reimbursement reductions. United appears to be taking the lead in offering more transparency to the process. See story in Benefits Pro.

Physicians Object to Opioid Restrictions in Medicare
The pushback has begun! Recent proposals by CMS to create hard edits to Medicare Part D prescriptions for opioids has drawn the attention of physicians, who object to a blanket solution to a difficult problem. The physicians, many of whom are academics, cancer specialists and pain specialists, have sent an open letter to CMS objecting to the agency's proposal, claiming that such "uninformed" policies fail to consider the patients in serious pain in need of relief. See article in Gizmodo

ASCP Welcomes Chad Worz as New Executive Director
The American Society of Consultant Pharmacists announced that Chad Worz, Pharm.D. has been named the association's new executive director and chief executive officer. Worz has been a long-time member of ASCP and most recently served as president of Medication Managers, LLC in Cincinnati, Ohio.

Express Scripts 2017 Drug Trends Report
Express Scripts has published its 2017 Drug Trends Report. The report features Express Scripts' success in holding the line on drug cost increases in private health benefits plans, Medicare plans and, to a lesser extent, Medicaid plans.

Milliman: Impact of Budget Act of 2018 on Medicare Part D
Actuarial firm Milliman produced a document discussing how the latest budget deal in Congress will impact Medicare Part D in 2019. The budget bill closed the "donut hole" or coverage gap by raising costs on manufacturers. There are other implications of this legislation, as Milliman points out.

When Drug Copays Exceed the Cost of the Drug
Reuters reports on a JAMA study that examined private health plan data from 2013 and determined that for 28 percent of claims for generic drugs, the copayment from the insured was higher than the cost of the drug. 

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