Life Sciences

Medicare & Reimbursement Advisor Weekly, November 13th, 2009

Medicare & Reimbursement Advisor Weekly, November 13, 2009

Inside:

Medication management at discharge takes back seat

Brand preservation: Part A in skilled nursing facilities

Outcomes-based contracting case studies

Medical home pilots, PDL changes, and local DM programs



Medication management at discharge takes back seat

Health plans won’t love this: St. Joseph’s Hospital in Atlanta tracks readmissions, and since implementing a more aggressive length-of-stay policy, many patients leave the hospital without adequate education, preparation, and follow-up to manage their medications and post discharge care. Adherence is a challenge. In the graph below, we illustrate the percent of readmissions in which patients return to the hospital within one month of discharge. The red line shows that about 10%–14% of all Medicare readmissions are within 30 days, whereas Medicare patient readmissions for congestive heart failure (CHF) are less predictable. However, Anne Pedersen, RN, case management director at St. Joseph’s, says there has been an upswing in CHF and lung-related (i.e., COPD) 30-day readmissions since the spring, as the hospital tries to reduce its inpatient lengths of stay. For a study abstract, contact the editor; the complete study will be published in early 2010.



Brand preservation: Part A in skilled nursing facilities

The formulary savings table (below) is an example of how Omnicare® promotes its formulary and how, in some cases, the long-term care facility goes against Omnicare to stay with hospital orders or chooses facility preferences for managing rehab/short stay, acute, and longer-term chronically ill patients. In total, the pharmacy provider says McLean Healthcare missed out on $3,940 for the second quarter.

The drug class–product column denotes McLean’s preferred formulary drugs.

Preserving it or regaining a script is possible as patients enter their Medicare Part A benefit in skilled nursing facilities (SNF). For example, a significant number of SNF residents come from hospitals. Some SNFs prefer to maintain continuity for shorter-stay patients and keep them on the regimen they were used to at home, although in many cases they may not know what this is. The majority follow hospital orders, which can be favorable if the orders are for a branded product, but many hospitals, as I’ve reported, are moving patients to generics for economic reasons during their short hospital stay and then writing the generic into discharge orders. Success with a product in Part A can have a ripple effect into Part D and the patient’s next level of care, since SNF nursing staff members can influence discharge instructions into a home- care/community setting. As a result, messaging to SNF decision-makers involved in transitions (i.e., the director of nursing) is important to regaining scripts lost in the hospital for both short- and long-stay patients. —BC



Outcomes-based contracting case studies

CIGNA and Merck have an outcomes-based pilot you may have heard about in which the insurer pays reduced prices for JanumetTM and Januvia®—two diabetes drugs—based on how well its members control their blood sugar.

Rebates will increase for the two medications as long as CIGNA members show improvement in adherence and in A1c levels. Individual commercial CIGNA members who have diabetes are eligible for the program even if they use other manufacturers’ diabetes drugs. This is one of many value- or outcomes-based contracts hitting the scene that one would think would help support plan adherence goals.

Noting obstacles to success, Dell Mather, vice president of clinical development at PBM NovoLogix, says “not all health plans can capture sufficient data related to patient outcomes, adequately track adherence, or find a mechanism to measure drug performance.”

The Health Alliance Medical Plan will be reimbursed for average medical expenses for non-spinal fractures that occur among certain members taking Actonel®. Director of Pharmacy Christina Barrington, says that during the first quarter of 2009, six people in the pilot had suffered a fracture. Barrington anticipates that about 14 out of 1,000 patients on Actonel (as estimated during clinical trials for the drug) will experience a fracture, which depending on the site, might cost as much as $30,000 to treat. “I have been relentless in pursuing manufacturers who will stand behind their products, prove they are superior, and share the risk with us,” she says.

Next steps

To research this issue, contact the editor.

Also, to access the full story which ran in Managed Healthcare Executive, click here.



Medical home pilots, PDL changes, and local DM programs

If a medical home pilot in Illinois is successful in enhancing care and helping control costs, it may serve as a national model for health system improvement, says Scott Sarran, MD, chief medical officer at Blue Cross and Blue Shield (BCBS) of Illinois. The state’s largest payer launched a medical home program with Pronger Smith Medical Care and Elmhurst Clinic—two Chicago-area doctor groups that have both primary care physicians and specialists. Under the medical home model, treatment and referrals are coordinated centrally as a way to keep costs down. More than 20,000 Illinois BCBS members will participate; if successful, the insurer would open it up to more of its 7.2 million members.

Iowa, Nevada PDL updates

State Medicaid in Iowa began enforcing new prior authorization criteria on November 1.

Here’s a look at the criteria. Classes that were affected are AmylinoMemetics, Alpha-Blockers (urospecific), Alpha Proteinase Inhibitor Enzymes, ADD/Narcolepsy agents.

Virginia Medicaid uses Facebook

The state’s Medicaid P&T issued a survey through Facebook—the online social networking community—to gather opinions about its preferred drug list as Virginia Medicaid revises its program. The results of its qualitative study will be made available if MRAW can obtain them from Virginia Medicaid. Standby.

Spillover and Medicaid

Speaking of a PDL’s impact on phys- cians, a study was completed on this issue (Applied Economics, September 2009), which found a significant decrease in post- PDL Medicaid prescription shares of drugs excluded from the PDL. Spillovers onto third parties and the cash market were statistically significant. A more restrictive prior authorization procedure has a greater impact on prescription shares. Not surprisingly, the impact of PDLs appeared stronger among physicians with a higher share of Medicaid prescriptions.

NJ pilots routine care for uninsured

Newark, NJ, has enrolled 400 uninsured and underinsured residents in a pilot program that enables them to obtain routine medical care from family doctors. The goal is to prevent people with chronic illnesses from seeking more costly treatment at hospital emergency rooms as a last resort. The yearlong program is expected to save Newark-area hospitals more than $2 million.

Retail: Disease prevention program in Louisiana

Louisiana is the eighth most obese state in the United States, with about 30% of all residents considered medically obese. Patrick Quinlan, MD, CEO of Ochsner Health System, a nonprofit healthcare organization that includes seven hospitals and 35 health centers in southeast Louisiana, has launched the Choose Healthy program in response. For the complete story, click here.

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