Life Sciences

Medicare & Reimbursement Advisor Weekly, March 11th, 2009

Medicare & Reimbursement Advisor Weekly, March 11, 2009



AMDA report: Nursing home-hospital disconnects highlighted in lively debate

The liveliest session at the American Medical Directors Association (AMDA) meeting March 6 in Charlotte, NC, dealt with Transitions in Care, a discussion of three cases in which patients died due to communication problems between caregivers. In a fourth case still under review by the Maryland Office of Healthcare Quality, a 78-year-old male is still alive, but barely, and his case and the growing numbers of others like it highlight an opportunity for pharmaceutical account managers at the local level.


The 78-year-old man was hospitalized in mid-February for exacerbation of congestive heart failure. After a five-day stay, he was transferred to a skilled nursing facility for rehab, but the man’s discharge folder contained summaries for two different patients, with similar medications and diseases. The nursing home followed the discharge instructions from the wrong summary.

In the nursing home, the man received Lasix 80mg twice a day compared to the 20mg once a day in the instructions for his actual discharge summary. In addition to his Metformin 5mg, he received 50 units once a day of Lantus and he had never before been on an injectable insulin. He was supposed to be on Lovenox for Deep Vein Thrombosis blood clots, but he did not receive it.

The patient has most recently been rehospitalized for acute renal failure and dehydration. The medical directors in the room debated the causes and brainstormed ways to prevent cases like this.

Merlyn Vermury, MD, a medical director for several nursing homes in the Potomac Valley, Maryland region, said at their nursing homes and hospitals, a team of clinicians and administrators meet monthly or quarterly to discuss communication processes for discharges and admissions, address cases and problems, and work toward refining communication.

This was not the consensus in the room, although it’s beginning to be a potential trend to follow: Hospitals, nursing homes, and community physicians are coming together in an organized regular format.

Regulations under way

The Joint Commission (formerly JCAHO), which accredits hospitals, has recently beefed up its requirements, calling on hospitals to provide a list of a patient’s home medications and hospital-ordered drugs to the patient’s primary care physician. In addition, hospitals must comply with the following or face losing accreditation or Medicare payments; any differences found between a patient’s home medication list and the list of medications ordered during a patient’s stay must be clarified and documented while the patient is in the hospital. This goal also requires that during a transfer of a patient’s care within the hospital, part of the documented handoff must concern the most up-to-date reconciled medication list, according to the Joint Commission’s 2009 National Patient Safety Goals.

Opportunities: What is your role?

Is there a place for pharmaceutical companies to add value to the communication process? Can NAMs at the local level become resources for nursing homes, doctors, and hospitals in their area and bring the settings together?

In a brief poll March 10 and 11 of 100 hospitals and 100 nursing homes in 45 U.S. cities/towns, 86% said they do not hold a regular meeting to their knowledge similar to the one in Potomac Valley, MD.

Meanwhile, the National Transitions of Care Coalition is developing tools to assist providers in appropriately and safely transferring patients between settings of care.

Given the fluctuation in medications as patients move from one setting to another, it would seem that account managers and others could play a resource-type role or more in ensuring safety and, perhaps, build a greater case that changing medications for nonmedical reasons has its downsides. A full report of the session will be published in a research paper this summer. Stay tuned, and if you have questions about the cases presented, contact the editor.



FoxRxCare beefs up employer business, seeks protocol development support, specialty pharmacy best practices

Fox Insurance Company (FoxRxCare) is among the top-growth prescription drug plan providers among Medicare Part D (500% from 2008 to 2009).

The growth comes from a few places, including the growth of its Employer Group Waiver Plans (EGWP). This is a program that allows employers (e.g., municipalities, private pension-providing corporations, unions) to contract with Fox to take on the responsibility of working with CMS to obtain a prescription drug benefit.

Fox is licensed to provide Medicare Part D services in 18 states, with plans to expand to another 28 by the end of 2009, and is licensed to provide EGWP service in all 50 states.

Fox’s business strategy has been to focus on smaller unions and municipalities, as with the recent agreement with Premier Consulting to provide service for the 3,000 retirees that that company manages, as well as future retirees under its umbrella.

Want to get the attention of FoxRxCare?

Its pharmacy chief wants help from pharmaceutical companies to develop protocols. “We would definitely like help developing protocols from manufacturers,” says Tony Arloro, RPh, vice president of pharmaceutical services at FoxRxCare. “I’d like to see protocols for the specialty pharmacy area in particular, including good use of prior authorization to encourage appropriate use of drugs.”

Arloro, who previously worked at ExpressScripts, also wants best practices for disease management techniques.

“We were more aggressive in our bid and expanded into more regions,” Arloro says. “Our premiums are lower and we’ve added more brand drugs.” Preferred generics have no copay on Tier 1 in Fox’s Value plan, and these products are covered without any copay through the coverage gap in its enhanced Grand plan, which costs an average of $30 in premiums per month. “I’d say the Value/Basic plan has a closed formulary and the Grand plan has a closed/open formulary,” Arloro says. “The Value plan covers more drugs, but not every product. We cover very few multisource products.” Fox added a step therapy edit for 2008.

“We’re doing this in a few classes, including statins and nonsedating antihistamines, to encourage use of generics,” he says. For example, the drug Loratadine was added as a first-tier product in 2008 in the nonsedating antihistamine class.



Survey snapshot

86% of hospital and nursing home administrators polled March 10 and 11 by MRAW’s publisher, HCPro, Inc., said they do not convene a regular session of clinicians and administrations of local hospitals and nursing homes to discuss communication issues, process, patients, and a host of transition-in-care problems and solutions. A “regular” session was defined as a scheduled meeting occurring every month or quarter with clinicians and administrations from multiple settings of care in the same geographic area. —BC