Health Care Reform: Where are the Pharmacists?

Opportunities and Challenges for Pharmacists in Health Care Reform

Anthony D. RodgersCMS Deputy Administrator

Center for Strategic PlanningJune 2011

“The US healthcare system produces significant level of

unjustified variance in patient safety, healthcare cost, quality performance and

health outcomes.”

Rationale for CMS Strategic DirectionTo Transform the US Healthcare Delivery

System

The Three Part Aims of CMS

Better care, better health, and lower costs through continuous improvement for all Americans

“What is the end of the game with Health Reform?”

The Essential Elements of a Transformed Healthcare System

Informed and

ActivatedPatient

ProductiveInteractions

PreparedClinical

Team

Web based health e-learning,Electronic Care PlanningSelf Care Management Tools

Electronic Health Records

Exchange of Health Information

Multi-disciplinary team

Coordinated Care Management

CommonSet of Patient

Health Information

Patient Centered Care

Informed and

ActivatedPatient

ProductiveInteractions

PreparedClinical

Team

Electronic Health Record & HIE

Clinical and Value Based Integrated Care

Management Decision Making

Supported by ACO

or Integrate

d Care System

Supporte

d By E-

Health

and

Learning

Tools

Accountable Care

Accountable Care

Healthcare Delivery System 2.0

• Transparent Cost and Quality Performance

– Results oriented– Access and coverage

• Accountable Provider Networks Designed Around the patient

• Focus on care management and preventive care

– Primary Care Medical Homes

– Utilization management

– Medical Management

IntegratedHealth

• Patient/Person Care Centered– Patient/Person centered

Health Care– Productive and informed

interactions between Family and Provider

– Cost and Quality Transparency

– Accessible Health Care Choices

– Aligned Incentives for wellness

• Integrated networks with community resources wrap around

• Aligned reimbursement/cost Rapid deployment of best practices

• Patient and provider interaction– Aligned care management– E-health capable– E-Learning resources

• Episodic Health Care– Sick care focus– Uncoordinated care– High Use of Emergency

Care– Multiple clinical records– Fragmentation of care

• Lack integrated care networks

• Lack quality & cost performance transparency

• Poorly Coordinate Chronic Care Management

Healthcare Delivery System 1.0

Driving Health Care System Transformation

Healthcare Delivery System 3.0

Episodic Non Integrated Care

CMS Strategic Plan Focus• Delivery System Transformation

▫ ACO and Integrated Care Management Delivery System Models Diffusion▫ Medical/Health Home Diffusion▫ Electronic Health Record and HIE Infrastructure

• Patient Safety ▫ Reduce Hospital Readmission Rates▫ Reduce Hospital Acquired Conditions Rates and Patient Harm▫ Improve Care Transitions▫ Improved Medication Management

• Cost and Quality▫ Value Base Purchasing▫ Aligned Performance Incentives and Penalties▫ New payment models ▫ Quality and Cost Public Transparency and Accountability

• Coverage and Access▫ Healthcare manpower capacity development (e.g. use of mid-levels, telemedicine) ▫ Medicaid/CHIP expansion▫ Health Insurance Exchanges

• Special Populations▫ Dual Eligible Individual▫ Complex Chronic Disease▫ Special Need Children▫ Frail Elderly and Disabled

Case Study # 1Health Delivery System

Performance: Geographic Variation in Cost and Quality Outcomes

Hospital Referral Region Per Capita Spending Varies Dramatically

Medicare per capita spending in Miami, FL is more than 2 times Medicare per capita spending in Honolulu, HI !

HRRs with Low Per Capita Spending

Per Capita Spending

Ratio to National

HI - Honolulu $4,959 0.66CA - San Francisco $5,822 0.78CA - San Jose $5,942 0.79

HRRs with High Per Capita Spending

Per Capita Spending

Ratio to National

FL - Miami $10,145 1.35LA - Monroe $9,468 1.26TX - McAllen $9,370 1.25

10

11

FL FL FL TX FL FL AL FL LA FL TX FL MI

MiamiFort Lauderdale Sarasota Harlingen Clearwater Bradenton Montgomery Orlando Monroe

St. Petersburg Tyler

Ormond Beach Detroit

Diabetes W/O Complication 1.31 1.34 1.73 1.58 1.78 1.55 1.38 1.20 1.24 1.45 0.66 1.39 1.04COPD 1.81 1.07 1.20 1.23 1.33 1.11 1.36 1.06 1.84 1.23 1.45 1.83 0.87Vascular Disease 1.88 1.36 1.36 1.55 1.27 1.46 1.05 1.32 1.37 1.00 1.06 1.48 1.53Breast, Prostate, Colorectal and Other Cancers and Tumors 2.15 1.35 1.55 1.14 1.55 1.29 1.00 1.11 0.60 1.39 1.21 1.79 1.35Specified Heart Arrhythmias 1.41 1.56 1.76 1.03 1.82 1.13 1.30 0.87 1.44 1.10 1.41 1.91 1.40Specified Heart Arrhythmias & CHF 1.33 1.15 1.02 1.20 1.26 1.21 1.83 1.28 1.51 1.10 1.14 1.29 1.22Metastatic Cancer and Acute Leukemia 1.65 1.54 1.74 1.47 1.08 1.52 1.80 0.79 0.93 1.80 1.81 1.08 0.84

Rheumatoid Arthritis and Inflammatory Connective Tissue Disease 1.40 1.33 1.80 1.31 1.32 1.82 1.38 1.37 0.65 1.08 1.58 0.83 1.02CHF & COPD 2.08 1.94 1.40 0.78 1.16 0.97 1.67 1.27 0.90 1.48 1.48 1.08 1.13Diabetes W/O Complication & CHF 1.60 1.17 1.18 1.88 1.17 1.72 0.80 1.27 1.17 0.86 1.44 0.85 1.38

Lymphatic, Head and Neck, Brain and Other Major Cancers 1.75 1.51 1.44 1.36 1.05 1.67 0.93 1.61 1.39 1.00 1.01 1.49 1.20Vascular Disease & COPD 2.45 1.72 1.77 0.90 1.38 1.03 1.68 1.01 1.68 1.50 2.18 1.39 0.84

Diabetes W/ Renal or Peripheral Circulatory Manifestation 2.36 1.58 1.61 2.08 1.77 0.84 0.72 1.36 1.19 1.31 0.92 1.09 1.33COPD & Diabetes W/O Complication 2.02 2.25 1.75 1.05 0.99 1.54 1.25 1.42 1.45 0.74 1.97 1.20 0.78Vascular Disease & Diabetes W/O Complication 1.67 1.24 1.26 1.88 1.17 1.13 1.42 1.00 1.12 1.46 1.17 1.39 1.31Major Depressive, Bipolar, and Paranoid Disorders 1.24 2.05 1.96 1.22 1.45 1.13 1.22 1.45 2.18 1.65 0.58 1.23 1.69

Diabetes W/ Neurologic or Other Specified Manifestation 1.93 1.27 1.72 1.36 1.68 1.45 1.01 0.86 2.25 1.80 1.74 0.90 1.16Lung, Upper Digestive Tract, and Other Severe Cancers 0.72 2.02 1.37 1.26 1.07 1.25 1.26 1.05 0.90 1.21 1.21Renal Failure 1.56 1.69 1.71 1.01 1.25 1.85 1.78 1.48 0.84 1.71 1.24 1.36 2.03CHF & COPD & Specified Heart Arrhythmias 1.73 1.23 0.96 1.69 0.98 1.28 1.37 1.38 1.63 1.27 1.11 0.81 1.26

Diabetes W/O Complication & CHF & Specified Heart Arrhythmias 1.13 1.44 1.01 2.22 1.06 1.29 1.04 1.14 1.45 0.83 1.22 0.64 1.21

Ischemia or Unspecified Stroke 2.46 1.97 1.41 1.23 2.19 2.16 1.28 1.76 1.02 1.11 0.82 1.11 1.38CHF 1.49 1.48 1.62 0.82 1.72 1.20 1.04 1.32 2.20 2.00 1.59 1.24 1.05

Study cohort minus cohort benes w/ one of the 23 HCC groupings 1.22 1.56 1.22 4.70 1.33 1.36 1.70 1.32 2.43 1.24 1.21 0.81 1.67

Sample Data Table for High-Cost Hospital Referral Region (HRR)A ratio for each HRRxHCC

12

Sample Data Table for Low-Cost Hospital Referral RegionA ratio for each HRRxHCC

WI WA WI AK CA VA OR CA WI WA MN OR MN HI

Madison Olympia Appleton AnchorageAlameda County Charlottesville Eugene Stockton La Crosse Yakima Duluth Medford Rochester Honolulu

Diabetes W/O Complication 0.67 0.65 1.19 0.54 0.82 0.69 0.72 0.69 0.45 0.46 0.41 0.83 0.84 0.56COPD 0.77 1.21 0.70 0.56 0.65 0.61 0.89 0.79 0.76 0.69 1.16 1.09 0.57 0.59Vascular Disease 0.60 0.53 1.22 0.65 1.18 0.75 0.65 0.80 0.64 0.78 0.78 0.42 1.07 0.56

Breast, Prostate, Colorectal and Other Cancers and Tumors 0.66 0.63 0.74 0.80 1.28 0.60 0.48 1.47 0.64 0.91 0.99 0.40 0.88 1.19Specified Heart Arrhythmias 0.53 1.03 0.53 0.50 0.79 0.64 0.64 0.63 0.89 0.57 0.80 1.06 0.69 0.87Specified Heart Arrhythmias & CHF 1.01 0.61 0.65 0.80 0.60 0.90 0.57 0.62 0.75 0.80 0.58 0.71 0.80 1.14Metastatic Cancer and Acute Leukemia 0.67 1.26 1.00 0.54 0.60 1.19 1.19 0.78 0.66 0.44 1.19 0.70 0.44 0.63

Rheumatoid Arthritis and Inflammatory Connective Tissue Disease 0.51 0.61 0.89 0.40 0.57 0.82 0.58 0.86 0.39 0.78 0.63 0.85 0.78 0.81CHF & COPD 0.37 0.93 0.65 0.83 0.66 1.50 1.23 0.75 0.97 0.93 0.66 0.77 0.76 0.92Diabetes W/O Complication & CHF 1.19 0.59 0.65 1.02 0.60 0.74 0.64 1.10 0.90 1.19 1.08 0.61 0.71 0.86

Lymphatic, Head and Neck, Brain and Other Major Cancers 0.58 0.75 0.88 0.70 0.67 0.58 1.46 0.78 0.68 0.74 0.73 0.82 0.76 0.94Vascular Disease & COPD 0.68 0.60 0.55 0.81 0.72 0.59 0.36 1.07 0.73 1.19 0.88 0.74 0.70 0.63

Diabetes W/ Renal or Peripheral Circulatory Manifestation 0.68 0.57 0.49 0.60 1.13 0.58 0.88 0.69 0.83 0.59 0.89 1.03 0.65COPD & Diabetes W/O Complication 1.41 0.91 0.58 0.91 0.76 1.16 1.48 0.91 0.92 0.66 0.73 0.76 0.96 0.65

Vascular Disease & Diabetes W/O Complication 0.42 0.68 0.59 1.05 0.76 0.67 0.87 0.73 1.08 1.28 0.80 0.75 0.65 0.78

Major Depressive, Bipolar, and Paranoid Disorders 0.70 0.46 0.63 0.69 0.81 1.03 0.92 0.82 0.75 0.77 0.56 0.69 0.75 0.95

Diabetes W/ Neurologic or Other Specified Manifestation 0.93 0.68 0.91 0.45 1.30 0.61 0.65 0.80 0.95 0.63 0.91 0.88 1.08 0.90

Lung, Upper Digestive Tract, and Other Severe Cancers 0.64 0.65 1.75 0.67 0.69 0.80 1.16 1.00 0.81 0.57 1.09 0.83Renal Failure 0.78 1.39 0.70 0.84 1.24 0.48 1.11 0.60 0.70 0.66 0.57 0.64 0.60 0.67CHF & COPD & Specified Heart Arrhythmias 0.81 0.50 0.77 0.79 0.76 0.74 0.66 0.65 0.85 0.60 1.14 0.97 0.97 0.81

Diabetes W/O Complication & CHF & Specified Heart Arrhythmias 0.61 0.75 0.51 0.71 0.79 0.62 0.72 0.69 0.94 0.52 1.02 1.28 0.70 0.51Ischemia or Unspecified Stroke 0.59 0.58 0.74 0.38 1.17 0.92 0.72 0.68 0.54 0.79 0.61 0.79 1.04 0.59CHF 0.59 0.60 0.52 0.51 0.76 0.92 0.45 1.01 0.55 1.24 0.66 0.99 1.10 0.30

Study cohort minus cohort benes w/ one of the 23 HCC groupings 0.87 0.79 0.88 0.67 1.38 1.00 0.47 1.21 0.53 1.07 0.65 0.68 0.59 0.54

Geographic Variation In Potentially Avoidable Hospitalizations

Potentially Avoidable Hospitalizations

All Duals NF SNF HCBS Other/CommunityAltered mental status, acute confusion, delirium * 0.3 0.6 0.6 * *Anemia * 1.0 2.2 2.3 * *COPD, asthma 17.0 6.0 5.5 23.6 26.6Congestive heart failure 22.9 11.6 16.8 33.0 30.8Constipation, impaction 1.4 1.1 0.8 2.0 1.6Dehydration 14.7 10.3 12.9 18.4 17.7Diarrhea, gastroenteritis, C. Diffi cile * 0.9 1.6 3.0 * *Falls/trauma * 3.8 9.4 5.2 * *Hypertension 1.0 0.2 0.2 1.0 1.8Pneumonia * 14.5 32.8 30.5 * *Poor glycemic control 2.4 0.7 0.7 2.0 4.1Psychosis, agitation, organic brain syndrome * 0.6 1.4 1.1 * *Seizures 4.2 2.6 2.1 3.6 6.1Skin ulcers, cellulitis * 2.3 4.9 5.9 * *Urinary tract infection 12.5 14.2 11.7 15.7 10.6Weight loss and malnutrition 0.6 0.4 0.8 0.7 0.7

Percentage of Potentially Avoidable Hospitalizations by Condition and Setting

Patient Settings : Variation in Results by Setting

Case Study #2

Dual Eligible Beneficiary Population: Potentially Avoidable Hospitalizations

Current Dual Eligible Population Hospitalization Rates

Population 5,569,903Percentage With at Least One Hospitalization

27%

Total hospitalizations 2,691,276 Total costs (in billions) $27.5 Hospitalization rate (per 1,000 person years)

574

Average length of stay (days) 7.1 Average Medicare cost $9,815 Average Medicaid cost $411

Health Reform: Dual Eligible with Complex Chronic Disease

Population 5,569,903

Percentage of Hospitalizations That Were Potentially Avoidable 26%

Percentage of Fully Dual Eligible individuals With at Least One PAH 9%

Percentage of All Medicare Hospital Costs from Fully Dual Eligible PAHs 3%

2011 Projected Costs Attributable to Fully Dual Eligible PAHs $7-$8 Billion

Potentially avoidable hospitalizations 699,818 Total costs (in billions) $5.6

Potentially avoidable hospitalization rate (per 1,000 person-years) 151

Average length of stay days 6.1

Average Medicare cost for potentially avoidable hospitalizations $7,665

Average Medicaid cost for potentially avoidable hospitalizations $333

The CMS Strategic Plan

Systematically guiding the Health Care System to achieve targeted measurable

improvements in care management, cost reduction, and population health.

CMS Tools for Transforming the Delivery System

HealthCare Delivery System

Transformation

Electronic Health

Records and HIE

Payment Reform

and Program

Policy

Quality and Cost

Transparency

Service Delivery Redesign

Investments

CMS Levers and Initiatives to Improve Care, Reduce Cost, & Impact

Population Health• Policy Levers and Initiatives

▫Align the Healthcare Industry to CMS Strategic Aims and Direction

▫ Initiate and Lead Major National Campaigns and Initiatives

▫10th Scope of Work for QIOs▫Program Policy Alignment▫Payment Reform and Incentives▫CMS Public Reporting, Public Access Databases▫Graduate Medical Education policy and funding▫Provide or Sponsor Learning Collaborative▫ Innovation Center Initiatives and Investments ▫Public-Private Partnering on strategic aims▫Building Knowledge Resources - Health Information

Databases, Collaborative Insight and Knowledge Discovery

Deploying Integrated Care Delivery System Models

Patient Centered Impact

Accountable Care Design Elements

Results In

An Accountable System for Beneficiary/Patient-Centered Care

Improved Care Coordination and

Integrated Delivery of Care

Increased Provision of Evidence-Based

Care

Patient Activation and Increased

Health LiteracyEfficient Delivery of

Care and Elimination of

Waste

Reduce and Contain Cost of Care

Population Health Improvement

Expected Outcomes

Advanced Primary Care Medical Home

24

Fully E-Health Capable

Advanced CareManagement

Capable

Community Practice

TranslationalResearch

Site

Connected to Community

ResourceDatabases

Patient E-Learning

Center

Psycho/SocialEvaluation

AndIntervention

CommunityHealth

SurveillanceInterfaces

HorizontallyIntegrated

WithInteroperable

HIT

Remote Bio-metricMonitoring

Capable

Clinical Pharmacist Role in Health Care Reform

ACO/IDS

•Medication Management Consultant and Information Resource

•Clinical Pharmacist as a Clinical Team Member Medi

cal Home

•Medication Management Consultant and Information Resource

•Clinical Pharmacist as a Medical Home Care Management Team Member

Patient Center

ed Care

•Health Literacy Promoter•Patient Compliance Consultant•Knowledge Discovery

Research

• Patient Compliance• Comparative Effectiveness

Questions?

Thank you!