SUSAN M. PETTEY has directed health policy and advocacy programs for long-term care physicians, administrators, and other professionals, including AMDA and the American Association of Homes and Services for the Aging. Her experience includes work with the Health Care Financing Administration (now the Centers for Medicare & Medicaid Services) and the National Association for Home Care. She currently is a health policy consultant.
Long-term care providers have a stake in the economic stimulus package that President Barack Obama signed in February, thanks to a provision that includes skilled nursing facilities, home health agencies, and other long-term care facilities among the health care providers that can receive some of the $19 billion allocated for health information technology. Sen. Herb Kohl (D-Wis.), chair of the Senate Select Committee on Aging, sponsored the amendment to include long-term care.
Another provision of the American Recovery and Reinvestment Act of 2009 with implications for long-term care is the provision for a temporary 4.9% increase in the federal matching rate for Medicaid payments to states. Those with high unemployment rates will qualify for additional increases.
The $87 billion Medicaid boost is a relief to state governors, many of whom have had to implement cuts in long-term care payments or services. The additional funding could avert other reductions that have been planned but not yet implemented.
Meanwhile, efforts to reform health care could stall as a result of former Sen. Tom Daschle's withdrawal as nominee for the dual jobs of Secretary of Health and Human Services and White House manager of health reform. President Obama apparently hadn't even considered other candidates.
While Obama searches for a new nominee, the reform initiative may now shift to Congress, particularly to Sen. Max Baucus (D-Mont.), chair of the Senate Finance Committee, who is another strong proponent of health care reform.
On to Plan D
As expected, Democrats have wasted little time in efforts to revise the Medicare Part D prescription drug program. Bills in the House (H.R. 684) and Senate (S. 330) would allow Medicare beneficiaries to choose a Medicare-operated drug plan as an alternative to private insurance for prescriptions. The bills would also require the HHS to negotiate with drug manufacturers on the price of drugs. That proposal is based on a system currently used by the Department of Veterans Affairs, which supporters claim has resulted in drug prices that are 20%-30% lower than Part D prices.
The Medicare drug plan would use a formulary as well as formulary incentives, such as those currently in use under Part D, including tiered copayments, reference pricing, prior authorization, step therapy, medication-therapy management, and generic drug substitution.
The Agency for Healthcare Research and Quality would initially be responsible for assessing the clinical benefit of covered Part D drugs and making recommendations regarding which ones should be included in the formulary. That assessment would be based on whether drugs in a class provide greater clinical benefit—including fewer safety concerns and less risk of side effects—than other drugs in the same class or similar clinical benefits.
Strict limits would be placed on the ability to make changes in the formulary during a benefit year. The HHS secretary would be required to appoint an advisory committee including physicians, pharmacists, and consumers, to recommend any changes to the initial formulary.
The bill calls for an improved appeals process, with requirements that it be efficient, impose minimal administrative burdens, and ensure timely access to nonformulary drugs or exemption from formulary incentives when medically necessary. Medical evidence would be based on professional medical judgment, the medical condition of the beneficiary, and other factors.
The Senate bill, introduced by Sen. Richard Durbin (D-Ill.), has four cosponsors. The House bill, introduced by Rep. Marion Berry (D-Ark.), has 16 cosponsors to date.
Medicare's ability to negotiate drug prices under Part D has been a major sticking point since the program's drug benefit was enacted. If the proposed legislation passes, it will probably lead to consolidation of private drug plans. To the extent that Medicare beneficiaries were to choose the federal plan option, simplification would result from the use of one formulary and a single set of administrative procedures.
Democrats have also discussed proposals to revise the noncoverage zone (the “doughnut hole”) in which Medicare doesn't pay for drugs for enrolled beneficiaries. One approach under consideration is to require provision of generic drugs in the doughnut hole. Concern about the coverage gap has been raised by a recent study showing that Medicare beneficiaries who reach it reduce their medication use by 14%. The study, reported in the health-policy journal Health Affairs, examined 2006 data in employer and Medicare Advantage plans. The study found that 25% of beneficiaries reached the coverage gap, and 4% reached the “catastrophic” gap threshold, above which Medicare resumes payment for prescription drugs.
The Obama administration wants an opportunity to reconsider some of the policies that govern the Medicare Advantage plans and Part D drug plans, so the Centers for Medicare & Medicaid Services has recalled the Medicare draft 2010 “call letter” that sets the ground rules for those plans. Following review, the letter will be reposted on the CMS Web site for review and public comment. Medicare Advantage and drug plans need the information in the call letter to prepare bids for 2010.
A Workforce Boost?
In an effort to increase and upgrade the long-term care workforce, House and Senate Democrats have reintroduced legislation to expand training for health professionals in geriatrics, long-term care, and chronic-care management.
The legislation responds to the Institute of Medicine 2008 report “Retooling for an Aging America: Rebuilding the Healthcare Workforce,” which concluded that the health care workforce will lack capacity, in both size and ability, to meet the needs of older patients in the future unless action is taken immediately. The legislation was introduced in the last days of the last session of Congress.
A bill introduced in both the House and Senate (H.R. 468 and S. 245) would improve geriatric training for physicians by allowing medical schools to use certain federal funds to provide 1 or 2 years of training for individuals who are seeking a certificate of adequate qualification in geriatrics. In addition, geriatric academic career awards would be expanded to federal traineeships that would be available to individuals who are preparing for degrees in geriatric nursing, long-term care, and geropsychiatric nursing.
Grants to provide training opportunities for direct-care workers (including nursing assistants, home health aides, and personal or home care aides) who work in nursing homes, assisted living facilities, and home care settings are also included.
The bill would provide grants to expand and improve geriatric-education centers and require a training demonstration for core competencies for personal or home care aides and additional training content for nurse's aides and home health aides. A National Center for Workforce Analysis would also be established.
Other News in Long-Term Care
CMS will begin an Acute Care Episode demonstration in which Medicare payments for both hospital and physician services would be made to the hospital to cover certain inpatient procedures. Procedures to be bundled include 28 cardiac and 9 orthopedic procedures. Five hospitals will participate in the demonstration, which is an effort to shift toward a payment system that provides physicians with incentives to prevent complications. Several private insurance companies are also experimenting with bundled payments. Several key members of Congress are interested in the bundled payment approach as a means of decreasing physician incentives for additional visits and services.
The Food and Drug Administration has sent letters to manufacturers of certain opioid drug products, indicating that they will be required to have further review to ensure that the benefits continue to outweigh the drugs' risks. The drugs in questions include both generic and brand-name products with active ingredients of fentanyl, hydromorphone, methadone, morphine, oxycodone, and oxymorphone.
The FDA has taken steps to prevent misuse, abuse, and accidental overdose of these drugs in the past, yet problems have persisted and increased. The FDA said it intends to meet with the companies, other federal agencies, patient and consumer advocates, representatives of the pain- and addiction-treatment communities, and other health care professionals and interested parties. The FDA is also planning a public meeting in late spring or early summer to allow for broader public input and participation in the agency's response to the handling of opioids.
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