Medicare & Critical insight for
Reimbursement managed markets
Advisor Weekly professionals
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4 5 6
Infusion reimbursement drop would shift Medicare
July 15th, 2009
Vol. 5 No. 23
patients to hospitals
In this issue by Bryan Cote 39.7%; other biologics would drop signifi-
cantly in 2010 as well, likely redirecting at
1 Infusion market changes
If Medicare has its way, it will eliminate all least some portion of Medicare beneficia-
the gains achieved several years ago in infu- ries to the hospital setting, says Joel Brill,
2 MTM conversation sion reimbursement for physician offices. MD. This could have a ripple effect in fur-
The infusion codes were revised a few years ther straining hospital formularies, reducing
2 Survey snapshot
ago to help offset average sales price (ASP) access, and creating higher plan costs. This
3 What do readmissions mean reimbursement, but it appears they would is an "if" scenario since the reimbursement
to product adoption? take a hit due to redistribution of practice rates here are proposed. A final fee schedule
5 June Medicare readmissions, expenses based on the AMA's supplemental is due in November.
St. Joseph Hospital physician survey. Using the chart below,
you can see that reimbursement for infusing The use of orals and injectables
5 Reporter's Notebook
chemotherapy for the first hour would drop could, in theory, benefit in a lower > p. 2
% change 2010 % change
2009 2010 facility 2009 2010 proposed 2009 proposed 2009
facility proposed facility facility fee to 2010 facility fee to 2010
CPT Short descriptor total RVU total RVU fee (21.5% CF cut) proposed (2009 CF) proposed
*96360 Hydration IV 1.57 1.30 $56.62 $36.82 -35% $46.89 -17%
infusion, init
*96361 Hydrate IV 0.46 0.35 $16.59 $9.91 -40.3% $12.62 -24%
infusion, add-on
*96365 Ther/proph/diag 1.91 1.65 $68.89 $46.73 -32.2% $59.51 -14%
IV inf, init
*96366 Ther/proph/diag 0.61 0.53 $22 $15.01 -31.8% $19.12 -13%
IV inf addon
*96372 Ther/proph/diag 0.58 0.60 $20.92 $16.99 -18.8% $21.64 3%
inj, sc/im
*96374 Ther/proph/diag 1.51 1.28 $54.46 $36.25 -33.4% $46.17 -15%
inj, IV push
96413 Chemo, IV 4.09 3.14 $147.51 $88.93 -39.7% $113.25 -23%
infusion, 1 hr
96415 Chemo, IV 0.93 0.71 $33.54 $20.11 -40.1% $25.61 -24%
infusion, addl hr
96417 Chemo, IV infus 2.04 1.57 $73.58 $44.46 -39.6% $56.62 -23%
each addl seq
1
HCPro, Inc. 200 Hoods Lane Marblehead, MA p. 860/232-6377 f. 781/639-0179 bcote@hcpro.com www.hcpro.com
2009 All Rights Reserved, HCPro, Inc.
Medicare & Critical insight for
Reimbursement managed markets
Advisor Weekly professionals
1 2 3
Contents | Survey snapshot | Reporter's notebook | Contact us
4 5 6 Infusion reimbursement < p. 1
Survey snapshot infusion reimbursement market. As we've Setting? Our conclusions could be helpful in
reported, the effect of a shift of Medicare understanding the effects these changes may
Account management beneficiaries to hospitals produces have on access and quality of care: Thirty-
success tighter margins and indirectly affects phar- eight percent of 302 responding physicians
"What impresses me when I talk macy and medical spend, says Faye Satterly, said it would help to have drugs that allowed
to a national or regional account director of Martha Jefferson Hospital's more infusions per hour, and 78% of 54
manager is that they have a good cancer center in Charlottesville, VA. The hospitals surveyed said they would consider
understanding of managed care changes in physician office infusion reim- being more aggressive in urging physicians to
and Medicare Part D and our bursement would hit at the same time as a select "cheaper drugs" for infusions, based on
benefit design. It's sometimes frus- drop in hospital reimbursement to ASP+4%. tightening margins. n
trating if I spend the first several
meetings explaining managed
In the wake of the 2003 Medicare reim- Editor's note: If you are interested in study-
care. It's good if the account man-
bursement changes, we studied the poten- ing the potential effect of these proposed
ager can come in and ask me,
tial impact in our report, What If Cancer changes, please contact me to discuss.
`What do you take into consider-
Care Shifts to the Hospital Outpatient BC (860/712-8960)
ation when adding a drug?'
"I take therapeutic indication,
safety profile, efficacy, cost-effec-
tiveness, treatment guidelines,
Greater payer MTM investment, reimbursement
and standard of care into consid- presents opportunities to make claims about
eration. We have to work within
CMS guidelines, but it's also very drug profile
important to us to ensure that the
patients have desired health out- by Bryan Cote Patients will be eligible for the plan's MTM
comes. If our formulary decision services if they have any three of the core
improves outcomes, it will help As you may know, Medicare Part D MTM conditions in Figure 1 (see p. 3) and take a
on the medical side, and [in] my programs are changing again for 2010 to minimum of five medications from KP's list
opinion, on the drug side as well, include more patients, with lower drug spend of drug classes. Patients must have an annual
by decreasing the need for other but more conditions. Here's how the changes minimum drug spend of $3,000, a drop
meds due to side effects or pro- will play out in California with Kaiser from the current $4,000 cutoff. If patients
gression of their disease state." Permanente (KP) and how its program has meet these criteria, they must opt out if they
worked so far. KP's MTM program used to do not wish to be contacted (as opposed to
--Ronnie DePue, former target its entire eligible population, taking some plan MTM programs that use an opt-
Coventry pharmacy director for all comers in a more global approach. But in model).
Medicare, on account manager many didn't have significant interventions
success. To access our Account after their complete med reviews with the One targeted population is looking at
Manager Success Files series, KP-employed ambulatory care pharmacist. patients discharged from the hospital in the
contact me for a copy (bcote@ Now, KP is trying to target special popula- past week. KP does this every week. It looks
hcpro.com or 860/232-6377). tions or use key patient lists by using its inte- to its EMR from all of its California medi-
grated EMR, KP HealthConnect, to identify cal centers and gets a list, by center, of all
where the most critical need is. discharges. The list can be broken > p. 3
2
HCPro, Inc. 200 Hoods Lane Marblehead, MA p. 860/232-6377 f. 781/639-0179 bcote@hcpro.com www.hcpro.com
2009 All Rights Reserved, HCPro, Inc.
Medicare & Critical insight for
Reimbursement managed markets
Advisor Weekly professionals
1 2 3
Contents | Survey snapshot | Reporter's notebook | Contact us
4 5 6 MTM investment < p. 2
out by type of discharge or admission, such Figure 1
as those for chest pain. The list is then com-
Core conditions
pared to the eligible MTM population KP KP criteria: Minimum of 3 conditions;
has for the program year, and any matches minimum of 5 medications overall
are referred to the KP-employed ambulatory Arthritis: Osteoporosis
care pharmacists for workup (med reconcili-
Arthritis: Osteoarthritis
ation, review of discharge orders, discussion
of meds). To date, there have been fewer Rheumatoid arthritis
readmissions for the MTM group compared Congestive heart failure
to those not receiving MTM services. Diabetes
Dyslipidemia
"Often, patients get new meds at discharge, Hypertension
so we can identify patients going home and
Respiratory: Asthma
reach out to them at an important time and
Respiratory: COPD
prevent readmissions or address bigger-pic-
ture issues with their treatment," says Erwin Respiratory: Chronic lung disorder
Jeong, RPh, a pharmacist at KP in Southern Mental health: Depression
California. Mental health: Schizophrenia
Mental health: Bipolar
Some KP ambulatory care pharmacists have
Mental health: Chronic and disabling
Editorial advisory board signed collaborative practice agreements
Ronnie J. DePue, RPh, PharmD with doctors to allow them to adjust doses, Source: Kaiser Permanente.
Joel Brill, MD switch medications, or initiate therapy.
Chief Medical Officer
Predictive Health
Michael Yanuck, MD Other examples of targeted populations Jeong says the program can help get patient
Michael Yanuck Medical Consulting
include using KP's lab data access to pull LDLs, for example, under control. Eligible
Susan Slaton
Director of Reimbursement a list of anyone with LDL-Cs greater than MTM patients in skilled nursing settings and
BayerHealthcare hospice are enrolled into the program using
100 or using pharmacy data to pull lists of
Matthew Murawski, RPh, CGP
Associate Professor of Pharmacy patients on drugs to be avoided in the elderly. the opt-out method. n
Purdue University
Howard Tag
Tag & Associates
Dawn Holcombe
The Oncology Network Reducing readmission: Can your products align with
Lynn Veith, RN, Administrator
McLean Nursing Home payer, hospital financial goals?
Todd Michael, MS, MBA
Healthcare Economics
Baxter BioScience by Bryan Cote are indirect financial benefits for adopting
Medicare & Reimbursement Advisor Weekly (ISSN: 1937-7541) products that keep patients from bouncing
Reducing hospitalizations is one of the top back after discharge.
benefits that plan medical directors look
for when evaluating products for formulary For example, four readers from five different
adoption. And in terms of hospitals, there pharmaceutical companies recently > p. 4
3
HCPro, Inc. 200 Hoods Lane Marblehead, MA p. 860/232-6377 f. 781/639-0179 bcote@hcpro.com www.hcpro.com
2009 All Rights Reserved, HCPro, Inc.
Medicare & Critical insight for
Reimbursement managed markets
Advisor Weekly professionals
1 2 3
Contents | Survey snapshot | Reporter's notebook | Contact us
4 5 6 Reducing readmission < p. 3
asked me whether there's any financial or QIOs may go beyond an electronic/distance
reimbursement benefit to hospitals that review if there's a pattern at the same
keep patients out of the acute setting after hospital.
discharge.
If a hospital is not paid for readmissions
Although you don't gain reimbursement by and a pattern begins, we're talking about a
keeping the discharged patient out of the significant revenue loss.
hospital beyond 30 days, you do avoid los-
ing reimbursement if the patient is readmit- What causes readmissions?
ted inside a month. Hospitals such as St. Joseph's in Atlanta are
now tracking their readmissions and work-
BaCkgRound ing to reduce their readmission rate and
Medicare doesn't want to pay for hospi- identify the chief causes. See the chart on p. 5
tal readmissions. Under Medicare's 9th for analysis of St. Joseph's June readmissions
Scope of Work rules, CMS' fiscal interme- (also see the July 10 MRAW for readmis-
diaries currently monitor hospital readmis- sions data). One-third of the readmissions in
sions, and if a patient is readmitted at the June were related to a precipitating surgery,
same facility for the same diagnosis within and 25 of those bounced back within five
30 days of discharge, the intermediary days, says Anne Pedersen, RN, the hospital's
flags and sends an electronic note to the care management director.
state Quality Improvement Organization
(QIO). HeaRt FailuRe/CHeSt Pain examPle
The DRG for congestive heart failure is 293
The QIO then contacts the hospital ask- (if the patient does not have other major
ing for documentation and background comorbid conditions). Reimbursement under
records (e.g., the patient's discharge plan this DRG has a blended payment rate. For
and care plan). example, if a patient enters the hospital
within 30 days of discharge for the same
The QIO reviews the records and has the DRG, the average blended rate for hospi-
authority to deny payment for the readmis- tals concerning this DRG comes to about
sion if it believes there's enough evidence $4,500. But the cost of the second admission
that the hospital could have avoided the may be higher if you factor in two to three
readmission or if the documentation or dis- days' worth of emergency department costs,
charge plan are not of good quality. supplies, and nursing time. The hospital eats
these costs if the QIO determines that the
Generally, if the QIO determines that there discharge plan documentation or plan of
was not a great effort to get the patient care were not adequate.
the best discharge at the next best level of
care (i.e., a skilled nursing facility), the hos- meSSage
pital will not be reimbursed for the second If your product keeps the coronary artery
readmission. stable and patients out of the hospital > p. 5
4
HCPro, Inc. 200 Hoods Lane Marblehead, MA p. 860/232-6377 f. 781/639-0179 bcote@hcpro.com www.hcpro.com
2009 All Rights Reserved, HCPro, Inc.
Medicare & Critical insight for
Reimbursement managed markets
Advisor Weekly professionals
1 2 3
Contents | Survey snapshot | Reporter's notebook | Contact us
4 5 6 Reducing readmission < p. 4
for more than 30 days, the drug indirectly reduce so-called bouncebacks and have hos-
helps hospitals avoid revenue/reimburse- pital staff work more in collaboration with
ment loss. CMS' goal is to help save $17 the community (doctors, nurses, skilled nurs-
billion through these efforts. It wants to ing, etc). n
JUNE MEDICARE READMISSIONS
Number of readmissions, June 2009 77
Medicare discharges 595
Readmission rate 12.9%
Average days between readmissions 10.4%
Average length of stay for readmission 5.19%
Hospice/expired 12 (15.6%)
Precipitated by OR 27 (35.6%)
Common primary diagnosis at readmission UTI, sepsis
Common secondary diagnosis at readmission ESRD, ARF, Afib
Source: St. Joseph's Hospital, Atlanta, and HCPro 2009 Readmissions Study.
Reporter's Access to meds difficult for Medicaid
notebook Medicaid's cumbersome policies often lead providers and plans, whose officials say that
to patients not getting or filling their pre- getting those people eventually re-enrolled
scriptions, receiving important diagnostic becomes an even bigger administrative and
tests, or managing their chronic diseases, costly headache.
which will lead to more costs down the road,
according to a new report released by the Officials from several health plans say cre-
Association for Community Affiliated Plans ating policies that provoke churning is a
(www.communityplans.net). common practice in states that are trying to
reduce costs.
Under current practice, the report estimates,
Medicaid will cover 68 million people dur- "States use the redetermination process to
ing the course of this year, but 13 million save money in times of tight budgets," says
will not be enrolled in any given month Elaine Batchlor, MD, chief medical officer at
mainly because their eligibility expired and LA Care, a Medicaid plan with 750,000 mem-
they did not have a chance or the means to bers. "They tend to increase the frequency of
renew it. That results in lowered payments redetermination; that's one way to decrease
from the state and federal government to the the number of people covered." > p. 6
5
HCPro, Inc. 200 Hoods Lane Marblehead, MA p. 860/232-6377 f. 781/639-0179 bcote@hcpro.com www.hcpro.com
2009 All Rights Reserved, HCPro, Inc.
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