Health Care Reform: Where are the Pharmacists? Opportunities and Challenges for Pharmacists in Health Care Reform Anthony D. Rodgers CMS Deputy Administrator Center for Strategic Planning June 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 Direction To 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 Activated Patient Productive Interactions Prepared Clinical Team  Web based health e-learning,  Electronic Care Planning  Self Care Management Tools  Web based health e-learning,  Electronic Care Planning  Self Care Management Tools  Electronic Health Records  Exchange of Health Information  Multi-disciplinary team  Coordinated Care Management  Electronic Health Records  Exchange of Health Information  Multi-disciplinary team  Coordinated Care Management Common Set of Patient Health Information Common Set of Patient Health Information

Patient Centered Care Informed and Activated Patient Productive Interactions Prepared Clinical Team Electronic Health Record & HIE Clinical and Value Based Integrated Care Management Decision Making Supported by ACO or Integrated Care System Supported By E- Health and Learning Tools

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 Integrated Health 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 # 1 Health 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, CA - San Francisco$5, CA - San Jose$5, HRRs with High Per Capita Spending Per Capita Spending Ratio to National FL - Miami$10, LA - Monroe$9, TX - McAllen$9,

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

12 Sample Data Table for Low-Cost Hospital Referral Region A ratio for each HRRxHCC

Geographic Variation In Potentially Avoidable Hospitalizations

Potentially Avoidable Hospitalizations

Patient Settings : Variation in Results by Setting

Case Study #2 Dual Eligible Beneficiary Population: Potentially Avoidable Hospitalizations

Current Dual Eligible Population Hospitalization Rates

Health Reform: Dual Eligible with Complex Chronic Disease Population5,569,903 Percentage of Hospitalizations That Were Potentially Avoidable26% Percentage of Fully Dual Eligible individuals With at Least One PAH9% Percentage of All Medicare Hospital Costs from Fully Dual Eligible PAHs3% 2011 Projected Costs Attributable to Fully Dual Eligible PAHs$7-$8 Billion Potentially avoidable hospitalizations699,818  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 ▫ 10 th 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 for Continuum of Care improvements Transformative Clinical Leadership and Governance Structure Organized Care Management Process, Including Prevention Alignment Around Performance and Outcome Measurements Effective Use of Health Information Technologies Ability to Manage Clinical Knowledge and Skills for Effective Teams Learning Organization Able to Adapt to Change 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 Literacy Efficient Delivery of Care and Elimination of Waste Reduce and Contain Cost of Care Population Health Improvement Expected Outcomes

Advanced Primary Care Medical Home 24 Medical Home Fully E-Health Capable Advanced Care Management Capable Community Practice Translational Research Site Connected to Community Resource Databases Patient E-Learning Center Psycho/Social Evaluation And Intervention Community Health Surveillance Interfaces Horizontally Integrated With Interoperable HIT Remote Bio-metric Monitoring Capable

Clinical Pharmacist Role in Health Care Reform ACO/IDS Medication Management Consultant and Information Resource Clinical Pharmacist as a Clinical Team Member Medical Home Medication Management Consultant and Information Resource Clinical Pharmacist as a Medical Home Care Management Team Member Patient Centered Care Health Literacy Promoter Patient Compliance Consultant Knowledge Discovery Research Patient Compliance Comparative Effectiveness

Questions? Thank you!