2015-04-14 CASE MANAGEMENT - CASE MANAGEMENT

Question 1

The Patient Protection and Affordable Care Act

Answer 1

was signed into law by President Obama on March 23, 2010 taken together with the Health Care and Education Reconciliation Act of 2010 (signed into law on March 30, 2010), is commonly referred to as “health care reform outlined a series of changes to US health insurance, to be implemented over a period of 4 years, to “bring an end to some of the worst abuses of the insurance industry It changed the landscape for Medicare Parts A, B, and D, as well as for Medicaid

Question 2

Provisions of the Affordable Care Act NEW CONSUMER PROTECTIONS ( part 1 ) 2010

Answer 2

Putting Information for Consumers Online. The law provides for an easy-to-use website where consumers can compare health insurance coverage options and pick the coverage that works for them. Prohibiting Denying Coverage of Children Based on Pre-Existing Conditions. The law includes new rules to prevent insurance companies from denying coverage to children under the age of 19 due to a pre-existing condition. Prohibiting Insurance Companies from Rescinding Coverage. In the past, insurance companies could search for an error, or other technical mistake, on a customer’s application and use this error to deny payment for services when he or she got sick. The new law makes this illegal. After media reports cited incidents of breast cancer patients losing coverage, insurance companies agreed to end this practice. Eliminating Lifetime Limits on Insurance Coverage. Under the new law, insurance companies are prohibited from imposing lifetime dollar limits on essential benefits

Question 3

Provisions of the Affordable Care Act NEW CONSUMER PROTECTIONS ( part 2) 2010

Answer 3

Regulating Annual Limits on Insurance Coverage. Insurance companies’ use of annual dollar limits on the amount of insurance coverage a patient may receive are restricted for new plans in the individual market and all group plans. Starting in 2014, the use of annual dollar limits on essential benefits like hospital stays is banned for new plans in the individual market and all group plans. Appealing Insurance Company Decisions. The law provides consumers with a way to appeal coverage determinations or claims to their insurance company and establishes an external review process.

Question 4

Provisions of the Affordable Care Act NEW CONSUMER PROTECTIONS ( part 3) 2010

Answer 4

Establishing Consumer Assistance Programs in the States. Under the new law, states that apply receive federal grants to help set up or expand independent offices to help consumers navigate the private health insurance system. These programs help consumers file complaints and appeals; enroll in health coverage; and get educated about their rights and responsibilities in group health plans or individual health insurance policies. The programs also collect data on the types of problems consumers have, and file reports with the US Department of Health and Human Services to identify trouble spots that need further oversight

Question 5

Provisions of the Affordable Care Act NEW CONSUMER PROTECTIONS 2014

Answer 5

Prohibiting Discrimination Due to Pre-Existing Conditions or Gender. The law implements strong reforms that prohibit insurance companies from refusing to sell coverage or renew policies because of an individual’s pre-existing conditions. Also, in the individual and small group market, the law eliminates the ability of insurance companies to charge higher rates due to gender or health status. Eliminating Annual Limits on Insurance Coverage. The law prohibits new plans and existing group plans from imposing annual dollar limits on the amount of coverage an individual may receive. Ensuring Coverage for Individuals Participating in Clinical Trials. Insurers are prohibited from dropping or limiting coverage because an individual chooses to participate in a clinical trial. This provision applies to all clinical trials that treat cancer or other life-threatening diseases.

Question 6

Provisions of the Affordable Care Act IMPROVING QUALITY AND LOWERING COSTS 2010

Answer 6

2010 Providing Small Business Health Insurance Tax Credits. Up to 4 million small businesses were eligible for tax credits to help them provide insurance benefits to their workers. The first phase of this provision provided a credit worth up to 35% of the employer’s contribution to the employees’ health insurance. Small non-profit organizations received up to a 25% credit. Providing Free Preventive Care. All new plans that beginning on or after September 23, 2010 must cover certain preventive services such as mammograms and colonoscopies without charging a deductible, co-pay or coinsurance. Preventing Disease and Illness. A new $15 billion Prevention and Public Health Fund invests in proven prevention and public health programs that can help keep Americans healthy - from smoking cessation to combating obesity.

Question 7

Provisions of the Affordable Care Act IMPROVING QUALITY AND LOWERING COSTS 2014 (Part1)

Answer 7

Making Care More Affordable. Tax credits to make it easier for the middle class to afford insurance becomes available for people with income between 100% and 400% of the poverty line who are not eligible for other affordable coverage. (In 2010 measurements, 400% of the poverty line comes out to about $43,000 for an individual or $88,000 for a family of four.) The tax credit is advanceable, so it can lower premium payments each month, rather than making people wait for tax time. It’s also refundable. These individuals may also qualify for reduced cost-sharing (copayments, co-insurance, and deductibles).

Question 8

Provisions of the Affordable Care Act IMPROVING QUALITY AND LOWERING COSTS 2014 (Part2)

Answer 8

Establishing Health Insurance Exchanges. Starting in 2014 if an employer doesn’t offer insurance, the employee is be able to buy insurance directly in an Exchange - a new transparent and competitive insurance marketplace where individuals and small businesses can buy affordable and qualified health benefit plans. Exchanges offer a choice of health plans that meet certain benefits and cost standards. Starting in 2014, Members of Congress receive their health insurance through Exchanges

Question 9

Provisions of the Affordable Care Act IMPROVING QUALITY AND LOWERING COSTS 2014 (Part3)

Answer 9

Increasing the Small Business Tax Credit. The law implements the second phase of the small business tax credit for qualified small businesses and small non-profit organizations. In this phase, the credit is up to 50% of the employer’s contribution to provide health insurance for employees. There is also up to a 35% credit for small non-profit organizations.

Question 10

Provisions of the Affordable Care Act IMPROVING QUALITY AND LOWERING COSTS 2015

Answer 10

2015 Paying Physicians Based on Value Not Volume. A new provision ties physician payments to the quality of care they provide. Physicians see their payments modified so that those who provide higher value care receive higher payments than those who provide lower quality care.

Question 11

INCREASING ACCESS TO AFFORDABLE CARE 2010 (Part1)

Answer 11

Providing Access to Insurance for Uninsured Americans with Pre-Existing Conditions. A new Pre-Existing Condition Insurance Plan provides new coverage options to individuals who have been uninsured for at least 6 months because of a pre-existing condition. States have the option of running this new program in their state. If a state chooses not to do so, a plan is established by the Department of Health and Human Services in that state. Extending Coverage for Young Adults. Under the new law, young adults are allowed to stay on their parents’ plan until they turn 26 years old. (In the case of existing group health plans, this right does not apply if the young adult is offered insurance at work.)

Question 12

INCREASING ACCESS TO AFFORDABLE CARE 2010 (Part2)

Answer 12

Expanding Coverage for Early Retirees. Too often, Americans who retire without employer-sponsored insurance and before they are eligible for Medicare see their life savings disappear because of high rates in the individual market. To preserve employer coverage for early retirees until more affordable coverage was available through the new Exchanges in 2014, the new law created a $5 billion program to provide needed financial help for employment-based plans to continue to provide valuable coverage to people who retire between the ages of 55 and 65, as well as their spouses and dependents. For more information on the Early Retiree Reinsurance Program, visit www.ERRP.gov

Question 13

INCREASING ACCESS TO AFFORDABLE CARE 2010 (Part3)

Answer 13

Rebuilding the Primary Care Workforce. To strengthen the availability of primary care, there are new incentives in the law to expand the number of primary care doctors, nurses and physician assistants. These include funding for scholarships and loan repayments for primary care doctors and nurses working in underserved areas. Doctors and nurses receiving payments made under any State loan repayment or loan forgiveness program intended to increase the availability of health care services in underserved or health professional shortage areas do not have to pay taxes on those payments.

Question 14

INCREASING ACCESS TO AFFORDABLE CARE 2010 (Part4)

Answer 14

Holding Insurance Companies Accountable for Unreasonable Rate Hikes. The law allows states that have, or plan to implement, measures that require insurance companies to justify their premium increases to be eligible for $250 million in new grants. Insurance companies with excessive or unjustified premium exchanges may not be able to participate in the new health insurance Exchanges in 2014. Increasing Payments for Rural Health Care Providers. Today, 68% of medically underserved communities across the nation are in rural areas. These communities often have trouble attracting and retaining medical professionals. The law provides increased payment to rural health care providers to help them continue to serve their communities. Strengthening Community Health Centers. The law includes new funding to support the construction of and expand services at community health centers, allowing these centers to serve some 20 million new patients across the country.

Question 15

INCREASING ACCESS TO AFFORDABLE CARE 2012

Answer 15

Providing New, Voluntary Options for Long-Term Care Insurance. The law creates a voluntary long-term care insurance program - called CLASS - to provide cash benefits to adults who become disabled.

Question 16

INCREASING ACCESS TO AFFORDABLE CARE 2014

Answer 16

Promoting Individual Responsibility. The new law requires most individuals who can afford it to obtain basic health insurance coverage or pay a fee to help offset the costs of caring for uninsured Americans. If affordable coverage is not available to an individual, he or she is eligible for an exemption. Ensuring Free Choice. Workers meeting certain requirements who cannot afford the coverage provided by their employer may take whatever funds their employer might have contributed to their insurance and use these resources to help purchase a more affordable plan in the new health insurance Exchanges.

Question 17

HOLDING INSURANCE COMPANIES ACCOUNTABLE 2011

Answer 17

Bringing Down Health Care Premiums. To ensure premium dollars are spent primarily on health care, the new law generally requires that at least 85% of all premium dollars collected by insurance companies for large employer plans are spent on health care services and health care quality improvement. For plans sold to individuals and small employers, at least 80% of the premium must be spent on benefits and quality improvement. If insurance companies do not meet these goals, because their administrative costs or profits are too high, they must provide rebates to consumers

Question 18

HOLDING INSURANCE COMPANIES ACCOUNTABLE 2011

Answer 18

Addressing Overpayments to Big Insurance Companies and Strengthening Medicare Advantage. Today, Medicare pays Medicare Advantage insurance companies over $1,000 more per person on average than is spent per person in Traditional Medicare. This results in increased premiums for all Medicare beneficiaries, including the 77% of beneficiaries who are not currently enrolled in a Medicare Advantage plan. The new law levels the playing field by gradually eliminating this discrepancy. People enrolled in a Medicare Advantage plan still receive all guaranteed Medicare benefits, and the law provides bonus payments to Medicare Advantage plans that provide high quality care.

Question 19

Health care reform legislation passed in 2010 had foci in 2 related models of integrated health care delivery:

Answer 19

the Patient-Centered Medical Home (PCMH) and the Accountable Care Organization (ACO), the former being at the heart of the latter.

Question 20

The Affordable Care Act established ACOs

Answer 20

as a new payment model under Medicare and fostered pilot programs to extend the model to private payers and Medicaid

Question 21

The National Council for Community Behavioral Healthcare (NCCBH), in their January 2011 report,3 defined an ACO as

Answer 21

a structure through which a group of providers with shared governance takes responsibility for the management and coordination of a defined population’s total spectrum of care

Question 22

ACO

Answer 22

(Elliott S Fisher, MD, MPH) coined the term “Accountable Care Organization,” described as having 3 key attributes: organized care, performance measurement, and payment reform, “all aligned, if possible, to support physicians in their efforts to improve care While reimbursement will continue under the fee-for-service system initially, the provider organizations (the ACOs) that are able to improve quality and reduce costs will receive substantial bonuses and share in the savings physicians and hospitals come together to become more organized entities that are capable of managing and being responsible for the care of an entire population of patients regularly report on performance measures to reassure the public and payers that care is improving

Question 23

To help providers understand options for structuring partnerships with ACOs, the January 2011 report issued by the NCCBH urged providers to undertake the following action steps to ensure their readiness to participate in ACOs:

Answer 23

1. Prepare now for participation in the larger health care field 1. Identify community partners and build relationships, especially with primary care. 2. Develop competency in team-based care and health homes in particular. 3. Institute a measurement-based approach to care, incorporating standardized clinical assessment tools into routine service delivery. Gather data on population served in order to support recognition as a “high-volume” specialty provider. 4. Increase skills and knowledge in population health management, including wellness and prevention and disease management approaches. 2. Establish credentials as a high performer relative to the triple aim 1. Adopt quality tools and train staff in using them to track performance. 2. Assess clients’ experience of care (including its patient-centeredness and cultural/linguistic competence) and address gaps. 3. Document MH/SU and general health outcomes (e.g., body mass index) and implement a plan for improving areas of weaknesses. 4. Evaluate the cost and value of the care provided. 3. Ensure information technology readiness 1. Institute IT systems that are able to support: 1. Exchange of data within and outside the organization 2. Use of data as a routine part of clinical work 3. Performance review practices 4. Management of new payment structures (including linking performance to payment) 2. Reach out to community partners to begin forming local or regional health information exchanges. 3. Plan for an extended period of change 1. Implement a change management plan. 2. Identify key resources and support network for staying current around new and emerging practice and financing models. 3. Invest in educating board and staff on operational and clinical changes.

Question 24

Patients’ Role in ACOs

Answer 24

Increased access to health insurance as a result of health care reform will lead to thousands of newly insured Americans entering into “a strained, fragmented system that often fails to deliver effective, efficient care one area that has unfortunately not received much attention model focuses on provider and organization cooperation, but a provider-based accountability model that is disconnected from the way patients seek care may fail to achieve its cost saving and quality goals Because most patients are not obligated to obtain care only from the ACO provider group, the ACO has imperfect control over the care provided patients’ unwillingness to accept closed physician networks, coupled with the importance in the US for a patient to choose one’s provider freely, may provide an argument for finding ways to increase patients’ adherence to an ACO in order to improve efficiency and savings

Question 25

Method for creating incentive to build patients’ loyalty to an ACO:

Answer 25

Allow patients to pay less at the point of care depending on their choice of provider. Patients would pay lower copayments to physicians within their ACO. The barrier: Inadequate consumer awareness and low use of the networks Charge patients different premiums depending on which ACO they select. Patients choosing an ACO that has lower costs than an alternative ACO would pay lower monthly premiums. Barrier: Premium tiering presumes that once an ACO is selected, the patient is limited to it for the year or faces higher cost sharing for going outside the ACO for care Assign patients to primary care physicians within a low-cost, high-quality ACO as the default. Consumers frequently accept default settings and fail to switch out because of procrastination or a belief that a default reflects an expert’s recommendation BARRIER: Without new legislation, Medicare probably cannot offer such incentives Other ways: disseminate information to patients about the quality and cost-efficiency of the care they would get if they adhered to a particular ACO avoid the “pitfall of past capitation arrangements that left patients out of the equation

Question 26

Transitions of Care

Answer 26

is a series of actions that ensures continuity of health care delivery as patients navigate through the system refers to a patient moving from one level of care to another, such as from primary care to specialty physicians; from the emergency department to surgery or intensive care; or when patients are discharged from the hospital to home, to an assisted living arrangement, or to a skilled nursing facility

Question 27

handoff

Answer 27

refers to changing providers or settings within one level of care, while a transition of care refers to changing providers or settings from one level of care to another not to be confused with signout includes a change in provider or change in service, such as nursing staff shift change, resident sign-outs, or housestaff rotation change is a type of care transition and includes a temporary transfer of care, such as from inpatient, clinic, or ED to the OR, procedure area, or diagnostic area Multiple handovers create an opportunity for communication breakdown that may lead to increased medical errors, longer hospital stay, and unnecessary laboratory studies

Question 28

signout

Answer 28

is the transmission of patient information, not the transfer of responsibility for care

Question 29

The AHRQ recommends using the acronym ANTICipate as a mnemonic to summarize the components of a safe and effective signout:

Answer 29

• Administrative data (eg, patient’s name, medical record number, and location) must be accurate. • New clinical information must be updated. • Tasks to be performed by the covering provider must be clearly explained. • Illness severity must be communicated. • Contingency plans for changes in clinical status must be outlined, to assist cross-coverage in managing the patient overnight.

Question 30

The quality of patient handoffs and care transition has been found to be affected by 3 main factors:

Answer 30

Factor 1, Information Transfer, deals with the “technical aspects” of patient handoff, including transmission of the patient’s clinical information and the organization of how the handoff is conducted. Transmission of clinical information includes selecting and communicating all relevant information; handing over complete documentation; communicating an assessment of the patient; and addressing priorities for further treatment. The organization of the handoff should support effective information transfer between clinicians (including continuously using available documentation, allowing for enough time, and following a logical structure). Factor 2, Shared Understanding, deals with the means for establishing a shared understanding between the clinician handing off the patient and the clinician taking on responsibility for the patient. It concerns closing the communication loop (including ensuring completeness of the handoff and actively clarifying questions and ambiguities). Closing the communication loop also involves discussing possible risks and complications, in addition to the routinely communicated information that falls into Factor 1.3 Factor 3 Working Atmosphere, deals with the atmosphere surrounding the team of clinicians involved in a handoff (including tensions and establishing good contact). Working atmosphere also deals with respect for the patient (for example, considering the patient’s experience).

Question 31

National Transitions of Care Coalition (NTOCC)

Answer 31

To address the handoff/signout problem nationally and across care settings, coalition was formed in 2006 Bringing together industry leaders, patient advocates, and health care providers from various care settings, coalition is dedicated to improving the quality of care coordination and communication when patients are transferred from one level of care to another chaired and coordinated by the Case Management Society of America (CMSA) and has over 30 participating associations and organizations views transitions of care as a major challenge to health care delivery, realizing it can only be solved by breaking down the silos and barriers between different health care settings

Question 32

Patient Protection and Affordable Care Act

Answer 32

includes language that calls for improvements in transition of care and care coordination

Question 33

Example in Practice: Transitions of Care Initiatives Commended by NTOCC The Miami Project (EXAMPLE)

Answer 33

spearheaded by the FMQAI, one of 14 Medicare Quality Improvement Organizations selected by the Centers for Medicare and Medicaid Services to participate in the Care Transitions Project, the goal of which is to reduce unnecessary hospital readmissions that may increase risk or harm to patients and costs to Medicare improvement interventions address issues in medication management, post discharge follow-up, and plans of care for patients who move across health care settings strives to promote patient safety through improved care coordination between health care providers

Question 34

Example in Practice: Transitions of Care Initiatives Commended by NTOCC The Tallahassee Memorial Hospital’s Transitional Care Center (EXAMPLE)

Answer 34

provides follow-up care in a multidisciplinary clinic setting for patients who have been recently discharged from the acute care setting and are clinically stable. The target population is patients without an established outpatient medical home.

Question 35

Example in Practice: Transitions of Care Initiatives Commended by NTOCC Thomas Jefferson University Hospital (EXAMPLE)

Answer 35

began an anticoagulation program, because anticoagulants are one of the top 5 drug classes associated with patient safety incidents. Their plan included 1,300 patients managed from the day of surgery to the end of medication therapy by one single program: an interdisciplinary orthopedic team of both inpatient and outpatient surgeons, nurse practitioners, case managers, physician assistants, pharmacists, physical therapists, and visiting nurses.

Question 36

Example in Practice: Transitions of Care Initiatives Commended by NTOCC United Health Care, North East Region (EXAMPLE)

Answer 36

implemented a pilot to incorporate a Transitions of Care concept as part of a discharge planning and readmission management initiative, with an eye to national implementation. Clear roles of the patients and caregivers were defined and protocols were implemented; then, connections were made to other providers in the community.

Question 37

Transitions of Care a National Concern The Joint Commission

Answer 37

established its Center for Transforming Healthcare in 2009 as the quality improvement arm of the organization collaborates with hospitals to address difficult patient-safety problems In collaboration with 10 participating health systems, the Center has worked to identify root causes and barriers to good handoff communication - such as interruptions or inaccurate information - and to craft solutions has established handoff of care as a National Patient Safety Goal All hospitals accredited by The Joint Commission are required to implement these goals

Question 38

Transitions of Care a National Concern Medical errors

Answer 38

are reported to The Joint Commission from across the nation occur most frequently at times when health care providers communicate clinical information as providers change or as the patient moves across the continuum of care

Question 39

According to NTOCC, transferring a patient safely through multiple levels of care involves 7 essential elements

Answer 39

1. Managing medications 2. Planning the transition 3. Educating the patient so that he or she knows what to expect 4. Transferring information to the next provider or facility in a comprehensive and effective manner 5. Following up 6. Being actively engaged in the transition 7. Ensuring shared accountability across providers and organizations

Question 40

Transitions of Care a National Concern poor communication

Answer 40

can lead to confusion about the patient’s condition, duplicative tests, inconsistent patient monitoring, medication errors, delays in diagnosis, and lack of follow-through on referrals Medication errors cost the US billions of dollars annually, and they occur most frequently from communication breakdowns during handoffs and care transitions Patients with large numbers of providers and multiple care settings are at increased risk of poor communication, lack of follow-through, and medical and medication errors

Question 41

In 2010, the Cochrane Collaboration (study) published

Answer 41

a meta-analysis11 examining the effectiveness of discharge planning for patients being moved from the hospital setting to home. Included in the meta-analysis were randomized-controlled trials that compared individualized discharge planning with routine discharge care that was not individualized to the patient. The results indicated that hospital length of stay and readmission rates were significantly reduced for patients receiving individualized discharge planning. Three trials included in the meta-analysis also showed increased patient satisfaction when patients received individualized discharge planning. However, its effects on mortality, health outcomes, and cost were not concluded.

Question 42

Transition planning interventions:

Answer 42

Definition: is a formal process that facilitates the safe transition of patients from one level of care to another, including home, or from one practitioner to another conduct a comprehensive assessment of the patient’s and family’s needs and coordinate the discharge or transition plan with the family and health care team manage the patient’s and family’s needs that are specific to the transition, such as education and support regarding healthy lifestyle, consideration of literacy level, or performing a comprehensive home assessment to ensure safe transition to home completie a transition summary send an electronic summary to the next provider or provide the patient with a written summary, in the appropriate literacy level, upon discharge ask the patient to explain the details of the plan in his or her own words .

Question 43

Resources available to improve transitional communications include:

Answer 43

NTOCC’s Taking Care of My Health Care NTOCC’s Guidelines for a Hospital Stay The Transitions Toolkit from Caps Tools for Family Caregivers

Question 44

NTOCC’s Taking Care of My Health Care

Answer 44

a guide for patients and their family caregivers to use so they can be better prepared on what kinds of questions they need to ask when they see a health care professional.

Question 45

NTOCC’s Guidelines for a Hospital Stay

Answer 45

a brochure that helps guide the patient, family, and caregiver on how to ensure safe and successful health care at the hospital. It includes guidance on what to bring for an anticipated hospital stay, questions to ask the health care team, and items to consider after discharge.

Question 46

The Transitions Toolkit from Caps

Answer 46

which provides patients with the tools and information they need to make a smooth transition from the hospital to their next destination. It includes a list of advice and tips for making the most of their conversations with their doctor or nurse. It also includes tools for providers on how to open the lines of communications with their patients.

Question 47

Tools for Family Caregivers

Answer 47

a set of tips and educational materials developed for caregivers by the National Family Caregivers Association

Question 48

Transition: shared accountability interventions :

Answer 48

DEFINITION: across providers and organizations, including both the transitioning provider or organization and the one receiving the patient INTERVENTIONS: • The sending provider must communicate the plan to the patient and to the receiving provider before the handoff is complete. • The sending provider must be available to the receiving provider for any questions and clarifications after handoff. • The sending provider must remain responsible for the patient’s care until the receiving provider has acknowledged that he or she can effectively assume the care. • The receiving provider must acknowledge the receipt of transferred information in a timely manner, understand the plan, and be prepared to assume responsibility. • And, finally, if the receiving provider determines that the patient should go to another level of care, he or she is responsible for communicating with the next provider before handoff.

Question 49

HITECH Act

Answer 49

The American Recovery and Reinvestment Act of 2009 recognized the importance of health information technology by allotting 19 billion dollars toward electronic medical records in hospitals and physician offices

Question 50

Medication Therapy Management Programs (MTMPs)

Answer 50

problems in our society are costly and, in too many cases, injurious and deadly According to a 2006 Institute of Medicine report, more than 1.5 million preventable adverse drug events (ADEs) occur in the Unites States annually. Among Medicare enrollees in ambulatory care settings, costs for preventable ADEs are estimated to be $1,983 per case and $887 million for all cases annually.2 Moreover, each year in the United States, medication nonadherence is estimated to account for 125,000 deaths, 10% of all hospital admissions, 23% of nursing home admissions, and $100 billion in costs.

Question 51

The US Medicare Modernization Act (MMA) of 2003

Answer 51

was established with the goal of resolving medication-related problems among the elderly Included the requirement that, beginning in 2006, Medicare Part D sponsors provide reimbursable medication therapy management programs (MTMPs) had Centers for Medicare & Medicaid Services (CMS) goals provide selected beneficiaries with education and counseling regarding specific medications, to promote adherence to medications, and to detect and correct adverse drug events and misuse made MTMP distinct from disease management programs has the MTMP focus on medications, rather than on disease per se; they serve patients with multiple chronic conditions; and they engage the patient in self-management education and two-way communication with the MTM service provider specified that Part D sponsors must provide MTMPs for patients taking multiple prescription medicines for numerous chronic conditions, with annual medication costs exceeding $4,000 NOTE: pharmacy organizations have taken the lead in refining the definitions, core elements, and service models of MTMPs

Question 52

In 2004, 11 national pharmacy organizations developed a consensus definition of MTM as “a distinct service or group of services that optimize therapeutic outcomes for individual patients [that] are independent of, but can occur in conjunction with, the provision of a drug product.”6 As further defined by the American Pharmacists Association and the National Association of Chain Drug Stores Foundation, MTMP service models should include the following core elements:

Answer 52

• Medication therapy review, in which the provider collects detailed information about all medications that a patient is taking, assessing whether any medications may pose risks of adverse events, and creating a plan to avoid or resolve potential medication-related problems • Personal medication record, in which the provider documents a patient’s medications, including prescription drugs, herbal products, and dietary supplements • Medication-related action plan, in which the provider devises self-management strategies for the patient to follow, as the basis for tracking the patient’s progress and adherence, and for ensuring successful outcomes • Intervention and/or referral, whereby consultative services are provided, typically by the pharmacist, to address medication-related problems; when necessary, the patient is referred to a physician or other health care professional • Documentation and follow-up, which involves recording details about services provided and scheduling follow-up interactions with the patient.

Question 53

In a 2005 consensus document developed by the Academy of Managed Care Pharmacy (AMCP) and various stakeholder organizations, the following 7 key features of sound MTMPs were identified:

Answer 53

1. Patient-centered approaches addressing the individual;’s environmental, social, and medical status 2. Team-based, multidisciplinary approaches 3. Open lines of communication between the patient and health care team, with pharmacists overseeing MTM services 4. Approaches that consider population and individual patient perspectives 5. Flexibility and scalability of MTM services for diverse applications 6. Reliance on evidence-based medicine for developing MTM services 7. Active promotion of MTM services

Question 54

Clinical, Economic, and Acceptance Outcomes of MTMPs Clinical Outcomes

Answer 54

Most studies on clinical outcomes have unfortunately lacked control groups of patients who did not receive MTM services The results of these uncontrolled studies generally indicate positive clinical outcomes and fewer medication-related problems among patients enrolled Several studies focusing on clinical outcomes have not revealed significant benefits

Question 55

Clinical, Economic, and Acceptance Outcomes of MTMPs Economic Outcomes

Answer 55

A number of preliminary studies have indicated significant reductions in costs for patients and health plans in some cases, patients who opt into MTMPs wind up paying more for their medicines, perhaps as a result of enhanced monitoring and adherence NOTE: In an analysis of nearly 100,000 MTM claims submitted by community pharmacies over a 7-year period, mean estimated cost avoidance increased by an average of $93.78 per claim.16 Reported return-on-investment ratios among health plans providing MTMPs have been as high as 12:1.13 Among patients receiving MTM services, reports of monthly medication cost savings have ranged from approximately $15 to $75.

Question 56

Clinical, Economic, and Acceptance Outcomes of MTMPs Acceptance Among Patients, Pharmacists, and Physicians

Answer 56

study findings indicate generally favorable clinical and economic outcomes associated with pharmacist-provided MTMPs. patients and physicians hold moderately to strongly positive views of MTMPs. There are, however, cases in which clinical and economic benefits were not realized. a number of well documented barriers currently dissuade many pharmacists from providing MTM services. Commonly reported barriers are limited time for face-to-face consultations with patients, uncertainty regarding terms of reimbursement, lack of supporting staff for carrying out administrative functions, and cost of implementing administrative tools and MTM services

Question 57

Advancing MTM Models and Services: The Case for Nurse Case Managers

Answer 57

Regarding the resolution of medication-related problems, nurse case managers are ideally suited to coordinate and provide MTM services in collaborative care models. Support must be gained from the pharmacy community, other health care professionals, and patients. In addition, for Medicare-defined MTMPs, administrative and reimbursement policies must be established and agreed upon. NOTE:the nurse case manager is ideally positioned to play pivotal roles in directing and providing MTM services in collaborative practice models with pharmacists, physicians, and other health care providers

Question 58

All private health insurance plans offered in the marketplace cover the same set of essential health benefits. These benefits include at least the following items and services:

Answer 58

• Ambulatory patient services • Emergency services • Hospitalization • Maternity and newborn care • Mental health and substance use disorder services, including behavioral health treatment • Prescription drugs • Rehabilitative and habilitative services and devices • Laboratory services • Preventive and wellness services; and chronic disease management • Pediatric services

Question 59

health insurance exchanges

Answer 59

Effective January 1, 2014, all states are required to have fully operational as mandated by the Affordable Care Act of 2010. more formally recognized as “health insurance marketplaces,” are designed to provide a “one-stop-shop” for individuals and businesses to search, compare, choose, and purchase competitive health insurance plans from a menu of options. are government-regulated and standardized: each plan must include basic, comprehensive medical coverage and prescription drug benefits.