Health Care Reform - The Affordable Care Act

In March 2010, President Obama signed into law the Affordable Care Act (P.L. 111-148; ACA), also referred to as health care reform. Beyond provisions impacting patients and insurance companies, numerous provisions within the final law either impact directly or could impact pharmacists. ACA issues of importance to APhA, pharmacists, and the pharmacy profession include:

The health care reform implementation process at the state and federal regulatory level will continue for years to come along with ongoing Congressional discussions. APhA is advocating for inclusion of pharmacist-provided patient care services throughout this process. Members are encouraged to be an APhA Advocacy Key Contact to help APhA in such efforts. Members can also learn about some of the key concepts of the Patient Protection and Affordable Care Act and what it means for pharmacists by viewing the APhA/Boehringer Ingelheim short videos.

APhA’s Position

APhA supports the overall goals of health care reform which is to improve patient care, quality, and outcomes while reducing cost. APhA did not take a position on the overall health care reform bills when Congress considered the legislation. There were many elements of each proposal at the time which the Association did not have a consensus, such as how to expand access (e.g., health insurance exchange, employer mandate) and how to fund expanded access. Instead, APhA focused its advocacy efforts on the areas that were directly relevant to the practice of pharmacy and the patients the profession serves.

APhA worked diligently with the Health Care Reform Pharmacy Stakeholders group (A group of 14 pharmacy organization that APhA convened and co-chaired) to develop and advocate the Pharmacy Principles for Health Care Reform, a consensus document detailing key pharmacy provisions for inclusion in the law and supporting opportunities within health care reform for pharmacist-provided patient care services.

CMS Innovation Center (CMMI)

CMMI was established in the ACA to test payment and service delivery models to determine their effect on expenditures and quality of care for existing programs such as Special Needs Plans and Medicaid programs, including CHIP. Medication therapy management (MTM) services are among the models to be tested under the statute. In addition, CMMI is focused on transitions of care, reducing hospital readmissions, improving quality, and reducing costs.

In 2012, APhA and ASHP developed a white paper, Improving Care Transitions: Optimizing Medication Reconciliation, which provides a better understanding of the medication reconciliation process during transitions in care, its effect on patient care and outcomes, and how pharmacists can contribute to the improvement of this process through MTM. The paper advocates that pharmacists should take a leadership role in collaborating with other health care professionals in the coordination and implementation of medication reconciliation and identifies foundational concepts for medication reconciliation that can be applied in collaboration with other health care professionals across the health care continuum.

Recent Activity

CMS Announces Community-Based Care Transitions Program Webinar July 12  July 11, 2012

HHS Announces Health Care Innovations Awards  June 27, 2012

CMS Innovation Center Care Innovations Summit Recap Released  June 13, 2012

CMS Announces Payers in the Comprehensive Primary Care Initiative  June 13, 2012

CMS Innovation Center Community-Based Care Transitions Program Reminder  June 13, 2012

More Related Articles

Pharmacists well represented in Health Care Innovation Awards  June 19, 2012

APhA joins HHS's Partnership for Patients  April 22, 2011

Agency Resources

Accountable Care Organizations (ACOs)

Established through the ACA, the Medicare Shared Savings Program and ACOs are a new type of integrated care and payment model that creates incentives for health care providers to work together to treat patients across care settings. The concept behind this program is for providers to improve patient care and save money through innovation in care delivery. The Medicare program would retain some of the money but also share the savings with successful providers. Pharmacists interested in potentially participating with entities forming ACO’s are encouraged to make the case to them about how pharmacists can help ACOs save costs and improve patient care and help meet program requirements.

Recent Activity

CMS Announces 15 New Advance Payment ACO's  July 25, 2012

HHS Announces 89 New Accountable Care Organizations  July 11, 2012

CMS Innovation Center Announces New ACO Application Opportunity  June 27, 2012

Pharmacy Organizations Submit Joint Comments to CMS on ACOs  June 15, 2011

More Related Articles

ACO final rule released  November 8, 2011

Pharmacy to CMS: Explicitly include pharmacists in ACOs  June 13, 2011

Agency Resources

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Essential Health Benefits (EHB)

Beginning January 1, 2014, the ACA requires health benefits plans, with certain exceptions, to include at a minimum an essential health benefits (EHB) package that will be defined through regulation by the Secretary of the Department of Health and Human Services (HHS). The ACA provides little guidance concerning the EHB definition though it does require such benefits to minimally include general categories specified in the law and that the scope of the EHB be equal to those provided under a typical employer plan.

Recent Activity

HHS Issues Final Rule on Insurer Reporting Requirements for Essential Health Benefits  July 25, 2012

APhA Comments to HHS on Essential Health Benefits February 9, 2012

CMS Issues Essential Health Benefits Fact Sheet  February 22, 2012

HHS Delegates Essential Health Benefits Determinations to States  January 11, 2012

IOM Releases Report on Essential Benefits  October 19, 2011

More Related Articles

APhA to HHS: Include MTM in essential health benefits  February 7, 2012

Essential health benefits: ‘50 chances’ to get MTM included  January 3, 2012

APhA to IOM: Essential health benefits should include MTM  January 10, 2011

Agency Resources

Medical Loss Ratio (MLR)

The ACA included a provision requiring health insurers to spend a greater percentage of the premium dollars on medical care and quality rather than administrative costs (commonly referred to as the medical loss ratio (MLR) provision).

Recent Activity

CMS Announces Final Rule on Medical Loss Ratio  December 14, 2011

More Related Articles

No major changes: Final medical loss ratio rule announced  December 6, 2011

APhA to HHS: Include MTM in essential health benefits February 7, 2012

Integrated Care Models

To promote effective use of medications, the ACA includes pharmacists and pharmacy-related services as part of several integrated and collaborative care models developed through the health care reform law. These models take advantage of the specialized knowledge and skills of all professionals on the patient’s health care team, including pharmacists. Given the nearly universal role of medications in the care of patients with both chronic and acute disease, including pharmacist services is critical to these models success. APhA continues to advocate for pharmacist-provided patient care services in all such models.

Integrated Care Models of importance to APhA, pharmacists, and the pharmacy profession include:

  • Independence at Home Demonstration Program: Establishes an Independence at Home demonstration program that includes pharmacists on the team of health care providers. (Section 3024 of the ACA)
  • Community-Based Interdisciplinary Teams: Establishes a program to provide grants to establish community-based interdisciplinary teams that must support pharmacy care provider access to pharmacist-delivered medication management services, including medication reconciliation. (Section 3502 of the ACA)
  • State Option to Provide Health Homes for Enrollees with Chronic Conditions: Establishes a State plan amendment option to eligible individuals with chronic conditions who select a designated provider, a team of healthcare professionals operating with such a provider, or a health team as the individual’s health home for purposes of providing the individual with health home services. Such health teams may include a pharmacist. (Section 2703 of the ACA)
Recent Activity

Supreme Court Issues Affordable Care Act Ruling - APhA Prepares for Implementation July 11, 2012

CMS Announces Independence at Home Demonstration Program January 11, 2011

More Related Articles

Pharmacists well represented in Health Care Innovation Awards June 19, 2012

Pharmacists, nurses team up in Pittsburgh care transition project May 21, 2012

Agency Resources

Independence at Home Demonstration

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Transitional Care Models

The CMS Center for Medicare and Medicaid Innovation (CMMI) was established in the ACA to test payment and service delivery models to determine their effect on expenditures and quality of care for existing programs in Medicare and Medicaid. As part of these efforts, the CMMI demonstration projects that can impact pharmacy focusing on transitions of care include the Community Based Care Transitions Program and the Partnership for Patients.

Community Based Care Transitions Program (CCTP)

  • Tests models for improving care transitions from the hospital to other settings and reducing readmissions for high-risk Medicare beneficiaries.
  • Community-based organizations (CBOs) will use care transition services to effectively manage Medicare patients' transitions and improve their quality of care.

Partnership for Patients

  • Tests models for improving care transitions in order to reduce hospital readmissions.
  • Decrease hospital-acquired conditions by 40%.
  • Decrease readmissions due to preventable complications during transitions from one setting to another by 20%.
Recent Activity

CMS Announces Community-Based Care Transitions Program Webinar July 12 July 11, 2011

CMS Feedback Request on Care Transitions Programs July 27, 2011

More Related Articles

CMS references pharmacists in recent actions May 15, 2012

Pharmacy Organizations Launch Initiative to Improve Transitions of Care January 6, 2012

Transitions of care: Taking action under ACA August 23, 2011

APhA joins HHS’s Partnership for Patients April 22, 2011

APhA Resources

APhA and ASHP White Paper: Improving Care Transitions: Optimizing Mediation Reconciliation | March 2012
APhA and ASHP developed the white paper to stimulate discussion among health care providers and researchers on how to best research and implement improvements in the medication reconciliation process, with the goal of improving patient safety and patient care outcomes.

Agency Resources

Partnership for Patients

Partnership for Patients Fact Sheet

Learn how to Join the Partnership for Patients

CCTP General Fact Sheet and CCTP Partners

Improvements to Medicare Part D MTM

The ACA codified into law more robust MTM program requirements for Part D plans. Under the Medicare Modernization Act of 2003 (MMA; P.L. 108-173) all Medicare Part D prescription drug plans must offer a MTM program; however, the plans have had significant discretion in determining qualification criteria for beneficiaries, the type of services provided, and by whom. As such, there has been considerable variation between programs. The ACA strengthens and bring consistency to these programs by requiring plans to offer a minimum set of MTM services to certain targeted Medicare beneficiaries. (Section 10328 of the ACA).

Starting in 2013, Part D plan sponsors must offer MTM services to targeted beneficiaries that include, at a minimum, strategies to improve adherence to prescription medications or other goals.

Services and strategies must include:

  • An annual comprehensive medication review furnished person-to-person or using telehealth technologies (e.g., telephones, videoconferences) by a licensed pharmacist or other qualified provider.
  • Follow-up interventions as warranted based on the findings of the annual medication review or the targeted medication enrollment and which may be provided person-to-person or using telehealth technologies.

Medicare Part D plan sponsors must have a process to:

  • Assess, at least on a quarterly basis, the medication use of individuals who are at risk but not enrolled in the MTM program, including individuals who have experienced a transition in care (e.g., a hospitalization or stay in a skilled nursing facility), if the prescription drug plan sponsor has access to that information.
  • Automatically enroll targeted beneficiaries, including beneficiaries identified in the quarterly assessment.
  • Permit beneficiaries to opt-out of enrollment in the MTM program.

MTM program expansion and the support of pharmacists’ activities in health care reform, from CMS and other decision makers, continues to stimulate the growth of MTM programs. However, despite these many important advances, there is still much work to be done to bring MTM to all patients who could benefit from it.

Recent Activity

APhA Comments to CMS on Draft 2013 Medicare Part D and Medicare Advantage Call Letter March 21, 2012

APhA Comments on CMS Medicare/Medicaid Alignment Proposal July 27, 2011

More Related Articles

Student pharmacists advocate for MTM on Capitol Hill July 19, 2012

APhA CEO Blog: AARP policy paper on MTM a must read June 20, 2012

2012 Revisions to Medicare Part D December 14, 2011

Agency Resources – Medication Therapy Management Medicare Part D MTM Program Standardized Format Effective January 1, 2013

Instructions for Implementing the Standardized Format July 2, 2012

2012 Medicare & You handbook: CMS’ official guide to Medicare - for the first time, a description of the medication therapy management (MTM) benefit appears on page 93 in the handbook.

Medicare Prescription Drug Coverage (Part D): A reference to MTM (MTM Programs for Complex Health Needs) also appears online in the Part D section of the Medicare Web site.

Litigation to Determine the Constitutionality of the New Law

Whether the ACA would remain law hinged on the U.S. Supreme Court’s ruling on the constitutionality of the statute. In June 2012, the court upheld the ACA with the exception of a provision in the law that could strip existing Medicaid funding from those states not in compliance with the law’s Medicaid expansion requirements. With the issuance of the opinion, the focus the health care debate will continue with federal and state regulatory implementation, on the campaign trail, and through Congressional activity.

Recent Activity

Supreme Court Issues Affordable Care Act Ruling - APhA Prepares for Implementation  July 11, 2012

More Related Articles

Supreme Court hears oral arguments on Affordable Care Act  April 3, 2012

Supreme Court upholds Affordable Care Act  June 28, 2012

Agency Resources