April 2012 Policy & Advocacy Briefing

Analysis of CMS Consultant Pharmacist Independence Proposal

ASCPs Policy & Advocacy Department ltcrule@ascp.com www.ascp.com/ltcrule

Summary
No requirement for January 1, 2013 CMS believes any requirement needs to be broader in scope LTC community expected to voluntarily improve transparency immediately Measurable improvement on prevalence of unnecessary drugs, overutilization CMS plans a future notice and comment rulemaking Public comments due 60 days from Federal Register publication

Overview: Independence Policy

CMS believes public comments justified concerns over conflicts of interest Does not believe CP-SNF employment represents conflict of interest Pharmacy employment relationship = financial relationship that exerts pressure Oct. 2011 proposal disproportionately targets consultant pharmacists Must consider broader changes than CP independence for a future rulemaking

Definition of Independence
CMS did not respond directly to their definition or alternatives submitted through public comments No indication of whether CMS would consider modifying this definition

Alternative Approaches to Independence

ASCP suggested separate contracts, fair market rates, pharmacy attestation to CP clinical independence, disclosure statements CMS considered finalizing requirements which would have included: separate contracts, fair market rates, pharmacy attestation to CP clinical independence, disclosure statements

Alternative Approaches to Independence

CMS believes requiring independence is part of the right approach However other factors contribute to conflicts of interest, drug overutilization, unnecessary drugs Strongly encourages the industry to voluntarily adopt these recommendations to improve transparency

Measures for CP Performance

CMS suggests industry collect data
Number of interventions Type of interventions Outcomes

Work with PQA to develop performance measures

LTC Settings with Difficulty Complying with Proposed Independence

ASCP recommended a waiver option for certain settings including rural, Tribal, closed-systems, charitable, others CMS will consider comments in a future rulemaking

Relationships with Pharma

Public comments did not change CMSs belief that CP-pharma relationships should be banned, if CP is practicing Believe that CPs receiving remuneration from pharma may be influenced Cited exchange of scientific, educational information at event supported by pharma Service in Ad boards, speaker bureaus

Timeline for Implementation

CMS not finalizing at this time Changes as proposed would be disruptive Will seek a targeted less disruptive approach Expects voluntary changes from industry In the absence of measurable improvement, CMS will use future rulemaking

Cost Impact
CMS acknowledges that an independence requirement would be highly disruptive to the marketplace Would result in higher costs to the nursing homes

Profession Response to the Proposal

CMS did not respond specifically to the findings in ASCPs survey Says they were swayed by comments from current and former CPs, patient advocates Believe that change is necessary

Use of Antipsychotics in NH
CMS acknowledges other factors contribute to overprescribing, overutilization CMS must consider broader changes Will propose those changes in a future rulemaking

DRR Best Practices

CMS says resident safety is at risk if CPs dont have enough time to conduct a proper DRR DRR not currently yielding intended outcomes, beneficiary protections Questioning the purpose of CP DRR CMS may consider changes to the requirement to explore alternative approaches Expects industry to demonstrate value of CP DRR to resident quality of care

CMS Solicitation for Public Comments

CMS Question #1
What specific details regarding the financial (and other) arrangements between LTC facilities, consultant pharmacists, and LTC pharmacies providing consulting and/or dispensing services should be disclosed, and to whom should this information be available?

CMS Question #2
Should the public be informed of the financial and other arrangements between LTC facilities, consultant pharmacists, and LTC pharmacies providing consulting and/or dispensing services? If so, what metrics could be used?

CMS Question #3
What information is needed to assess the independence and adequacy of physician (and other prescriber) medication management and oversight on behalf of nursing home patients? What metrics could be used to assess the adequacy and appropriateness of prescriber response to consultant pharmacist recommendations?

Question #4
What metrics could be used to describe the adequacy and appropriateness of a LTC facility's medication management program?

Question #5
Describe the incentives and other arrangements that create the conflict of interest in LTC that contributes to overutilization and inappropriate drug use in LTC facilities. How can the conflict of interest stemming from these incentives and arrangements be contained or eliminated?

ltcrule@ascp.com www.ascp.com/ltcrule 703-739-1316 Lynne Batshon x141 Angelina Panetterie x151 Arnie Clayman x178