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HHS greenlights pilot for Medicare Advantage to get real-time access to patient discharge records

The department shared details about the initiative but redacted names of key participants.

Susan Morse, Senior Editor

Credit: <a href="">Matthew Bisanz</a>.Credit: Matthew Bisanz.

The Department of Health and Human Services' Office of the Inspector General has given permission for a drug company to start a pilot program that will allow a private Medicare Advantage plan real-time access to a hospital's electronic patient discharge records, according to an HHS letter posted December 11.

But we don't know which drug company sought approval. That's because in the aforementioned letter OIG and HHS redacted that name. It is common practice for entities to request advisory opinions and for the OIG not to name the source, according to the OIG.

A vendor, health plan and hospital system are also referred to but not yet named.

Here's what we do know.

The pilot program would provide Medicare Advantage plan pharmacists who conduct medication therapy management services with new technology that would permit real-time access to the discharge information, the letter said.

[Also: CMS expands Medicare Advantage value-based insurance design model]

The goal is to gain insight into the degree to which technology that provides pharmacists with this information can help improve transitions of care and decrease readmissions, the letter said.

The name of the pharmaceutical company was redacted in the letter and not named. Also, no MA plan has been identified, and no specific provider or vendor was named in the letter.

[Also: AHIP thanks CMS for adding flexibility in 2019 Medicare Advantage and Part D rule]

The vendor would provide the technology interface. It would be a company that currently works with hospitals to provide electronic medication and discharge reports, fill/refill information and which helps identify patients at high risk for medication non-adherence.

From the interface, the participating MA plan's pharmacists could view relevant clinical data elements taken directly from the hospital system's electronic medical record.

One issue with the program could be the potential for the arrangement to generate prohibited remuneration under the anti-kickback statute, if the intent was to reward referrals of federal healthcare program business, the OIG said.

Robert DeConti, assistant inspector general for Legal Affairs said the OIG would not impose administrative sanctions against the drug company for what it has proposed in the request.

The pharmaceutical company would fund and evaluate the collaboration between the MA plan, hospital system and vendor.

Information would be reviewed for those patients who were admitted to the hospital with one of the five diagnoses that are eligible conditions under the Hospital Readmission Reduction Program, including pneumonia, congestive heart failure, acute myocardial infarction, chronic obstructive pulmonary disease, and elective total hip or knee arthroplasty.

The drug company said it manufactures only two products that treat or prevent any of these eligible conditions, and one of the products is a vaccine.

Services provided under the pilot program would apply to any drug therapy taken by eligible patients, including both brand and generic alternatives.

The pharmacist would review all of the patient's medications, contact the patient's retail pharmacy, interact with the patient's providers, recommend adjustments to the patient's medications as needed, and contact the patient directly to ensure that the medications being taken are the appropriate usage.

The drug company would provide funding for the pilot, not to exceed $275,000, to contract with the hospital system and MA plan, deploy the interface, complete data analytics, a project summary and a training and the implementation toolkit.

It would not influence formulary decisions or have any role in the interface beyond funding, the letter said.

[Also: Hearing for HHS nominee Azar dominated by drug pricing issue]

The MA plan selected would be an MA-Prescription drug plan, responsible for covering its members' Part D drugs, and would not be selected based on its use of, or prescribing patterns, the letter said.

Among other data, the MA plan would track the number of discharges, percent of male vs. female patients, the percentage of interventions delivered within 24, 48, and 72 hours, and various outcomes.

The hospital system would identify and engage administrators and others needed to align the goals across members of the acute care team. It would also ensure resources are available to identify and recruit patients.

The program is expected to evaluate at least 200 patients. If successful, the pilot would be used to develop a training and implementation toolkit that could be provided to managed care professionals.

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