Annals of Long Term Care

Presidential election aside, medication management under Medicare promises to see some major changes that will affect access to medications in the coming year. This at a time—or perhaps because we are in a time—of increasing demand for access to innovative medications by an ever-expanding group of Medicare beneficiaries.

In a question-and-answer format, this article will highlight the major areas of change that are occurring to medication management within all parts of the Medicare program:

• Medicare Part A, which covers hospitalization, subacute services, and hospice
• Medicare Part B, which covers provider services and a few vaccinations
• Medicare Part C, or the Medicare Advantage managed care program
• Medicare Part D, the outpatient medication benefit

All aspects of the Medicare program affect medication management, especially for injectible medications.

Medicare Part A: Hospital Insurance

Q: How will changes in hospital reimbursement affect prescribing?

A: After more than 40 years of paying for preventable mistakes, Medicare is ceasing the practice. As a result, hospitals will no longer be paid for mistakes that occur during a hospitalization. This is but the first step; Medicare is closely looking at penalizing hospitals for readmissions that occur within 30 days of a hospitalization for the same diagnosis or a complication of the original diagnosis. This change in reimbursement of holding hospitals accountable is already having an effect on some providers and will likely have far-reaching effects in the near future.

Cardinal Health, Inc., one of the nation’s top drug wholesalers, expects its newer hospital supply and equipment businesses to grow faster as a result of Medicare tightening rules for no longer paying for “preventable” conditions, mistakes, and infections resulting from a hospital stay.₁ The majority of that growth will come from technologies for hospital automation systems for medicine and supplies. Even more important from a long-term care perspective is the expectation that hospitals will be forced to take a closer look at transitions of care. Medicare is deeply concerned, as pointed out in reports from MedPAC, about the readmissions that are common among Medicare beneficiaries within a 30-day timeframe. As mentioned above, hospitals may be penalized for readmissions that occur for the same diagnosis or complication of the original admitting diagnosis. This is likely to result in hospitals playing a more critical role in assuring that patients have access and understand their discharge medications. Compliance with the discharge plan, or rather lack of compliance, is often a cause for readmissions. This increased attention is likely to result in improvement in medication management at the time of discharge.

Q: What medication carve-outs exist within Medicare Part A?

A: While many believe that during a Medicare Part A stay all medications are included in the payment for that stay, there are exceptions. As in the case of hospice, Medicare Part A stays only include responsibility for medications that are related to that stay. The most significant outlier during a Medicare Part A stay are vaccinations. Vaccines that are rendered during a Medicare Part A stay are covered under the Medicare Part D or Part B program. Medicare Part B will continue to cover pneumococcal, influenza, and hepatitis B, while Medicare Part D will cover all other vaccines, including not only the medication but also the administration cost.