Deeper Than the Headlines: The OIG Update: Advisory Opinion December 2017

The OIG posted their most recent advisory opinion (AO) on Dec. 11th, 2017. Let’s talk about it. The AO is a response to a proposal by a pharmaceutical manufacturer to collaborate with a trade association, a Medicare Advantage plan, and a hospital system. They want to collaborate in order to implement, fund, and evaluate a pilot program to provide the Medicare Advantage plan pharmacists who conduct medication therapy management services with new technology that would permit real-time electronic access to patient discharge information.

Under the proposal, the pharmaceutical company, the trade association, and the vendor, would collaborate with the Medicare Advantage plan and hospital system to implement, fund, and evaluate a pilot program. The Pilot Program would provide the MA Plan pharmacists who conduct medication therapy management services with real-time electronic access to certain discharge information for qualifying MA Plan beneficiaries.

According to Requestor, one goal of the Pilot Program is to gain insight into the degree to which technology that provides pharmacists with real-time access to discharge information can help improve transitions of care and decrease re-hospitalizations. Requestor certified that the Pilot Program would focus on MA Plan beneficiaries who were admitted to the hospital with one of the five diagnoses that are eligible conditions under the Hospital Readmission Reduction Program: pneumonia, congestive heart failure, acute myocardial infarction, chronic obstructive pulmonary disease, and elective total hip or knee arthroplasty. The Vendor would develop and make available an interface from which the participating MA Plan’s pharmacists could view relevant clinical data elements, taken directly from the hospital system’s electronic medical record, in real time, for eligible patients discharged from the participating hospital system.

Patients’ eligibility would be determined based on objective measures: discharge condition, MA Plan enrollment, and eligibility for MTM services. The MTM services provided under the Pilot Program would apply to any drug therapy taken by eligible patients, including both brand and generic alternatives. Requestor certified that MTM pharmacists would review patient information and, if the patient meets existing MTM eligibility standards or the pharmacist otherwise determines that MTM services would be appropriate for the patient, then the patient would receive MTM services under the Pilot Program. As part of these services, the MTM 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 interact directly with the patient to assist with the MTM enrollment process and ensure that the patient understands which medications he or she is taking and appropriate usage.

The OIG concluded that based on the facts certified in the request for an advisory opinion that, although the Proposed Arrangement could potentially generate prohibited remuneration under the anti-kickback statute if the requisite intent to induce or reward referrals of Federal health care program business were present, the OIG would not impose administrative sanctions in connection with the Proposed Arrangement.

Keep in mind, that just like all of the OIG’s advisory opinions, this opinion is limited to the Proposed Arrangement and, therefore, they do not express an opinion about any ancillary agreements or arrangements disclosed or referenced in the request for an advisory opinion or supplemental submissions. This opinion may not be relied on by any persons other than the requester of this opinion.

Questions or Comments?