The Patient Protection and Affordable Care Act is already changing health care. Perhaps best known as Obamacare, the law has survived 30-plus votes to repeal or defund it, been upheld as constitutional by the U.S. Supreme Court and moved toward full implementation in the face of widely expressed public disapproval.
Almost unreported is the potential many PPACA provisions have to change everyday practice for community pharmacists.
Here, American Pharmacists Association and the National Community Pharmacists Association executives highlight how Obamacare is already reshaping the health care landscape for America’s most accessible medical professionals. They also identify which provisions need to be clarified or changed to allow pharmacists to contribute as fully as possible to increasing patients’ access to care, reducing medication costs and preventing illness.
Closing the Medicare Part D Donut Hole
Almost immediately, the PPACA exempted many independent community pharmacists from a Medicare rule requiring all sellers of durable medical equipment, prosthetics, orthotics and supplies to become accredited. NCPA Senior Vice President of Government Affairs John Coster, PhD, RPh, said this allowed pharmacies generating less than 5 percent of revenues from DMEPOS sales to continue meeting patients’ critical health needs without incurring the cost of complying with duplicative regulations.
Coster also said the gradual closing of the prescription drug coverage gap for Medicare Part D beneficiaries that began under the PPACA in 2011 has proceeded smoothly.
“It hasn’t presented too many problems we’ve heard about,” he said.
“The pharmacists front the discounts to patients in the donut hole, and plans must reimburse them within 14 days of receiving claims. The plans are paying on time so far. We’ll have to see if that continues when the donut hole closes completely in 2014.”
A Medicaid Muddle
Medicaid changes under PPACA could also be coming -- with an emphasis on “could.”
The PPACA gives states the option to expand Medicaid coverage to all people in households with annual incomes up to 133 percent of the federal poverty level. A few governors said they would not accept federal subsidies to do so, a larger number have taken a wait-and-see approach, and a smaller number plan to increase Medicaid enrollment.
“What pharmacists see with Medicaid will depend entirely on what state they practice in,” observed APhA Senior Vice President for Government Affairs Brian Gallagher, RPh, JD. “But even in states that decide not to cover more Medicaid patients, there are still issues with how the Medicaid programs will decide what the product costs and what is an appropriate dispensing fee that need to be worked out.”
Coster, with NCPA, also pointed to the need for ironclad Centers for Medicare & Medicaid Services rules that ensure accurate price and volume reporting to regulators who base pharmacy payments on those data.
“One of the proudest achievements for us was getting standards into the PPACA for PBM transparency, especially on rates of generic substitution. Getting those numbers will help us make our case on how much money pharmacists save patients and payers.”
Alternative Patient Care Models and MTM
The real sea change from the PPACA is likely to come with the launch of Accountable Care Organizations, medical homes and other alternative patient care models. CMS created its Center for Medicare & Medicaid Innovations in 2010 and has already awarded a variety grants and contracts for implementing such programs.
Defining ACOs et al. is beyond the scope of this article, but APhA Senior Vice President for Professional Affairs Anne Burns, BSPharm, said, “We’re seeing an opportunity for pharmacists to get involved in these emerging care models. Physicians are increasingly recognizing that including pharmacists on the health care team is valuable for services such as managing complex medication therapies, providing patient education, and reducing medication costs and prevent problems with drug therapy."
She added that "Implementing payment structures to support pharmacists' involvement in these models is a key focus of APhA right now. All the health value literature points to prevention being the key to improving patients' health outcomes.”
Also recognizing the ensuring pharmacists can receive reimbursement for operating within an ACO or other collaborative care organization, the National Association of Chain Drug Stores has pressed Congress to pass S. 274, the Medication Therapy Management Empowerment Act, and H.R. 891, the Medication Therapy Management Benefits Act. Both address paying pharmacists to provide MTM services, but the bills stand slim chances until a new Congress is seated and the proposals are resubmitted in 2013.
Getting involved at the local level will be key for community pharmacists, according to Burns. “ACOs and medical home practices are built at the local level so pharmacists need to be aware of what is happening in their communities. Outreach to state pharmacy associations, local physicians, community organizations and payers is critical to learning what opportunities are out there,” she said.
As an example of how pharmacists are already providing innovative patient care, NCPA’s Coster pointed to his association’s Simplify My Meds adherence initiative. Casting a wider net, APhA devotes an entire section of its website to MTM.