New law has provisions that will benefit patients
The ink has dried, the klieg lights cooled and Congress has turned the page to other issues—so what’s a community pharmacist to make of the new healthcare reform law? At the risk of oversimplification, local pharmacists’ healthcare priorities fall into two broad categories: the urgent challenges of the healthcare system as it is today and the vision of how it should be in the future.
Let’s start with the here and now. The Patient Protection and Affordable Care Act includes a number of pharmacy provisions that will help community pharmacists and the patients who rely on them:
■ Reasonable Medicaid reimbursement for generic drugs. A plan to pay pharmacists at rates well below even the acquisition costs for the generic drugs they dispense has been blocked by court injunction since 2007 (the result of a suit filed by the National Community Pharmacists Association and the National Association of Chain Drug Stores). But unlike Big Box stores, independent pharmacies rely almost entirely on prescription sales to stay in business and serve twice as many Medicaid recipients. The new law scales back those generic drug cuts and sets reimbursement at a practical level that will keep more Medicaid patients in local pharmacies instead of costly emergency rooms.
■ Relief from Medicare Part B accreditation requirements. The law includes a sensible compromise to crack down on fraud while ensuring patient access to legitimate medical services. Diabetes testing supplies and other “durable medical equipment” make up only a small portion of pharmacy sales, yet Medicare was demanding that all pharmacies go through an expensive, time-consuming process to continue providing those goods. A number of pharmacies simply couldn’t justify the costs of accreditation and were leaving the market—creating access concerns for patients. Now most legitimate pharmacies have been exempted while barriers remain in place to deter would-be fraudsters.
■ No more coverage gap in the Medicare drug benefit. Without fail, every year millions of surprised seniors ask their pharmacists why their pharmacy bill suddenly exploded in cost. They’ve fallen into the Medicare Part D benefit’s coverage gap or “doughnut hole” in which the patient pays the full cost of drugs until the catastrophic coverage kicks in. In 2010, these patients will receive a $250 rebate. Starting next year, patients will pay 50% of the drug’s cost in the coverage gap, a figure that will gradually lessen in coming years.
■ Limited disclosure requirements for prescription drug middlemen. Pharmacy benefit managers, such as CVS Caremark, Medco Health Solutions and Express Scripts, are hired by many health plan sponsors and insurance companies to administer drug coverage and many operate mail-order pharmacies. They’ve grown from small-time claims processors to multibillion-dollar corporate giants that erected a mind-numbingly complex drug payment system. <<