Aid­ing phar­ma­cists

New law has pro­vi­sions that will ben­e­fit pa­tients

Modern Healthcare - - Opinions Commentary - Bruce Roberts Ex­ec­u­tive vice pres­i­dent and CEO Na­tional Com­mu­nity Phar­ma­cists As­so­ci­a­tion Alexan­dria, Va.

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. <<

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