Health Care Reform’s Pharmacy Provisions Help Patients

April 26, 2010

As published in abbreviated form in Modern Health Care
By Bruce T. Roberts, RPh
Executive Vice President and CEO
National Community Pharmacists Association 

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 health care reform law? 

At the risk of oversimplification, local pharmacists' health care priorities fall into two broad categories: the urgent challenges of the health care 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 (H.R. 3590) 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 – H.R. 3590 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 (PBMs), like CVS Caremark, Medco Health Solutions and Express Scripts, Inc., 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 multi-billion dollar corporate giants that erected a mind-numbingly complex drug payment system. A growing chorus of critics alleges that the current system primarily fuels record PBM profits without adequately controlling costs. The new law requires modest transparency from PBMs so that plan sponsors and the government can more easily ensure that PBMs don't keep too much of the money passing through their hands. Transparency helps to level the playing field between mail order and community pharmacy by encouraging plans to hold PBMs accountable for excessive profits and the tactics used to drive those profits up.

Looking to the health system of tomorrow, community pharmacists can play a critical role in reducing the estimated $290 billion in health care expenditures that result from inappropriate medication use or non-compliance. H.R. 3590 includes a medication therapy management (MTM) grant program that will help test new and innovative methods to provide MTM, which has been shown to work best at the local level, with pharmacists with whom patients can identify. 

The new law is far from perfect. Independent pharmacists are small business owners and have serious concerns about whether the legislation does enough to help them continue to provide health care for their employees. Pharmacies serving long-term care patients would be required to purchase expensive new equipment that puts independents at a disadvantage. And there's much to be determined as to how the new health insurance exchanges would work and how they would affect pharmacies. 

The overall verdict on health care reform is still out and, in a sense, the debate has just begun. But H.R. 3590 contains some pharmacy provisions that will be positive for patients and the community pharmacists who serve them. 

The full article can be found in modernhealthcare.com.

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