As appeared in McKnights.com
By Susan Janeczko
NCPA Director of LTC Regulatory and Policy Affairs
National Community Pharmacists Association
Some 59% of community pharmacies provide critical long-term care (LTC) services to patients and 100% of them face unprecedented challenges as 2011 gets into full swing. Rising health care costs and soaring budget deficits are exacerbating the already significant downward pressure on provider reimbursement. New government regulations complicate operations. All this as U.S. demographic trends would indicate that LTC pharmacies are needed now more than ever.
High up on the uncertainty list for LTC pharmacies is the so-called "short cycle rule." Section 3310 of the Patient Protection and Affordable Care Act (or health reform law) required changes in LTC dispensing methodology intended to "reduce waste associated with 30-day fills." In response, the Centers for Medicare and Medicaid Services (CMS) proposed requiring all LTC pharmacies to dispense brand name medications to enrollees in no greater than 7-day supplies.
But is the cost savings associated with the dispensing of smaller quantities of medications worth the increased costs of pharmacy and nursing time to dispense and check in medications three more times per month? No one really knows. More data are required about the costs and benefits of 7-day-or-less dispensing, and a study or pilot should be utilized to test different types of dispensing techniques. LTC pharmacists should get engaged in the policymaking process and work with Congress and CMS to implement the right policy to produce the least waste and provide the most systemic savings.
To help quantify the costs associated with short-cycle dispensing, our organization is conducting an LTC-specific, cost-of-dispensing study. Without such data, it's difficult to evaluate policies like short-cycle, much less to ensure accurate and appropriate LTC dispensing fees are paid by states and third-party insurers.
Providing enhanced patient care services to Medicare Part D long-term care residents, such as specialized packaging and delivery services, is required by the Medicare Prescription Drug Benefit Manual and differs substantially from the paradigm of retail dispensing. Pharmacists must be able to quantify the additional effort necessary to provide these services to residents in LTC facilities to help ensure these patients receive needed high-quality and timely care.
In addition, virtually any LTC pharmacy reimbursed by third-party insurance companies can attest to the need to reform the seemingly abusive business practices of the pharmacy benefit manager (PBM) industry. Transparency is paramount because, as the profit margins of PBMs increase, plan sponsors, patients and pharmacies are being squeezed and kept in the dark. Limited PBM disclosure requirements, as mandated for certain plans in healthcare reform, would offer plan sponsors neutral data with which to evaluate their prescription benefits and help deter costly PBM tactics, such as switching patients to a more costly drug to pad profits.
Other remedies include identifying on a weekly basis sources for maximum allowable cost (MAC) pricing and reimbursement benchmarks; ending PBM ownership conflicts of interest by preventing PBMs from mandating that patients use a specific pharmacy in which they have an ownership interest (or vice versa); and prohibiting the offering of incentives to encourage patients to use only the PBM-owned mail order pharmacy or its commonly owned but inconveniently located retail chain pharmacy.
In terms of PBM audits of pharmacies, more fairness should be introduced into the process, such as prohibiting statistical extrapolation of results and offering a written appeals process, to allow legitimate pharmacy oversight, while letting pharmacists focus on patient care.
Providing needed medications to LTC patients in a timely manner has become more difficult due to recent changes in the interpretation and enforcement of the Controlled Substances Act by the Drug Enforcement Administration (DEA). The standard of practice of allowing the nurse to relay information between the physician and the pharmacist has been upended. U.S. Senator Herb Kohl, D-Wisc., has led commendable efforts to rectify the situation, but the problem is far from resolved. LTC patient advocates and pharmacists should stay engaged to make sure LTC patients are not put in the untenable position of not being able to get badly needed pain medication because of bureaucratic hurdles.
While challenges abound, in each lies an opportunity for LTC pharmacists to tell their story and increase recognition of the critical, cost-saving care that we provide. By striving to get better legislative and regulatory outcomes, we believe that LTC pharmacies will be able to not only survive, but thrive.
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