The Pharmacy and Medically Underserved Areas Enhancement Act, or Provider Status, was introduced into Congress about a month ago and since that time we have seen a flurry of discussion about the bill. Advocates are sending letters and meeting with their members of Congress to discuss the importance of this bill for Medicare beneficiaries in underserved areas across the country. Although we are seeing progress with 32 cosponsors on the House and Senate bill combined, there is still a lot of work that needs to be done before this bill will pass. Despite many being excited for this bill, nothing in the bill text has changed since its introduction in the 115th Congress and we expect that the primary opposition to the bill will remain that the cost is too high. This week, we break down why Congress thinks services pharmacists provide are so expensive and how we can prove them wrong.
The Congressional Budget Office
So, you may be asking yourself, “How does Congress determine how expensive a bill is going to be?” There is an entire office dedicated to just this, referred to as the Congressional Budget Office (CBO). The job of the CBO is to score a bill or determine its cost to the federal government should the bill become law. Usually, this cost estimate is for a five to ten year time frame. All bills introduced into Congress ideally would receive a score, however, due to the thousands of bills introduced into each session, the CBO is not able to score all bills and must prioritize which bills will be scored. If a bill does not receive an official score, sometimes the CBO will share an unofficial estimate of the cost of a bill with bill advocates and sponsors to give them an idea of the estimated cost of the legislation but is not officially or publicly reported. However, all bills that are signed into law must receive a score from the CBO.
The CBO has faced criticism for scoring bills too high because their analysis does not factor in for the potential of cost savings. An example of this came from a study from The Commonwealth Fund which found that the CBO underestimated cost savings that would come from healthcare reform. The CBO has never officially scored The Pharmacy and Medically Underserved Areas Enhancement Act, however, they have provided unofficial estimates in past sessions indicating that the bill was expected to be very expensive. The concern around this cost has been one of the primary points of opposition the profession of pharmacy has faced when trying to move this bill forward. Given the criticism of the CBO, this high price tag is likely inflated because they are not factoring in the potential for long-term cost savings associated with pharmacist provided care.
Conflicting evidence on the value of pharmacists
If someone was to only look at the cost implications (and not cost savings) associated with pharmacist’s services, the idea of adding another provider group to Medicare could sound very expensive and like a bad idea. Let’s do an experiment to showcase this. Let’s pretend that provider status passes, but participation in the pharmacy profession is low and only 5% of pharmacists are billing for services. Let’s pretend that patient interest is also low and these pharmacists are only seeing 3 patients a week, a very simple patient (billed as a 99211), a slightly more complex patient (billed as a 99212), and a more complex patient (billed as a 99213). Only 5% of pharmacists only seeing 3 patients a week billed at 85% of the Medicare physician fee schedule can’t cost the government that much…right? Well, our little experiment would cost over $122 million every year. Remember, this is assuming extremely poor pharmacist and patient participation and still it’s costing millions of dollars annually.
So, no surprise if you look at it this way, it seems like it would be incredibly expensive. But this doesn’t factor in the known cost savings associated with pharmacist provided care. There have been numerous studies that showcase the long-term cost savings that come from pharmacists being more involved in patient care. This can come from simple interventions like switching from an expensive medication to a therapeutically equivalent cheaper option or from patients having more controlled chronic conditions decreasing the incidence of future expensive complications, hospitalizations, and medications.
It seems like one of the primary points of opposition to the Pharmacy and Medically Underserved Areas Enhancement Act is the CBO estimated high cost of the bill. However, this high cost is not taking into account cost savings which may bring down the cost of the bill to a more palatable level for members of Congress. If only there was a way for pharmacists to advocate for the CBO to factor cost savings into their analysis. Well, you’re in luck, there is!
An indirect way to advocate for provider status
The Preventive Health Care Savings Act (S. 1685) was reintroduced into Congress this past week. This bipartisan supported bill would require the CBO to factor cost savings into their score of a bill if requested by certain members of Congress. InsideHealthPolicy covered the reintroduction of this bill, and that its focus is in preventive care which is known to decrease costs and should be factored into the CBO analysis. By factoring in cost savings into the CBO estimate, there is potential that this could impact the CBO score of the Pharmacy and Medically Underserved Areas Enhancement Act. This bill has been introduced in past sessions at which time the American Pharmacists Association (APhA) has supported it.
While pharmacists are directly advocating to their members of Congress for the passage of the Pharmacy and Medically Underserved Areas Enhancement Act, they should additionally consider advocating for The Preventive Health Care Savings Act. This bill has the ability to indirectly impact the primary point of opposition for pharmacist provider status and could help in the passage of provider status and future health policy bills important to pharmacists.