The Federal Retail Pharmacy Program for COVID-19 Vaccination will launch this week with a goal to increase access to the vital vaccination across the United States. Early on in the pandemic, pharmacists were identified as trusted members of the health care team to provide testing and education to the public. As vaccines have become available, some states have already engaged pharmacists to assist with vaccination efforts, however, there have been calls to better utilize pharmacist in these efforts. This program will expand pharmacies’ access to supplies and pharmacist’s opportunity to make an even greater impact on the pandemic.
What is the Federal Retail Pharmacy Program for COVID-19 Vaccination?
This collaboration between the federal government, states, and numerous national pharmacy partners and networks of independent pharmacies, is part of the strategic plan to help meet President Biden’s goal of administering 100 million vaccines during his first 100 days in office (18 days into his term, 40.5 million doses have been administered in the US). Initially, select community pharmacies will receive limited supplies of the vaccines, the allocation of which is dependent on the number of people in the jurisdiction, number of pharmacies, and reach. For a complete list of participating pharmacies, and which pharmacies based on location will have supply during the roll-out phase, please visit the CDC website. Pharmacies who are not enrolled in the Federal Retail Pharmacy Program can enroll directly with a state or territory’s immunization program to offer vaccination in their communities.
In addition to improving access, the program is believed to decrease logistical and operational burdens on state, local, and territorial health departments, as the vaccines will be provided directly to the pharmacies from the federal government. The CDC is also offering the Pharmacy Transfer Program, which allows states and territories to transfer allocated vaccine doses to the federal pharmacy partners. However, the states will remain responsible for determining the eligibility of the patients and phases of rollouts within the communities.
Although this program may be a step in the right direction to improve access to vaccines, the initial list of participating pharmacies is restricted based on limited supplies, and new programs do not come without anticipated challenges. For patients who have not received services at the limited number of pharmacies with access, the pharmacy team will need to take time to create new patient profiles, including adding and assessing allergies, current conditions, medication regimens, and insurance information. The pharmacy team will also need to document vaccine administrations to ensure appropriate tracking, all while maintaining the high level of chronic and acute care needs required by patients.
In our opinion, the biggest challenge we continue to face during this pandemic remains equitable access for all populations, especially our most vulnerable communities. Although the CDC states that they will continue to collaborate with states and territories to shift vaccine inventory as needed to ensure fair access, how can we ensure equitable administration of the vaccines?
Goal: Improve equitable access to vaccines
The Biden Administration states that the Federal Retail Pharmacy Program is a key component of the Administrations’ strategy to expand equitable access to vaccines for the American public. But will it?
The CDC worked with states and territories to select initial pharmacy locations that would provide access in the communities. Factors that were considered included the “number of stores, the ability to reach some of the populations most at risk for severe illness from COVID-19 (those over 65 years of age, socially vulnerable communities), and alignment with their existing vaccination plan.” Despite vaccine availability in these communities, there’s no guarantee the vaccines will be administered to the most vulnerable populations and providing vaccines in socially vulnerable communities may not prevent people from wealthier neighborhoods from signing up for doses at these locations.
Additionally, people in underserved neighborhoods continue to experience barriers, including lack of transportation, ability to take time off from jobs to get to appointments, and skepticism about the vaccine, which this program does not address. The CDC does note that this program relies on a collaboration with public health departments to encourage individuals to receive the vaccine and community outreach to educate on the importance of vaccination and where vaccines are available, though no specific plans are outlined. Furthermore, access to or difficulty navigating registration websites, or even the access to check online to see if a local pharmacy will be administering the vaccine, remains a barrier.
Pharmacists are highly trusted and trained professionals to help with vaccine administration and increasing supplies of vaccines in the pharmacies may help, but innovative approaches such as mobile vaccination vans and partnerships with faith-based organizations may be key to overcoming some of the barriers that remain to equitable access to the vaccine
It is hard to believe, but we at The Grassroots Pharmacist have been putting out content and resources for nearly a year. During the first year of the pandemic, we saw such dramatic health policy changes happening so frequently that it warranted continual blog posts on all that was changing. As we look forward, and less frequent health policy changes occur, we wanted to identify a more sustainable way to inform and empower pharmacists to be involved in grassroots advocacy efforts. That is why we will be publishing a monthly roundup of legislative and regulatory updates relevant to pharmacists moving forward. Many of the topics discussed on these monthly roundups should not only be viewed as us sharing information with our readers, but as calls to action to increase civic engagement and discourse on issues that directly and indirectly relate to pharmacists and the communities we serve. There is so much room for improvement in the healthcare system, and active civic engagement is necessary to ensure advancements in the delivery of quality, equitable, and accessible healthcare.
So with that, let’s get started. There is no time like the present to advocate for the change we hope to see in the world.
There has been a lot of action in the new Congress with the reintroduction of bills that died at the conclusion of the last Congress and discussions on the next COVID package. Here are a few of the top bills we are tracking:
Of course, much of the focus of Congress and the new administration has been on President Biden’s American Rescue Plan. This $1.9 trillion stimulus package is planned to move forward in the coming weeks utilizing the budget reconciliation process in order for Democrats to pass the law without any Republican support. Key provisions of this bill that are relevant to pharmacists include:
The creation of a national vaccination program that would include the creation of community vaccination sites nationwide. Pharmacists have already been tapped by the administration in expanding COVID vaccine efforts, and would likely be a key piece of this national vaccination program
Increasing equitable access to the COVID vaccine by ensuring access to those in underserved communities
Expand access for employers of frontline workers to Occupational Safety and Health Administration (OSHA) grants to ensure workers are protected from unsafe working conditions
Expand the subsidization of COBRA health benefits through September for those that lost employment and thus health coverage during the pandemic
S. 298: Pharmacy Benefit Manager Accountability Study Act
Introduced by Senator Blackburn (R-TN), this bill would require the Government Accountability Office to study the role of pharmacy benefit managers (PBMs) in the drug supply chain and submit a report to Congress. This bill was introduced in the last Congress (S. 1532/H.R. 3223), though it did not make any progress and gained minimal cosponsors. If the language of S. 298 is consistent with the last version of the bill, the report that would be submitted to Congress would include 1) the state of competition in the PBM industry, 2) the use of rebates/fees by PBMs and who the rebates benefit (patients, payors, or PBMs), 3) if PBMs structure formularies to prioritize high-rebate drugs over lower-rebate drugs, 4) average prior authorization time, 5) analysis of step therapy, and 6) the extent of spread pricing.
The bill has been referred to the Senate Health, Education, Labor, and Pensions (HELP) Committee, which is chaired by Senator Patty Murray (D-WA). Although Senator Murray has supported legislation in the past that looked to reign in PBMs, S. 298 is currently only supported by Republicans, giving it a low likelihood of being prioritized for a committee hearing. If the profession of pharmacy would like such a bill to advance, grassroots efforts should be focused on drumming up bipartisan support for the bill, especially for constituents whose members serve on the Senate HELP Committee.
H.R. 153: Protecting Consumer Access to Generic Drugs Act
Introduced by Representative Bobby Rush (D-IL-1), this bill would prohibit brand name drug manufacturers from paying generic drug manufacturers to delay bringing generic drugs to market. This is one of those bills that leaves you scratching your head and thinking, “Wow…we need a bill for this? This isn’t already illegal?” Well, unfortunately it’s not, and the Federal Trade Commission estimates it’s resulting in $3.5 billion in higher drug costs per year. H.R. 153 would prohibit drug manufacturers from agreeing not to compete with each other in what is referred to as “pay-for-delay.” Banning these anticompetitive deals would benefit patients by ensuring that they have greater access to generic medications.
Versions of this bill have been introduced since 2007. The current bill has been referred to the House Energy and Commerce Committee and the Judiciary Committee. It has gained 15 cosponsors so far, and according to GovTrack and Skopos Labs has a 46% chance of being enacted, which is one of highest rated probabilities of any health-related bill in Congress right now. However, a companion bill has not yet been introduced into the Senate, which means there are still many steps ahead for this bill if it has any hopes of passing into law.
Introduced by Representative David McKinley (R-WV-1), this bill would create a pilot program in five states to integrate a substance use disorder (SUD) and behavioral health treatment locator tool into their prescription drug monitoring programs (PDMP). This tool could then be utilized by health care providers if they suspect misuse or abuse to refer patients for treatment or an assessment. The language of this bill does not specify which health care providers this would apply to. However, with more than half of states requiring pharmacists to register with their PDMP, it would not be surprising if additional expectations may be placed on the pharmacist as a result of H.R. 280. Assuming the implementation of such a policy is done in a way that does not result in significant more burden on the pharmacist, the profession would be in a key and accessible position to provide counseling to patients for SUD assessment and treatment.
This bill does have bipartisan support, but has gained minimal cosponsors and may not make much progress in the current Congress.
Things have slowed down a bit on the regulatory side as the new administration works to get its legs under itself. Below are some of the big updates over this past month:
A past Obama Administration official, Ms. Brooks-LaSure brings with her decades of experiences including roles in the Centers for Medicare and Medicaid Services (CMS) and the U.S. Department of Health & Human Services (HHS). She previously played a large role in the crafting and implementation of the Affordable Care Act (ACA). Ms. Brooks-LaSure has not spoken publicly in the past regarding pharmacy/pharmacist policy, so it is too early to say where she will align herself on some of the policy priorities of pharmacists. Given her past work on the ACA and the resulting increase in access to healthcare for millions across the country, one could make the argument that she could be supportive of further leveraging health care professionals, such as pharmacists, to further increase access to care.
Delays in effective dates of regulations
A normal course of action for new presidential administrations is to place a regulatory freeze on the work that agencies were completing under the direction of the past administration. There are two regulations that have been delayed in being implemented that are relevant to pharmacists. The first is a program that would have required the use of an electronic prior authorization program for Medicare Part-D covered medications. This rule was set to go into effect on February 1, 2021, but has been delayed to March 30, 2021 in order for the new administration to further review the rule.
The second rule is related to pharmaceutical rebates, point-of-sale of medications reductions, and PBM fees. This rule makes three changes under safe harbor regulations within the anti-kickback statute in the Social Security Act. First, protections will be removed that allow PBMs to reduce the price of medications in connection with the sale or purchase of the medication from manufacturers or plan sponsors under Medicare Part D. Second, protections are set in place for certain point-of-sale reductions in prices. And finally, new protections were added for fixed fees that manufacturers pay to PBMs for the services they provide. This rule has been delayed until March 22, 2021, but may be delayed further due to pending litigation from the Pharmaceutical Care Management Association.
Now is the time to take action
Civic engagement should not be limited to voting at the ballot box. Engaging in grassroots advocacy can happen throughout the year and as legislation and regulation advance. As healthcare professionals, our viewpoints and passion for our communities are important perspectives to our elected leaders. Take this moment to reach out to your elected leaders regarding the issues above, or any issue you are passionate about. Our collective voice and vision for a better healthcare system is exactly what needs to be shared during these times of great potential.
This week you’re going to hear the same two phrases… a lot. Budget resolution and budget reconciliation. We’ve provided an overview of The Budget Reconciliation Process in a previous blog post, but this time we wanted to get a bit more in depth, especially since a closely divided Congress may end up using the reconciliation process more frequently as a way to pass substantial health policy.
The Budget Resolution
Earlier this week, the House Committee on the Budget released the 2021 Budget Resolution, a framework that will guide Congress as it seeks to pass President Biden’s American Rescue Plan, a $1.9 trillion proposal aimed at responding to the pandemic and providing economic security for those affected by its consequences.
Simply put, the main purpose of the budget resolution is to define a process by which Congress will consider budget-related legislation that addresses federal spending, revenue, and debt. While it is true that Congress is required to pass a budget for each fiscal year (October 1 – September 30), this process rarely happens in one bill. Usually, there are multiple budgetary measures that establish fiscal policy.
The Budget Process
Usually the budget process begins at the beginning of each calendar year (January-February), with the President submitting a budget proposal to Congress. While the President’s budget does not have any legal authority, the submission is intended to reflect the President’s policy priorities for the following fiscal year, and offers a series of recommendations related to funding federal programs and changes in revenue (e.g. taxes). This budget also gives Congress a good idea of what the President will or will not sign when the final budget passes both chambers and requires a signature from the President.
After submission of the budget proposal, Congress sets to issue a budget resolution. It is important to remember that the budget resolution itself does not go to the President and cannot become law. The budget resolution instead is an agreement between both chambers of Congress on what the federal budget ought to be and the funding levels delegated to each category of federal spending (e.g. National Defense, Medicare, Social Services, etc.) While it does not have the effect of law, the budget resolution is enforceable in Congress and can be used to contest legislation that is being introduced based on the resolution.
The Budget Reconciliation Process
Sometimes, the budget resolution will include reconciliation instructions that direct Committees to enact legislation within each committee’s jurisdiction to meet agreed upon changes in revenue, spending, or the national debt. These instructions are incredibly specific in that they identify specific committees in Congress, and how much spending needs to be reduced or increased, on programs within that Committee’s jurisdiction. The Committee then has full autonomy on policy changes it takes to meet that target. These policies are then usually bundled together into an Omnibus package and passed through both houses. Omnibus may be an unfamiliar word, but you likely better know past Omnibus bills by their acronyms, like COBRA 85 (Consolidated Omnibus Budget Reconciliation Act of 1985).
One unique aspect of the budget reconciliation process is the fact that unlike regular order legislation, the bills passed through reconciliation are limited to 20 hours of debate and only require 51 votes in the Senate. Usually, bills considered by the Senate have no time limits and require 60 votes to end debate – known as cloture – to be considered for a vote. Because of this rule, the minority party in the Senate can often block bills from being brought up for consideration by threatening to filibuster the bill. The reconciliation process prevents that from happening.
The reconciliation process has been used 26 times by Congress, the most recent being the Tax Cuts and Jobs Act, which passed both houses of Congress and was signed into law in 2017.
Limits to the Reconciliation Process
So if Congress has a method to pass votes with simple majorities in both houses, why doesn’t the majority party use it more often? There are predominantly two reasons. First, the reconciliation process is often seen as incredibly partisan. If one party controls both chambers of Congress, they technically do not have to work with anyone in the other party to enact major policies, as long as they get enough votes to cross a simple majority. This is often seen as divisive and can prevent members from working together on other legislation in the future. As divided as the country is today, Congress does still work together to get meaningful legislation passed (e.g. Surprise Medical Billing).
The other reason is the Byrd Rule. In the mid-1980s, the Senate adopted the Byrd rule to prevent any and all legislation from being added to a reconciliation bill as a result of vague instructions in the budget resolution. The Byrd rule prevents the inclusion of any extraneous provisions in reconciliation legislation and defines extraneous provisions if:
It does not produce a budgetary change
It produces a budgetary change outside of it’s instructions in the budget resolution
It is outside of the jurisdiction of the Committee that proposed it
It is the result of a non-budgetary component
It would increase the deficit beyond 10-years
It changes Social Security
Congress also has limits to the number of times reconciliation can be used. The Congressional Budget Act limits reconciliation instruction to only specific changes in spending, revenue, or debt. The Senate has often interpreted these limitations to mean that reconciliation can only be used to specify changes to each of these categories no more than once per fiscal year. In other words, if Congress passes a reconciliation bill that addresses spending, revenue, and the debt in one year, then they cannot use reconciliation again until the following year.
What Can I Expect This Week
With the House Budget Committee releasing its version of the budget resolution, you can expect the Senate Budget Committee to release its version very soon (if not already by the time this post is published). Once these resolutions pass both chambers of Congress, committees will begin including provisions into a reconciliation bill that meet the instructions from the budget resolution. It is important to remember that the reconciliation instructions have been structured to meet the costs associated with President Biden’s American Rescue Plan. While the reconciliation instructions do not specify which policies the committees have to include, it is likely that the final bill will mirror the policy priorities set forth by the White House.
Once the reconciliation provisions are finalized into one bill, Congress will set to debate. The House of Representatives will consider the bill under special rules to expedite the approval of the bill, while the Senate will consider the bill with a limit of 20 hours of debate. Once debate is over and the consideration of all amendments is complete, Congress will take a final vote. If it passes both Houses, the bill will head to President Biden’s desk some time in the next 1-2 weeks for his approval.
How Does Pharmacy Fit Into This
While the American Rescue Plan does not call out pharmacists specifically, the plan does have significant implications for the profession. The President’s Plan calls for:
$20 billion for a national vaccine program with the goal of vaccinating 150 million people within his first 100 days
Investment in community vaccination sites and mobile vaccination clinics to reach areas where there is inadequate access
$50 billion to scale up testing
Hiring 100,000 new public health workers to support in COVID response activities
Strike teams to address outbreaks in long-term care facilities
Additional funding to community health centers and IHS facilities to address health disparities
$10 billion to expand domestic manufacturing for personal protective equipment
Subsidizing COBRA and expanding tax credits available through the Affordable Care Act
Investment in behavioral health services
Pharmacists, pharmacy technicians, student pharmacists, and pharmacy interns are vital resources that must be used to meet these goals.
However, beyond this bill, reconciliation poses significant opportunities for pharmacy. Of the 26 bills that Congress has considered under the reconciliation process, there are numerous provisions that have brought about changes in payment and scope of practice for health care professionals. Furthermore, the reconciliation process could also be used to fund demonstration projects focused on pharmacist-provided services, later requiring the Secretary of Health and Human Services to issue a report to Congress on the cost-effectiveness of these programs and legislative recommendations.
The Future of Provider Status Legislation
It’s time to recognize that the main pathway to achieve provider status under Medicare Part B over the past decade, passage of the Pharmacy and Medically Underserved Areas Enhancement Act, is over. Despite multiple introductions and a majority of cosponsors in both the House of Representatives and the Senate, the effort has stalled due to concerns over the cost and opposition from the American Medical Association. While our national pharmacy associations continue to seek out additional opportunities engaging with the Centers for Medicare and Medicaid Services, we think that the reconciliation process could lay the groundwork for a new approach.
On January 20th, President Biden was sworn into office, along with Jon Ossoff and Raphael Warnock who were sworn in as Senators representing Georgia. This marks the transition of majority control for both bodies of the legislative branch and the Presidency to the Democrats. The idea of a united government, or one party having majority control, is not rare with ~56% of Congresses and the Presidency (23 Republican, 22 Democrat) being controlled by one party at the same time since the formation of the modern-day political parties in 1861. However, we will note that one party having majority control is decreasing in frequency, with rates falling to 45% over the last 20 years and occuring only a third of the time over the last 10 years.
For years, prominent opinions have expressed that democratic control of Congress and Presidency would be the only hope for any healthcare reform. Now with control of all three seats, we are seeing many news reports of all that is planned to be accomplished. This week, as we prepare for what could be a productive Congress, we review this idea of a united versus divided government’s impact on healthcare bills, and the process by which new bills may move through the current Congress.
Healthcare reform does not require one party control of the government
There have been many bills introduced and passed through Congress that impact the healthcare system. Anecdotally, we have heard from experts, friends, and colleagues (and have even expressed in conversation ourselves), that passage of a major healthcare bill in the U.S. requires one party to have majority control of the government, and likely that party needs to be the democrats. However, as we look to history, we quickly realize that this may not be true. We have compiled a list of major healthcare bills that have passed and the party that held majority control at the time in table 1, below. In table 2 at the end of this article, we provide a more comprehensive, but not exhaustive, list of healthcare bills.
As one can see, despite ~56% of Congresses being majority controlled by one party, most healthcare bills have been passed in a state of divided government. It is important to note that the most major reforms of healthcare in the U.S. did occur when one party controlled the government in 1965 and 2010 with the establishment of Medicare/Medicaid and the passage of the Affordable Care Act, respectively. Relevant to pharmacists, the Medicare Drug, Improvement, and Modernization Act (MMA), which established the Medicare Part D program, was passed in 2003 when Republicans controlled all seats of federal government.
An example of a bill that did not pass during majority control is The Health Security Act, also known as President Clinton’s health plan. The bill was introduced in November of 1993 into the 103rd Congress which had a democratic majority of 82 members (total 258 democrats in the House in 103rd Congress) in the House and 14 members (total 57 democrats in the Senate in 103rd Congress) in the Senate with Democratic President Clinton in the White House. After much debate and media coverage, the bill, which would have been a step towards universal healthcare, was declared dead by then Democratic Senate Majority Leader George Mitchell. The reason for its downfall is multifaceted, however, a large reason is attributed to a series of ad campaigns that rallied public support to oppose the plan. This exemplifies the power of constituent’s voices as advocates and that the public can make an impact on the legislative process outside of just voting at the ballot box. Grassroots advocacy at it’s finest!
As you can see, just because one party controls Congress and the Presidency does not guarantee that a healthcare bill will pass. In fact, the majority controlled by democrats now is slimmer than the majorities when the ACA was passed and when Clinton’s health plan was defeated. The introduction of any healthcare bill is likely going to result in significant debate and it is up to us as constituents and healthcare providers to inform our elected leaders of our opinions on a bill. In an effort to understand where advocacy efforts may be focused over the coming two years, let’s examine how a healthcare bill will likely move through Congress.
How a health bill may move through Congress
There are many complicated rules for how a bill can work its way through Congress. For the purposes of this overview we will not be getting into too much detail (however, if you are interested in learning more click here). The typical pathway is for a bill to first be introduced into both the Senate and the House of Representatives. Following introduction, the bill is then assigned to a committee or a subcommittee. Once assigned, it is then up to the leadership of that sub/committee to determine prioritization of bills to receive hearings. A bill will receive several hearings where proponent and opponent testimony can be heard and legislators can ask questions, debate the bill, and amend the bill. If the leadership of a sub/committee decides to, the bill can be brought to a vote. If a majority votes in favor of the bill, it is then sent to the floor of whichever chamber it was introduced in for debate and potentially a vote. The only difference is if the bill is in a subcommittee, to which a successful vote then moves the bill on to the full committee. If the Senate and House end up passing bills with different language, the bills are then sent to a Conference Committee to reconcile differences in the bills and then are sent to the Senate for a final vote before going on to the President to sign or veto the bill.
Understanding the committee process is incredibly important because this is where most bills “die” or become void due to no action being taken on them before the Congress ends. Knowing the elected leaders on these committees, especially if you are a constituent of theirs, can be vitally important. If a piece of legislation that could improve the healthcare system is referred to a committee, constituents have an opportunity to contact their legislators and advocate on behalf of the profession and their patients. In table 3, we include the most common committees in the Senate and the House that health related bills are referred to and links to the members of each committee.
Table 3: Common committees health related bills are referred to and their members
*The membership of some house committees are still being assigned but the links provided will be the location of committee assignments once updated
Generally, a majority is needed to advance a bill out of the House and 60 out of 100 Senators are required to pass a bill out of the Senate. This need for 60 votes in the Senate is to be able to stop a filibuster, which is one of the only tools of the minority to prevent a piece of legislation from passing. However, there is a word that is prominent across healthcare legislation which indicates a different process used to advance the bills, reconciliation.
Reconciliation is a process by which legislation can be passed if it is going to have a fiscal impact on the government and only requires a 51 majority (instead of the normal 60) in order to pass out of the Senate. This is because rules for reconciliation bills limit debate to a certain period of time, thus essentially banning the filibuster. This is how the bills listed in table 1 and 2 with reconciliation in their name and more prominent healthcare reform bills like the ACA were able to pass. There are additional limitations on the reconciliation process, for example the number of times it can be used by each Congress, which is the reason it is not used for all legislation. However, given the slim majority the democrats hold, any healthcare bill is likely dependent on the use of reconciliation.
Most historical healthcare bills were passed under a divided government, though often using the reconciliation process. Healthcare continues to be one of the most important policy issues, exacerbated by the pandemic, and there will likely be the introduction of a major healthcare bill during the current Congress that could increase patient access to quality affordable healthcare provided by pharmacists and other members of the healthcare team. Regardless of democrats having control of the Presidency and Congress and the reconciliation process, we cannot assume a bill will pass, as exemplified by the Clinton health plan. Grassroots advocacy is needed, especially at the committee level, to educate our elected leaders on our viewpoints of legislation as constituents and healthcare providers. Over the next two years, there will be the opportunity to improve the healthcare system, but a key piece of the advancement of any bill will be dependent on constituents speaking up and advocating for the change we wish to see in the world.
In the final days of the Trump administration, the Centers for Medicare and Medicaid Services (CMS) have finalized a flurry of rules and made announcements that can impact both the profession of pharmacy and the patients of pharmacists. This week, we review these rules and what to look out for as the leadership of CMS switches hands.
Prescription Drug Card for Seniors
Earlier this fall, President Trump signed an executive order (EO) in which he promised to send $200 debit cards ($6.6 billion in total) to seniors to assist them in paying for prescription medications. He claimed under this plan that 33 million Medicare beneficiaries would qualify to receive the assistance, which means over 70% of total Medicare Part D enrollees were set to receive this benefit. In the midst of a pandemic that has had a dramatic economic impact, especially on seniors, the possibility of extra assistance was well received. However, questions quickly arose as to the true impact such a policy would make. For example, if a Medicare beneficiary was in the coverage gap (or donut hole), they have to spend around $2,500 to reach the point of catastrophic coverage.
Although an 8% discount provided by the $200 debit card would likely not be turned away, the burden our seniors face is hardly minimized. This EO brought to the conversation that policy instituting meager debit cards is not the way to help our seniors with the rising cost of medications. Widespread changes are needed in federal policy to lower the cost of medications and ensure unrealistic financial expectations are not passed on to the patient (read about plans from the incoming administration to address this here). In recent days, news sites have reported that the promised debit cards would not be sent out. Although challenging news for seniors that were anticipating the help, we can only hope that with the plan scrapped, the billions that would have gone to these seniors instead goes towards policy changes that may actually address the underlying issue of rising drug costs.
Prior Authorization – but not the one we hoped for
The Patients Over Paperwork Initiative is a Trump-era program launched by CMS Administrator Seema Verma to decrease regulatory burdens in order to increase the efficiency and quality of healthcare delivery. An example of these efforts may be the removal of certain documentation requirements from providers to allow them more time to deliver patient care rather than filling out electronic health records. One of the targets of the initiative has been prior authorization and attempting to find ways to decrease burden on both providers and patients.
On January 15, 2021, CMS announced a major rule that will impact patients, providers, and many health insurers, including Medicaid managed care organizations. This rule requires health insurers to include additional information in application programming interfaces (APIs) that will be used to increase efficiency of prior authorizations. This additional information includes, claims data, lab results, and information about prior authorizations and their statuses. There is hope that this information will facilitate more efficient prior authorizations and decrease repeat unnecessary submissions. Although not specifically mentioned in the press release, upon further examination of the rule, one learns that surprisingly “prescription drugs and/or covered outpatient drugs” are excluded.
Where there may have been hope from pharmacist providers of additional resources to increase efficiency of medication prior authorizations, this rule unfortunately does not move the needle on these efforts, despite creating a façade as if it does so. It was evident from many of the comments included in the rule that health care provider associations were frustrated with this exclusion. Although this rule will not address it, there is hope that change of the prior authorization process for services may result in reevaluation of the medication authorization process in the future. Additionally, many of the comments submitted on this rule were in regard to medication prior authorization, making it challenging for CMS to ignore calls from many of its providers to address issues with the process. The importance here is continuing to voice issues with the process both at the provider level and patient level. There can be hope that continued expressions of the burdens and gaps created in patient care will result in the changes needed to improve the system.
Changes to Medicare Advantage and Part D
One of the final actions taken by CMS leadership in their last days is the expansion of coverage for Medicare Advantage and Part D beneficiaries that hope to lower beneficiary costs, compare costs between different medications, and could save the federal government over $75 million over ten years. Additionally, included in this rule are CMS regulatory changes regarding The Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act.
Regulations specific to the SUPPORT Act are focused on addressing the misuse of opioids. Relevant to pharmacists is that part of the provisions of implementing these rules will allow for the suspension of payments to pharmacies if there are credible allegations of fraud. Additionally, CMS, Medicare Advantage Programs, and Part D plans will be increasing data sharing to decrease risk of misuse and abuse of opioids. More information on these rules can be found here.
New Leadership for CMS
The work of CMS has changed over the past four years, with one of the primary focuses being on decreasing regulatory burdens. In the final days of this administration, large packages of rules are being finalized that have the potential to greatly impact both patients and providers, however, it is unclear at this time the true impact they will have. President-elect Joe Biden has chosen Xavier Becerra to be the incoming Secretary of Health and Human Services. It is unknown at the time of writing who will take the place of CMS Administrator. Given the campaign focus of President-elect Biden, and Mr. Becerra’s history as California’s Attorney General, it can be expected that a strong focus of HHS and CMS will be on strengthening and protecting the Affordable Care Act.
We will have to wait and see how they will work to accomplish this, and what else will be on the table. But if CMS continues the momentum seen in the past several years, we can expect to see continued rapid changes in the rules and regulations that oversee how millions of patients and providers deliver care across the country.
This post will review the various proposals that President-elect Biden plans to implement over the coming years to reduce prescription drug costs.
Medicare Part D drug price negotiations
One of the hallmarks of President-elect Biden’s plan is to allow Medicare to negotiate directly with drug manufacturers as a way to lower prescription drug costs. The Medicare Prescription Drug, Improvement, and Modernizations Act of 2003 (MMA) introduced the Medicare Part D Program, which is the voluntary prescription drug benefit for Medicare beneficiaries. To receive drug benefit, beneficiaries have to enroll in one of the two options: as a stand-alone drug plan (PDP) or as an add-on to Medicare Advantage plan (MA-PD). Medicare provides Part D benefits by contracting with private health plan sponsors that offer standard Part D plans and reimbursing sponsors on a per-member-per-month amount. Plan sponsors are able to compete for enrollees based on their benefit designs, formulary inclusions, and drug cost-sharing. This market competition is protected by the noninterference provision of the MMA which states that the Secretary of the US Department of Health and Human Services (HHS) “may not interfere with negotiations between drug manufacturers and pharmacies and PDP sponsors”. By repealing this clause and allowing the Secretary to negotiate with manufacturers for lower drug prices, President-Elect Joe Biden hopes to decrease federal spending on drugs and render medications more affordable for Medicare beneficiaries.
While the incoming administration has not stated any implementation strategy, evidence supporting the success of federal interventions to control patients’ drug costs are well-documented in European countries. Additionally, propositions allowing price negotiations between the federal government and manufacturers have received wide bipartisan public support. Supporters have stated that employing price negotiations and formulary management strategies comparable to those used by the US Veterans Affairs could lead to Medicare cost-savings of about $14.4 billion. On the contrary, opponents have argued that authorizing federal price negotiations can disrupt the market competition among private payers and undermine research and development; potentially diluting treatment pipelines and patient access to life-saving medications.
External Reference Pricing and Independent Review Board for Specialty Medications
IQVIA, a multinational health information and biotechnology consulting company, reports that 27% of patients who were prescribed a specialty drug did not receive treatment due to unaffordable costs. The recent upsurge in biologics delivered novel therapeutics for diseases with significant unmet needs. Unfortunately, their extremely high costs render specialty medications inaccessible to patients who need them the most. Payers often place specialty medications in higher formulary tiers which require greater patient cost-sharing percentage. Specialty medications administered via infusion or by a physician are covered under Medicare Part B, while self-administered drugs are part of the Part D benefit. Because the patient co-share is not based on a set amount (copay), but rather as a percentage of the drug price, the patients’ out-of-pocket (OOP) costs can generate substantial financial burden.
To control for the skyrocketing launch prices of specialty medications, President-Elect Biden proposed the use of External Reference Pricing (ERP) and an Independent Review Board. ERP, a widely used practice in international markets, utilizes drug prices in foreign countries to calculate for the value which will be set as the benchmark drug price in their own country. President-elect Biden anticipates a potential cost-saving of $72.9 billion for Medicare Part D if ERP is employed to determine the reference price for specialty medications covered by Medicare. Unfortunately, despite the cost savings, the use of ERP has been unpopular in the United States. One reason is that newly approved medications often enter the US market first, automatically rendering ERP as inapplicable.
To confront this issue, the Biden administration recommends the formation of an independent review board. The board, led and created by the Secretary of HHS, will be held responsible to conduct health technology assessments (HTA) to calculate and set the most appropriate price for the drug. Similar to ERP, HTAs are commonly used by European governments in order to regulate prices by identifying the cost-effectiveness indices of patented pharmaceuticals, biotechnology drugs, and medical devices.
While there is no mention of who the independent review board will be composed of, it may be modeled after the Institute of Clinical and Economic Review (ICER). ICER is an independent, non-profit organization that reviews the cost-effectiveness of new treatments and/or health technology products by comparing the products in the same medication class or product category. In a similar fashion, the Independent Review Board will evaluate the drug, align its value with cost, then recommend a launch price for Medicare-covered drugs. As an incentive, private health payers can access the same low launch price if those payers offer health plans in the CMS individual marketplace. Successful implementation of such strategies can decrease both the patient’s out-of-pocket costs and the rate of uninsured patients in America.
Tax penalties for medications priced above the general inflation rate
The President-Elect plans to impose tax penalties on manufacturers who increase prices of pharmaceuticals (both brand and generic) and biologics above the general inflation rate. Though it was not explicitly stated, this proposal resembles a section of the House passed bill: H.R. 3 Elijah E. Cummings Lower Drug Costs Now Act. Under H.R.3, drug manufacturers are required to pay the inflation-based rebates to the federal government if their set medication price demonstrates a trend increase that is faster than the inflation rate. The objective of enforcing tax penalties is to discourage manufacturers from setting immensely high drug prices to maximize product profitability.
A report conducted by the United States House Committee on Ways and Means confirmed that US patients have been paying for medication at a significantly higher rate compared to other consumers from other countries, including American-made drugs. Manufacturers’ narrow revenues in international governments, due to cost-containing strategies, drive the price hikes in the US market. Manufacturers are able to compensate for marginal profits by subjecting US consumers with high-cost medications. Therefore, it is no surprise that such unfair pricing strategies instigated drug importation considerations.
Similar to President Trump, President Elect-Biden intends to permit consumers to import drugs as a means to reduce drug costs. Importation is limited to products that were considered safe by the Secretary of HHS. However, this proposal is widely unsupported and criticized by national pharmacy associations and government leaders of foreign countries, as it compromises patient safety and drug supply without substantial cost-savings.
New Hampshire (D) Senator Jeanne Shaheen introduced a bipartisan-supported legislation that would eliminate tax breaks for DTCPA expenditures. Supporters of the bill End Taxpayer Subsidies for Drug Ads Act, including President-Elect Biden, argue that DTCPA are not necessary and do not qualify for subsidy as it is impossible to learn all of the necessary information of prescription medications in the time duration allotted for DTC advertisements. If passed, the bill will drive down the DTCPA expenditures of manufacturers and (hopefully) discourage its use. However, whether its passage will directly impact prescription drug pricing is uncertain.
Endorse proposals that will increase the supply of generic medications
The law expands access to affordable generic medications by preventing manufacturers from conducting tactics that delay the market entry of generic equivalents. For example, manufacturers may apply for, and are subsequently granted, secondary patent exclusivity for minor formulation modifications, an application that is often completed prior to patent expiration. These damaging tactics can deprive patients of critical life-saving medications since they keep drug prices high. By endorsing proposals spearheaded by other lawmakers, President-elect Biden acknowledges that prescription drug pricing reform requires collaboration and agreement with legislators.
As patient advocates, pharmacy professionals are in a prime position to assist patients and facilitate access to essential medication. Although we can do our best to help patients navigate their prescription benefits, utilize coupons for savings, and apply for patient assistance grants when able, ultimately, the health care system needs drastic reform to reduce drug pricing and ensure adequate access to medications. Knowledge of drug pricing reform and health policy proposals enhances our ability to successfully connect our patients to affordable medication and advocate on their behalf.
Guest Writers Profile
Grace Singson (they/them) is a 3rd year student pharmacist at the University of Southern California, where they are pursuing a dual-degree Doctor of Pharmacy and Master of Science in Healthcare Decision Analysis (HCDA) program. Grace is currently serving as the Vice-President of Professional Conferences, an Affinity Group Liaison, and for the USC School of Pharmacy Student Government Board and the Rx Pride LGBTQ+ Affinity Group, respectively. They are also involved with California Society of Health-System Pharmacists (CSHP), AMCP, ISPOR, CPNP, and Student Committee for Diversity, Equity, and Inclusion (SC-DEI). In addition to health policy, Grace has professional interests in managed care and health economics and outcomes research. They are passionate about optimizing pharmacy practice and medication access to reduce health disparities in marginalized communities.
We hope that each of you are making the most of the season and are finding some comfort in what might be a very different holiday celebration. We here at The Grassroots Pharmacist didn’t anticipate writing an end of the year post, partly because so much of this had been played out and said elsewhere. And while we are all ready to turn the page on this year, we wanted to try and take some time to find things to be hopeful about. There are so many stories of pharmacists advancing health policy this year that gave us pause, gave us a reason to feel happy in 2020, and a reason to be hopeful in 2021.
Make no mistake though, as we reflect on this past year, there’s a lot that comes to mind. There are shared moments of grief, frustration, and sadness. Long anxious nights that turned into lonely mornings. And as we look forward to January 2021, there’s a lot that we are ready to say goodbye to: Zoom meetings and virtual happy hours, social distancing, convincing our patients (and also probably our loved ones) why they need to wear a mask and follow public health guidelines, and if you’re anything like us, Friday evening press releases from CMS. But it says a lot about us as a people (and for our pharmacists readers, as a profession), that despite the hardships of the last year, so many of us remain optimistic and hopeful about the new year. That we remain willing to challenge ourselves and to incorporate the tough lessons we learned this year.
For all of us at The Grassroots Pharmacist, 2020 brought its own challenges both professionally and personally. We experienced the loss of loved ones, weathered the anxiety and stress of trying to care for patients at the expense of ourselves, and fought the daily struggles against anxiety, burnout, and possibly depression. And through it all, we are still trying to find our place in the changing health care landscape and in the profession at large.
However, in the midst of the changes of the past year, each of us on this team found a calling in helping to educate members of our profession on the legislative and regulatory changes taking place during the public health emergency, and empowering individuals to better advocate for their patients. None of us are strangers to advocacy and we recognize the opportunities that exist when everything is changing. None of us expected to be authoring a blog at the start of the year, but looking back, we are incredibly thrilled not only to have this platform, but to have readers that have come along with us as we discussed health policy issues that could have consequential impacts on our profession. Here were some of our favorite posts of this past year:
Posts that Focused on the Expanded Role for Pharmacists
Looking back at 2020, there is no doubt that we will remember the hardships and the struggle. But it’s important that we don’t lose sight of all the great strides that our profession has made. Even beyond these blog posts, it’s important we don’t lose sight of the biggest stories that pharmacy made this year. The stories of pharmacists serving each and every day on the front lines throughout the pandemic. Pharmacists who worked in emergency departments and medical ICUs taking care of patients diagnosed with COVID and saving countless lives. Pharmacists who set up COVID-19 testing sites in underserved communities, often without adequate personal protective equipment. Pharmacists who continue to play a major role in the largest vaccination effort in our nation’s history. Those are the stories that defined 2020 for our profession. And so while we look forward to the new year with a renewed sense of optimism for the profession, this year has reaffirmed that you have great power in your voice to advocate for the improvements in the healthcare system our patients deserve.
A sincere thank you to each of you for being a part of this journey with us. Wishing you the best in the New Year.
Recently, the Journal of the American Pharmacists Association published a secret shopper study describing counseling provided during the dispensing of naloxone at chain pharmacies in Texas. Although it may seem crazy that the average counseling time was only 89 seconds, what was more striking was that any formulation of naloxone was unavailable at almost one-third of the randomly selected chain pharmacies. Keep in mind, this is naloxone, a drug with no major side effects, is responsible for reducing opioid related overdoses by almost 14%, and does not require a prescription in numerous states. Unfortunately, problems with accessing or utilizing pharmacist services are not unique to naloxone dispensing. So why aren’t pharmacies and pharmacists adopting policies designed for accessibility? The long answer involves a lengthy discussion of stigma, discrimination, and logistical constraints. A reasonable discussion requires highlighting the importance of ensuring the decisions made during the policy process allow for efficient and effective policy implementation.
Why is Policy Implementation so Important?
Nurse Practitioners (NPs) interested in expanding their scope of practice use a major talking point that they need independent practice ability so NPs can practice in medically underserved and rural areas and thus increase access to care. However, the American Medical Association recently made a statement arguing that ineffective policy implementation in underserved areas, the main argument many professional groups have utilized to advance scopes of practice, is why these scopes should remain limited and dependent on physicians. You may think this argument is invalid but persistent and equitable implementation issues already exist in states with advanced pharmacy practice, such as those seen with pharmacist-prescribed and OTC hormonal contraception in Los Angeles County.
Successful policy implementation not only has a significant effect on policy outcomes but also agenda setting and issue framing for subsequent issues that follow. Given pharmacists are the most accessible healthcare provider (with most people living within 5 miles of a pharmacy), it is essential pharmacists effectively and efficiently implement expanded scope policies such that these arguments are discredited. If pharmacists fail to do this, policy agendas concerning expanded practice will be much harder to push in the future. Of course, more important than expanding pharmacist scope of practice is the responsibility of pharmacists as healthcare providers to ensure all patients (regardless of their geographic location) are receiving affordable and accessible healthcare. Likewise, if pharmacists truly wish to continue to expand the scope of practice to help provide accessible healthcare to patients in need and serve as better members of interprofessional collaborative healthcare teams, then pharmacists must focus on successful implementation of the initial policies at hand.
What Impacts Policy Implementation?
There are numerous factors which contribute to a policy’s implementation and success. However, when discussing pharmacy practice policy there are three main areas pharmacists are missing in their implementation: comprehensive implementation style, policy feasibility, and policy salience.
There are two main forms of policy implementation styles, top-down and bottom-up. Top down policy implementation follows a more traditional path of governance. Healthcare organizations see this with CMS performance measures. CMS incentives encourage management to require healthcare providers to change their practice behaviors or implement a desired policy/action. Bottom-up policy implementation emphasizes policy decisions that are influenced by the target groups or service deliverers. This is usually seen in patient safety where systems allow individuals to make mistakes and in turn force management to implement new policies. If the failures that result in mistakes go unaddressed and occur frequently, larger policy change may occur through actions by accreditation organizations (e.g. the Joint Commission) or the regulatory system (e.g. CMS or FDA).
Pharmacy organizations utilizing the narrative of patient need for medical access intuitively emphasize a bottom-up policy implementation style. However, pharmacists are utilizing a top-down implementation style at the federal level by focusing on large centralized statutory changes to be further diluted as it gets implemented downstream. This approach often leads to disconnected, uneven, and sometimes ineffective policy implementation, especially regarding issues regulated at the state-wide level like pharmacy practice. Likewise, if a bottom-up argument is going to be made, suggested policies will have to be significantly more responsive to lower level needs. Currently, surveys repeatedly show that needs of pharmacists to implement these services not only revolve around reimbursement but also time constraints, lack of healthcare communication, and much more.
Unless other issues barring the implementation of expanded pharmacy services at community pharmacies are addressed, it is unlikely these services will be implemented in areas with the most need. This brings us to the second missing factor in pharmacy policy implementation: ensuring feasibility. Without appropriate resources, pharmacists will be unable to implement these services across the board. Although provider status will address the issues of payment, if other underlying barriers are not addressed it is unlikely that underserved areas will implement these services due to a constraint in resources. Instead, implementation will mostly be seen in areas with the means to do so. Likewise, pharmacists need to advocate for innovative solutions which allow pharmacies to shift current resources to better fit the policy agenda at hand such as increasing technician responsibilities to focus on administrative functions so the pharmacist can focus on providing care.
Assuming pharmacists address the underlying barriers within pharmacies, it comes down to policy salience to ensure successful usage of these services. Saliency refers to the visibility of a policy to those it impacts. For instance, if prescription prices change for a pharmacy or insurance company due to regulation changes but the co-pay for the patient stays the same, then it is not a salient policy for the patient. In this scenario, the patient is largely unaware this change has occurred since there is minimal interruption to their life. However, if the patient’s prescription co-pay drops then it would become a more salient policy to the patient. A good example of this is how co-pays for birth control dropped after the passage of the Affordable Care Act and subsequently resulted in an increase of birth control usage. In a similar fashion, pharmacists need to ensure expanded services are salient and widely known to the patient to ensure reasonable usage.
Let’s go back to the secret shopper study discussed earlier and apply these concepts of policy implementation. To start, pharmacists dispensing naloxone is already a bottom up policy change stemming from the opioid epidemic. So what could encourage a more equitable implementation? Well the average counseling time was 89 seconds, indicating a possible underlying issue of time constraint. This means future policy should focus on feasibility, which may be addressed by encouraging legislation allowing technicians to practice in more advanced roles so pharmacists have more time to discuss naloxone with patients. The second issue of naloxone being unavailable at one-third of stores could be addressed by increasing policy salience. Pharmacy organizations and pharmacists utilizing ads targeted directly to consumers in locations where pharmacies are not dispensing naloxone, advising them to obtain naloxone from a pharmacy near them, would likely increase the saliency of this policy. This could result in increased demand and force implementation of services at more locations, much like what happened with immunization policies.
Although regulatory and legislative changes can help pharmacists increase the accessibility of care through expanded practice, if pharmacy organizations fail to successfully implement policy, then future agenda setting could be at risk. To avoid this, pharmacists need to advocate for changes at the state level that will make practice expansion more feasible and responsive to the needs of the individual pharmacists and organizations responsible for implementing expanded practice services. Additionally, pharmacy organizations need to make these policy changes more widely known when they occur. If pharmacists truly want to expand patient access to medical services, then they must focus on ensuring successful policy implementation.
Guest Writers Profile
Matthew Westling is a PGY1 Pharmacy Resident at the Ralph H Johnson VA Medical Center. Matthew received his Doctor of Pharmacy and Master of Public Administration from the University of Kentucky. During his time at the University of Kentucky, Matthew was involved with SNPhA, the Kentucky Pharmacist Association, SCCP, Kappa Psi Fraternity inc., Phi Lambda Sigma, and the Student Philanthropy Board. He has a strong interest in policy implementation and research. Specifically, Matthew is interested in how pharmacy practice policy can be best utilized to help correct health inequity/disparities. He believes pharmacists are uniquely positioned to help directly break down barriers to health equity and wants to ensure policy implementation does not leave under-served patients behind.
Wow! We thought things may slow down for a bit after the election, but instead health policy changes seem to be happening more frequently than ever. As rates of COVID surge across the country, it is vitally important pharmacists understand these changes and how they apply to practice. By better understanding these rapid health policy changes, pharmacists will be better informed on how they can currently practice and understand where advocacy initiatives need to be focused to advance patient care in the future.
An important advocacy initiative that we have discussed on the blog is the necessity to establish a sustainable business model for the provision of pharmacist provided patient care services. Although the ability to directly bill for services is a vital goal for the profession (for more see: Why do pharmacists need provider status?), other methods have been employed to allow pharmacists to indirectly bill for their services. One of these methods is for pharmacists to bill incident to a physician for the services that they are providing. For years, there has been a lot of confusion and questions around this indirect billing method. Just last week, the Centers for Medicare & Medicaid Services (CMS) released their annual Physician Fee Schedule (PFS). Within this behemoth of a two thousand page document, it includes key information regarding pharmacist’s ability to bill incident to. This week we review incident to billing and what updates are included in the PFS.
A brief history of incident to billing for pharmacists
Pharmacists billing incident to the physician or nonphysician practitioners (NPPs) is a step in the direction toward provider status. It allows pharmacists to bill insurance companies for services that they would not normally be able to be reimbursed for because they are not recognized as healthcare providers. When this first began, it was a big breakthrough for the profession of pharmacy because it allowed pharmacists to bring in revenue to the businesses that they work for as a result of the cognitive services and medical decision making that they were providing.
Pharmacists billing incident to likely began when the American Academy of Family Physicians (AAFP) sent a letter to CMS asking for clarification if pharmacists could bill incident to physicians. In March 2014, CMS responded by confirming that pharmacists could in fact bill incident to the physician. The ability for pharmacists to bill incident to is consistent with other mid-level practitioners such as nurse practitioners and physician assistants. Although this was trumpeted as a major victory for the profession, there were major roadblocks to pharmacists in all practice settings to be able to utilize this new reimbursement methodology. One of the biggest barriers was the fact that a physician needed to be directly available to the pharmacist when providing incident to services. This was largely interpreted that the physician and pharmacist were in the same physical location and patients were being seen in person. This limited pharmacists billing incident to the physician for telehealth services and created barriers for many community pharmacists that were not practicing in the same physical location as a physician.
Another major barrier to rolling out sustainable programs where pharmacists provided services and billed incident to was regarding a belief that pharmacists could only bill the lowest level of Evaluation & Management (also known as E&M) codes. Normally, in the outpatient setting there are two sets of billing codes that physicians use as the foundation of their patient visits. These are known as E&M codes and the two sets are for new patients (99201-99205) or for established patients (99211-99215). The lower numbers of both of these codes, for example 99201 or 99211, are used for less complex patients, that require less time, and less medical decision making. These lower E/M codes are reimbursed at a lower amount than other E&M codes. As patient visits increase in complexity and time, physicians bill higher E&M codes which are reimbursed at a higher level. This helps to associate the value of services being provided by the physician with a comparable reimbursement amount. Below is a table exemplifying this from the current physician fee schedule of national payment amounts:
After pharmacists learned that they could bill incident to, it quickly began to spread that pharmacists were only allowed to bill the lowest level of return patient code (99211) regardless of the amount of time that a pharmacist spends with the patient or the number of interventions that are made. This information likely came from a regional Medicare Office that provided clarification that pharmacists could only bill these lowest level codes. Obviously, this is not ideal because the level of service being provided by a pharmacist would not align with the amount of reimbursement. This misalignment would create further barriers to pharmacists providing services and growing their practices.
Although information was published from Regional Medicare offices regarding pharmacists only billing the lowest level codes, there was never an explicit justification as to why this was the case. Additionally, it is not clear if all regional offices have provided this information and because of this, depending on the geographical area that pharmacists practice in, some have been billing the higher E&M codes where others have not been able to. There have even been publications (here is one from the Journal of Managed Care Pharmacy) stating that the belief that pharmacists can only bill 99211 E&M codes is simply “not true” (keep reading because this statement is in fact false). This inconsistency in policies from a national health insurance program (Medicare) is abnormal.
As the pandemic hit 2020, many of the regulations on pharmacist practicing and billing for their services have been changed. One of the key updates that we covered previously was the indication that pharmacists would continue to be able to bill incident to the physician for telehealth services. With the publication of the coming year’s PFS last week we have seen more information come out regarding pharmacists ability to bill for services incident to.
How does the PFS change incident to billing?
The PFS is an annual document that outlines the fees that Medicare will be using to pay physicians and other practitioners for the services that they provide. Additionally, CMS will take time to respond to stakeholder questions in order to provide clarification for how to appropriately utilize the PFS. The 2021 PFS can be accessed here.
Relevant to pharmacists billing incident to the physician or NPPs are pages 352-357, where stakeholders ask for clarification as to whether pharmacists can bill incident to and if they can bill all E&M codes. This question has been asked of CMS previously, however, the information included in the PFS is the most detailed response they have given to date. Included in this response is confirmation from CMS that pharmacists billing Medicare incident to physicians or NPPs can only bill the lowest level of E&M codes (99211). This is a pretty striking confirmation and may result in some pharmacists changing how they are billing for their services if they are billing Medicare incident to for higher level E&M (99202-99205; 99212-99215) codes.
Although it is not ideal that this confirmation may result in a decrease in revenue generation from some pharmacists depending on their billing practices, included in the PFS is an explanation as to why pharmacists cannot bill these higher level codes. With this explanation comes an understanding of what changes need to be advocated for in order to allow pharmacists to bill Medicare for all E&M codes incident to physicians or NPPs.
CMS explains that the reason pharmacists can only bill the lowest level E&M code is because of two definitions used in the Current Procedural Terminology (CPT) codebook. In the CPT codebook the term ‘physician or qualified health professional’ (QHP) and ‘clinical staff’ are used in descriptions as to which individuals can provide different services, such as those included in E&M codes. Specifically, included in the 2021 CPT Codebook is information that higher level E&M codes can only be provided by physicians or QHPs. These definitions are included in the table below:
So, there is no overlap here. A QHP cannot also be ‘clinical staff’. These are mutually exclusive definitions. Included in the CPT codebook is the requirement that higher level E&M codes must be provided by a physician or QHP. Unfortunately, CMS states that they do not consider pharmacists QHPs and because of this, this is the reason pharmacists can not bill Medicare incident to for higher level E&M codes. The justification for why CMS does not consider pharmacists QHPs is that “there is no Medicare statutory benefit allowing them to enroll, bill and receive direct payment for PFS services.” The key term here is ‘direct payment’. So, even though we would be billing incident to the physician, the fact that direct payment is being used is indicative that this is still all coming back to recognizing pharmacists as providers under the Social Security Act (more information about this can be found here).
Additionally CMS states that in some settings pharmacists could be considered QHPs, however under current Medicare Law (the dreaded Social Security Act) even if a pharmacist billed Medicare, CMS says “we do not have ability to pay (or even price) services that are furnished and billed directly by pharmacists.”
What are the next steps?
So this news is not necessarily good or bad, it’s a little of both. It is bad that some pharmacists may not be able to continue to bill Medicare for higher level E&M codes, however, it is good that we now understand what must change in order to allow pharmacists to bill incident to for these higher level E&M codes. So, what needs to change? We believe there are potentially two alternate answers to this question.
The first answer would be for Medicare to recognize pharmacists as QHPs and thus allow them to bill for higher level E&M codes. Although this seems to be a simple advocacy initiative, it gets more complicated as you review the specific language that CMS used as its justification for why pharmacists are not considered QHPs. The justification that CMS uses ties back to pharmacist’s inability to directly bill for services from Medicare, which ties back to pharmacist recognition as providers in the Social Security Act, aka ‘Provider Status’. So the first answer to this question is for pharmacists to get Medicare provider status, which is not something we would recommend anyone holding their breath over…
The second alternative answer is actually outlined in the PFS as something CMS states should be considered. This is indicated when they state, “We note that new coding might be useful to specifically identify these particular models of care.” What they are suggesting here, is that the CPT codebook change the codes for higher level E&M codes to allow clinical staff (which pharmacists are frequently defined as) to bill incident to physicians or NPPs for services they have provided. This would allow CMS the ability to allow pharmacists, designated as clinical staff, to bill Medicare for higher level E&M codes incident to physicians or NPPs. Although this might seem like a simple enough ask, you are not going to like it when we tell you who owns the rights to the CPT codebook…the American Medical Association (AMA).
The AMA has expressed concern over expanded reimbursement models for pharmacists, and has even passed a resolution in their House of Delegates to this effect. Here is where you can make the difference though. Under the current model, pharmacists practicing in incident to reimbursement models are throwing away money and undervaluing their services every time they provide a level of care above a 99211 code. Expressing that revenue is being left on the table to leaders of health systems may be an enticing argument for physicians in leadership positions over health-systems or outpatient clinics. We all want the same thing, which is increasing access to high quality, effective healthcare. We know that with more revenue we can further the missions and visions of the organizations that we work for. Why leave money on the table, when a simple change by the AMA could better patient care and revenue streams for many of their members?
If you work for a health-system or outpatient clinic, we encourage you to ask this question to your administrators and physician leaders. This, along with advocating to the AMA and CMS, may open up incident to billing opportunities for pharmacists across the country, and thus enhance access to patient care.
Earlier during the COVID-19 pandemic, we reported on the racial differences affecting our communities and the potential solutions pharmacists can provide. As the pandemic continues on, we see how these disparities remain magnified during public health emergencies. An analysis published last week describes continued higher mortality rates of communities of color as compared to Whites, despite these differences having been identified early during the COVID-19 pandemic. As the rate of infections and deaths continue to rise, and with 12 million Americans at risk for losing unemployment benefits come December 26th, we are likely to see worsening rates of food insecurity, homelessness, and of course, inability to pay for health care over the coming months.
In our last post, we noted several inequities in social determinants of health that put racial and ethnic minority groups at an increased risk of morbidity and mortality associated with COVID-19. These factors include, but are not limited to, healthcare access and utilization, such as access to COVID-19 testing; occupations, as many people of color are essential workers; and housing. Another factor that has amplified these disparities and must be addressed in order for solutions to be made, is the delay in translating critical health alerts and recommendations into other languages. Pharmacists practicing in different areas are faced with this problem all too frequently.
We have shared the stats and have seen the widespread impact that without policy solutions these racial differences, amplified by the pandemic, will continue to expand. Recognizing the power of stories and that each of us need to hold ourselves accountable for addressing racism, inequities, and disparities in our society, we bring you a narrative reflection on how language barriers can impact patient care from a pharmacist in the field.
Where Do We Go From Here? A Reflection by Larry Selkow, A Pharmacist in the Field
I have been a community pharmacist for almost 40 years. Currently, I live in a well-to-do golf course community in the Palm Springs area of Southern California. President Barack Obama played a round of golf on the course where I live a few years ago. My current position also puts me in a very affluent area. However, a few years ago I was employed by a large retail pharmacy chain in a not so well-to-do neighborhood, not too far from my current home. Actually, if I drive around 5-10 minutes from my home, the area is very poor with a large Latino population. When I worked in that neighborhood, there was a huge language barrier that I faced on a daily basis.
I do not speak Spanish, but my pharmacy technicians did and they would often have to translate for me back and forth. If my technician was not there, which occurred at night and on weekends, I would often have to page another Spanish speaking employee to the pharmacy to translate for me. When I think about my work in the Latino neighborhood, I often wonder… what kind of care was I really providing? In the current state of affairs in this country, what I have experienced happens on a daily basis. Actually, when you think about it, a language barrier is a huge public health issue in this country. If patients are not able to communicate properly with their pharmacist or any other health professional, this creates a public health issue,: like any other public health issue such as smoking, HIV, or obesity. It is perfectly fine to have someone translate back and forth. But, does it provide equitable care to these patients? Do these patients fully understand their current health situation?
Many pharmacists may not have the ability to speak Spanish fluently when working in a Latino neighborhood. This creates a problem for all. These patients often do not get the proper consultation or health information that they need. During the pandemic, we are facing a time when timely dissemination of accurate information is crucial, there has been a lot of press coverage about the huge disparities between different ethnic groups. The Latino population has been hit especially hard from COVID-19. Imperial County in California, which is about an hour drive from my home, has been devastated by COVID-19. This area has an even larger Latino population than where I worked. I know a few pharmacists that have worked in Imperial County, and from talking to them, the language barrier is even worse than I experienced. Again, what level of health care is actually being provided? Sometimes I myself, get frustrated that I am letting my patients down. I know other pharmacists that get frustrated as well. But, we as health professionals must do the best we can with the current situation, while also advocating for future equitable solutions.
We became pharmacists to provide care to all patients regardless of the language that they speak. We must realize that a language barrier is a huge public health issue, like any other public health issue. So, the question is: where do we go from here? There is no perfect answer, but if we can look at the current situation in this country, one word comes to mind: Empathy. Yes, we heard that word often during the 2020 Presidential campaign. Now that the campaign is over, we must apply that word to our daily practice. I feel a little more understanding of our patients needs can go a long way towards providing the necessary care that they deserve. In the long run, their health and well-being will be much better off.
Solutions Needed: Empathy and Policy Change
Empathy is crucial not only to understand our patient’s needs, but to build trusting relationships that allow for patients to express their thoughts and concerns. Although there is hope for a COVID-19 vaccine becoming available soon, historically communities of color have been underrepresented in clinical trials and have a deeper mistrust for the healthcare system, which may cause significant barriers to administering vaccines to this vulnerable population. In a recent New England Journal of Medicine perspective the authors note “When Covid-19 vaccines are eventually approved by the FDA, their success in Black and other communities will depend on whether members of these communities not only trust that they are safe and effective, but also believe that the organizations offering them are trustworthy.” Although there are steps that must be taken, such as ensuring these communities have access to necessary healthcare if they are injured as a result of receiving the vaccine, they also note that efforts must be grounded in grassroots involvement of individuals and organizations with reputations of trustworthiness among these populations. We believe pharmacists are key players in building and maintaining these relationships, and serving as a voice for the underrepresented.
Additionally, advocating for our patient’s needs, ensuring access to care, and providing educational resources that are easily understood by all patients will also help build these trusting relationships. As we described in August, policy changes including development and implementation of payment models are needed in order to ensure access to pharmacist’s services, such as COVID-19 testing and vaccines, for all people. Furthermore, funding to support agencies to provide public health infrastructure are crucial to combating the inequities of social determinants of health that impact many of our patients. We challenge pharmacists and national pharmacy organizations to also consider these factors when developing resources for your communities and ensuring minority voices are properly represented.
Featured Writers Profile
Larry Selkow lives in La Quinta CA. He graduated in 1982 from The Arnold and Marie Schwartz College of Pharmacy, Brooklyn NY. He has always worked in community pharmacy and belongs to various pharmacy organizations, including the American Pharmacists Association (APhA) in which he is heavily involved with various committees and special interest groups. He also works with APhA on Policy, being a member of the APhA House of Delegates for many years. He is currently President of the Palm Springs Chapter of the California Pharmacists Association. Larry has a huge interest in pharmacy policy as it pertains to community pharmacy on a State and Federal level.