Whenever I think of our current health insurance system, I’m reminded of Jenga, the old wooden block-stacking game. Shifting just one piece of the shaky tower can result in collapse. As Congress proceeds toward repeal and replacement of the Affordable Care Act, it would do well to keep Jenga in mind and carefully consider which pieces should stay while moving to keep the tower standing.
Newly insured patients through the ACA’s health exchanges and Medicaid expansion — some 22 million of them according to the Congressional Budget Office — are a case in point. Providing these previously uninsured patients with the medications necessary to manage chronic health conditions sooner rather than later is essential if we are ever to truly bend the health care cost curve. While enactment of the ACA and repeal and replace were and remain highly-charged partisan issues, attempting to contain costs has widespread support in both parties. Several of the policies discussed below also have had bipartisan support in Congress.
Medications are the primary method of treating chronic disease and are involved in 80 percent of all treatment regimens. Unfortunately, medication-related problems, including poor adherence, cost the nation more than $290 billion annually and result in health complications, worsening of disease progression, emergency room visits, and hospital stays, all of which are costly and avoidable. Any ACA replacement must preserve prescription drug coverage as an essential benefit to help reduce overall health care costs.
However, prescription drug coverage alone is ineffective if beneficiaries can’t use the benefit. As former Surgeon General C. Everett Koop famously noted, prescription drugs don’t work in patients who don’t take them. Patients must continue to have access to a robust pharmacy network that includes meaningful access to retail pharmacies, including independent pharmacies, to fill their prescriptions and promote proper adherence.
A 2013 report by Langer Research Associates found the leading indicator of adherence was the patient’s personal relationship with the pharmacist or pharmacy staff. In recognition of the importance of face-to-face interaction between patients and pharmacists, ACA implementing regulations provide that health plans may not mandate that patients receive their prescriptions via a mail-order pharmacy — but rather that patients must have the ability to choose. Any ACA replacement should retain this valuable component.
The ACA also recalculated the Medicaid generic drug reimbursement formula. Implementing regulations clarified that reimbursement should include the cost of the medication as well as the cost of dispensing, such as pharmacist counseling and overhead. ACA replacement legislation should retain these critical provisions.
Independent pharmacies are often located in underserved rural and urban communities and serve a large number of Medicaid patients. For the average independent, 17 percent of its prescription revenue comes from Medicaid. Overall, prescription drugs account for 92 percent independents’ total revenues. It is imperative that pharmacies be fairly compensated for the medications they dispense. Otherwise, some pharmacies may quit Medicaid, creating medication access issues to those who rely on the program.
In 2015, the National Governors Association released a white paper encouraging states to better integrate pharmacists into the health care delivery system based on the significant role pharmacists can play in helping patients manage chronic disease. The ACA also recognizes the importance of the pharmacist’s role in this area by improving Medicare Part D medication therapy management programs, including an annual comprehensive medications review. These provisions should be retained and built upon to further integrate pharmacists into the health care delivery team.
Any ACA replacement package also should keep provisions that create greater oversight of pharmacy benefit managers and the role they play in escalating drug prices and increasing costs to taxpayers.
In an effort to gain greater insight into secretive PBM business practices, ACA requires PBMs serving exchange plans and Medicare Part D to disclose to the Department of Health and Human Services the generic drug dispensing rate for retail and mail order pharmacies, the amount of monetary rebates collected from generic drug manufacturers, the amount passed onto the health plan, and the difference between what the PBM charged the plan and what it paid pharmacies. Such transparency provisions allow government entities to better determine whether PBMs are providing appropriate value, or are “playing the spread,” pocketing the lion’s share of the manufacturer rebates, and benefitting from high drug prices.
Retaining the ACA’s patient access, medication adherence, and taxpayer transparency building blocks — and remembering Jenga — can only help Congress as it moves to rebuild the health insurance tower.
B. Douglas Hoey, RPh, is the CEO of the National Community Pharmacists Association.
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