Identifying Opportunities to Advance Coverage for Clinical Pharmacy Services in the 118th Congress

The 118th Congress convened January 3, 2023, with a new Republican majority in the House of Representatives, the first female Senate president pro tempore (Patty Murray), the first Black party leader (Hakeem Jeffries) in congressional history, and the longest-serving party leader (Mitch McConnell) in the Senate.

ACCP approaches the new Congress with an aggressive agenda aimed at targeting key leaders on congressional committees with jurisdiction over health care issues. In the House of Representatives, the College targets members of the Ways and Means Committee and the Energy and Commerce Committee. In the Senate, the College primarily focuses on members of the Finance Committee and the Health, Education, Labor and Pensions (HELP) Committee.

ACCP’s team in Washington, D.C., has identified the following strategic policy areas to advance opportunities for clinical pharmacists:

• Establishing coverage for Medication Optimization services for chronically ill patients
• Integrating clinical pharmacists into substance use disorder and mental health care teams
• Prescription Drug Reform – helping to address cost and coverage issues by getting the medications right on behalf of patients
• Establishing Medicare coverage for Pharmacogenomic Consultations by clinical pharmacists

Establishing Coverage for Medication Optimization Services for Chronically Ill Patients 

It is estimated that $528 billion per year, equivalent to 16% of total health care spending, is consumed because of inappropriate or otherwise ineffective medication use. Despite the central role of medications in the care and treatment of chronic conditions; the continuing growth in the range, complexity, and cost of medications; and the growing understanding of the genetic and physiologic differences in how people respond to their medications – the nation’s health care system consistently fails to deliver on the full promise that medications can offer.

ACCP’s top advocacy priority in the new Congress is focused on advancing coverage for pharmacists’ clinical services delivered under collaborative, patient-centered payment and delivery structures, aimed at optimizing medications on behalf of chronically ill older adults with complex conditions.

“Getting the medications right” through a team-based approach to medication optimization also contributes to enhanced productivity for the entire health care team, allowing all team members to focus more fully on their own patient care responsibilities. By fully using the qualified clinical pharmacist’s skills and training to coordinate the medication use process as an interdependent team member, physicians and other team members can maintain focus on respective patient care activities that align with their professional responsibilities as defined by the scope of practice that reflects their area of expertise.

Clinical pharmacists are also uniquely positioned to address health equity by improving access to a standardized process for optimizing medications that facilitates collaboration with other members of the interdisciplinary team to ensure each medication has an appropriate indication, is effective for the condition, can help achieve clinical goals, is safe, and offers a regimen the patient can adhere to.

The College’s goal for the coming Congress is to facilitate the full integration of clinical pharmacists into the Medicare program by amending the Social Security Act to authorize clinical pharmacists to serve in Medicare-eligible patient care teams, helping to optimize medications for chronically ill patients with complex conditions.

Integrating Clinical Pharmacists into Substance Abuse and Mental Health Care Teams 

Lawmakers across both political parties remain firmly committed to addressing America’s ongoing mental health and substance use crises by facilitating the full integration of mental health care with physical health care services and expanding access to crisis care and follow-up services to get Americans the longer-term care they need. Proposed legislation in Congress would increase payment rates to help providers integrate behavioral health and primary care and create a Medicare bundled payment for crisis stabilization services, including providing observation care, screening for suicide risk, screening for violence risk, and assessing immediate physical health needs.

• ACCP recently submitted a one-page statement that calls on Congress to formally recognize and pay for services that optimize medications on behalf of patients with complex conditions in evolving payment models.

Prescription Drug Reform – Helping to Address Cost and Coverage Issues by Getting the Medications Right on Behalf of Patients 

The inexorable rise in health care inflation is a perennial bipartisan priority issue to lawmakers on Capitol Hill. As Congress grapples with how to limit drug prices to slash the federal deficit and reduce out-of-pocket spending by Medicare beneficiaries, ACCP believes there is opportunity to advance a comprehensive medication management benefit.

As far back as 2003, the Centers for Medicare & Medicaid Services (CMS) stated that its medication therapy management (MTM) program would be a “cornerstone of the Medicare Prescription Drug Benefit.” MTM was intended to be a “patient-centric and comprehensive approach to improve medication use, reduce the risk of adverse events, and improve medication adherence.” However, CMS has acknowledged that it has not been possible to fully demonstrate the value and success of the Part D MTM program. ACCP has already been engaged through the Get the Medications Right (GTMRx) Institute’s “Buy Right Strategy” to develop a dialogue with America’s major employers, who collectively sponsor health benefits for more than 160 million Americans and pay billions of dollars for prescription drug coverage yet typically have limited insight into the effectiveness of their drug benefit programs and the outcomes they produce on behalf of patients.

ACCP recognizes Congress’s growing understanding of the value of qualified clinical pharmacists in the therapeutic management of complex conditions and is dedicated to advancing a quality-focused, patient-centered, team-based improvement in health care delivery that (1) helps ensure medication optimization, (2) enhances patient safety, (3) promotes value-based rather than volume-based care, and (4) contributes to greater affordability and sustainability for the Medicare program.

• ACCP recently released a statement to the Senate Finance Committee recommending that, to modernize access to and coverage of innovative therapies, the Medicare program should use the unique contributions of clinical pharmacists in the area of medication optimization.

Establishing Medicare Coverage for Pharmacogenomic Consultations by Clinical Pharmacists 

ACCP’s legislative strategy recognizes that health policy often evolves incrementally. Cures 2.0 legislation aimed at modernizing access and coverage to innovative therapies generated bipartisan support in the last Congress. Of importance, the bill included Section 408: Medicare Coverage for Pharmacogenomic Consultations, which would establish a program to cover pharmacogenomic (PGx) consultations delivered by qualified clinical pharmacists. ACCP has been collaborating with its partner organizations to advance this potentially impactful provision.

• Click here to send a letter to Congress calling for reintroduction of legislative language that would cover PGx consultations by qualified clinical pharmacists.

ACCP Calls for Significant Structural Reforms to Medicare Part D MTM: Advance Coverage of Team-Based Pharmacists’ Comprehensive Clinical Services to Get the Medications Right 

ACCP is calling on the Centers for Medicare & Medicaid Services (CMS) to advance reforms to the Medicare Part D medication therapy management (MTM) program to include coverage of medication optimization services provided by clinical pharmacists working as fully integrated members of the health care team.

Background of Medicare Medication Coverage 

After the implementation of the Part D benefit and the launch of the MTM program, pharmacists across all practice settings worked to deliver high-quality patient care to beneficiaries within the Part D MTM structure and sought to make the program a success.

After almost 2 decades of experience, however, it is evident that the Part D MTM program as currently structured – delivered primarily through prescription drug plans and detached from the patient’s health care team and medical records – fails to support a patient-centric, comprehensive process of care necessary to realize the full potential of effective, team-based medication management with respect to improved outcomes and lower costs.

This concern is shared by the Medicare Payment Advisory Commission (MedPAC). In a March 2019 report to the Congress, MedPAC stated:

We continue to be concerned that sponsors of stand-alone prescription drug plans (PDPs) do not have financial incentives to engage in MTM or other activities that, for example, reduce unnecessary medical expenditures. Further, the effectiveness of the current MTM services in improving the quality of overall patient care is unclear.¹

Like MedPAC, ACCP questions whether medication optimization for beneficiaries can be achieved through improvements to the current Part D MTM program. By design, Part D MTM is an administrative benefit delivered by the patient’s Part D plan sponsor, rather than a comprehensive medical benefit coordinated through the patient’s health care team. Part D MTM is largely delivered using drug claims data and is narrowly focused on issues such as duplications in therapy, gaps in adherence, use of certain classes of medications, and generic substitution. Experience has shown that physicians may be reluctant to accept recommendations from drug plans with which they have no direct relationship.

ACCP’s Recommendation 

Medication misuse and the ensuing adverse drug events are estimated to account for at least $528.4 billion in unnecessary health care spending annually. Comprehensive medication management (CMM) has been shown to improve outcomes, increase patient satisfaction, alleviate physician “burnout,” and save money.

CMM is a well-established standard of care in the nation’s leading private sector health systems, including Geisinger, Kaiser Permanente, Mayo Clinic, and Johns Hopkins. Nationally, VA clinical pharmacy specialists (CPSs) hold scopes of practice that confer medication prescriptive authority and the responsibility to modify, start, stop, and/or continue medications according to guideline recommendations, collaborative practice agreements, and the CPS’s clinical judgment. CPSs also perform associated physical assessments, order laboratory tests, and initiate consultations for other services.

Integrating CMM provided by clinical pharmacists, in close collaboration with physicians, is a critically important step to help ensure medication therapy is fully optimized and contributing to better care, lower costs, improved outcomes, and enhanced equity for the entire Medicare program.

Click here to read ACCP’s comment letter in response to the 2024 Medicare Proposed Rule.

ACCP Leads Profession’s Effort to Include Medication Optimization in the ACA 

The Affordable Care Act insurance marketplace reforms included a requirement that health plans in the individual and small group markets cover essential health benefits (EHBs) in 10 key categories:

• Ambulatory patient services
• Emergency services
• Hospitalization
• Maternity and newborn care
• Mental health and substance use disorder services, including behavioral health treatment
• Prescription drugs
• Rehabilitative and habilitative services and devices
• Laboratory services
• Preventive and wellness services and chronic disease management
• Pediatric services, including oral and vision care.

Policymakers at the Centers for Medicare & Medicaid Services (CMS) recently published a request for information (RFI) seeking input on how to enhance and modernize the EHB regulation across variety of areas, including overcoming barriers to accessing services because of coverage or cost and addressing gaps in coverage.

Collaborating with its partner organization, the Get the Medications Right (GTMRx) Institute, ACCP is leading an outreach to the Biden administration, calling for coverage of comprehensive clinical pharmacists’ services to help achieve medication optimization on behalf of patients with complex health conditions.

Background of Medicare Medication Coverage 

The Medicare Part D drug benefit successfully expanded Medicare to include prescription medications in the early 2000s. Medicare Part B has long covered some physician-administered medications. However, beyond the limited Part D medication therapy management service, Medicare beneficiaries still lack access to a meaningful benefit to ensure that expensive and complex prescription medications provide maximum value.

There is a broad, bipartisan consensus shared by the Biden administration and both parties in Congress on the need for prescription drug price reform and greater transparency in the pharmacy benefit manager market. But ACCP believes there is also a need to look beyond the affordability of medications and truly examine the value of the medication therapies prescribed. Comprehensive medication management (CMM) delivered by clinical pharmacists is the best way to achieve this critically important goal.

ACCP’s Recommendation 

Medication misuse and the adverse drug events that ensue are estimated to account for at least $528.4 billion in unnecessary health care spending annually. CMM has been shown to improve outcomes, increase patient satisfaction, alleviate physician “burnout,” and save money.

CMM is a well-established standard of care in the nation’s leading private sector health systems, including Geisinger, Kaiser Permanente, Mayo Clinic, and Johns Hopkins. Nationally, in the integrated Veterans Health Care Administration system, clinical pharmacy specialists (CPSs) hold scopes of practices that confer medication prescriptive authority and the responsibility to modify, start, stop, and/or continue medications according to guideline recommendations, collaborative practice agreements, and the CPS’s clinical judgment. CPSs also perform associated physical assessments, order laboratory tests, and initiate consultations for other services.

CMM provided by clinical pharmacists, in close collaboration with physicians, is a critically important step to help ensure medication therapy is fully optimized, contributing to better care, lower costs, improved outcomes, and enhanced equity.

• Click here to read ACCP’s statement in response to the EHB RFI.
• Click here to read GTMRx’s statement in response to the EHB RFI.

ACCP Calls for Inclusion of Clinical Pharmacists in President Biden’s Budget Request to Congress 

ACCP is calling on the Biden administration to include coverage for team-based comprehensive medication optimization services delivered by clinical pharmacists in its Fiscal Year 2024 budget request to Congress.

Background of Medicare Medication Coverage 

The Medicare Part D drug benefit successfully expanded Medicare to include prescription medications in the early 2000s. However, Medicare has never had a meaningful patient care benefit to ensure that expensive and complex prescription medications provide maximum value and contribute to optimal patient outcomes.

We believe the time for that to change is now. ACCP supports the Biden administration’s efforts to lower the cost of prescription drugs to patients and believes that medication optimization is just as important as – if not more important than – medication affordability. Integrating clinical pharmacists into Medicare patient-centered teams could achieve this critically important goal at a national level.

ACCP’s Recommendation 

Suboptimal medication use – medication misuse and the adverse drug events that ensue – is estimated to account for at least $528.4 billion in unnecessary health care spending annually. Comprehensive medication management (CMM) provided by clinical pharmacists, in close collaboration with physicians, is one critically important way to address this challenge. CMM has been proven to deliver improved patient outcomes, reduce physician “burnout,” and lower overall health care spending.

CMM is a well-established standard of care in the nation’s leading private sector health systems, including Geisinger, Kaiser Permanente, Mayo Clinic, and Johns Hopkins. The Veterans Health Administration care system has systematically integrated clinical pharmacist specialists into patient-aligned care teams to significantly improve patient outcomes for a range of chronic conditions.

Since the inception of the Medicare program, however, beneficiaries have not had access to a meaningful benefit to ensure that expensive and complex prescription medications provide optimal value. Click here to read ACCP’s January 2023 letter to the Biden administration calling for inclusion of comprehensive clinical pharmacists’ services in the 2024 Budget Request to Congress.

ACCP Urges Senate Finance Committee to Include Clinical Pharmacists in Mental Health Legislation 

ACCP’s team in Washington, D.C., has prioritized mental health care reform as a key target to advance in the next Congress. The College recently submitted a statement to the Senate Finance Committee urging the inclusion of clinical pharmacists in mental health teams.

The statement calls for the qualified clinical pharmacists to participate in and be reimbursed for services provided on the health care teams treating mental health disorders, including substance use disorder. As shown by ample evidence in the published literature as well as the practical experience in public and private health care systems, clinical pharmacists offer highly valuable care to individuals with mental health disorders.

Click here to read ACCP’s statement to the Senate Finance Committee.

ACCP-PAC: Political Action for Clinical Pharmacists 

ACCP’s Political Action Committee (PAC) allows the College to participate in political campaign activities that strengthen its relationships with key policymakers on Capitol Hill. Providing financial support to influential leaders helps raise the profile of clinical pharmacy and demonstrates ACCP’s ideological commitment to the College’s core mission.

To maximize its impact, ACCP must be strategic in targeting its limited resources on the health policy leaders best placed to advance its agenda. Here’s how ACCP’s leaders decide who should receive financial support.

Consistent with all of ACCP’s initiatives, ACCP-PAC is member driven and managed by a Governing Council, which is responsible for decisions related to how PAC money is spent.

• ACCP-PAC is nonpartisan – committed to working with health policy leaders across all political parties and ideologies.
• ACCP-PAC supports candidates according to their alignment with ACCP’s mission to advance the profession and improve human health through research, training, and education.
• ACCP-PAC strategically targets members of Congress who sit on committees with jurisdiction over health care. In the Senate, ACCP-PAC primarily supports members on the Finance Committee and the Health, Education, Labor and Pensions (HELP) Committee. In the House, ACCP-PAC focuses on those who sit on the Ways and Means Committee and the Energy and Commerce Committee.
• ACCP-PAC is committed to transparency – all contributions are reported to the Federal Election Commission, and the information is available to the public.

PAC contributions are a constitutionally protected part of the U.S. political system under the First Amendment’s guarantee of free speech. ACCP-PAC is the only means through which the College can provide financial support for candidates for Congress. With its 17,000 members, ACCP can become one of the most prominent pharmacy PACs in Washington. To do so, however, the College needs the widespread support of its membership. If each ACCP member contributed just $25, ACCP-PAC would raise over $425,000. All ACCP members should consider contributing at least $25 to ACCP-PAC.

CLICK HERE to support your PAC today!

Reference

¹MedPAC Report to the Congress: Medicare Payment Policy. March 2019. Available at https://www.medpac.gov/wp-content/uploads/import_data/scrape_files/docs/default-source/reports/mar19_medpac_ch14_sec.pdf.