Almost exactly a year has passed since the ACCP Board of Regents endorsed a policy platform to pursue legislation that would recognize the direct patient care services of qualified clinical pharmacists as a covered benefit under Medicare Part B. During the past 12 months, ACCP has made important progress in advancing our Medicare Initiative on Capitol Hill while working to develop and strengthen our relationship with physician groups and other important stakeholders.
ACCP staff in Washington, DC, have undertaken a comprehensive schedule of meetings targeting key lawmakers on committees of jurisdiction in both the House and the Senate, including strategically vital conversations with the offices of Speaker John Boehner and Senate Finance Chairman Max Baucus.
Concurrent with our Hill outreach, ACCP has been engaged in an ongoing dialogue with several organizations representing the physician community, including a formal presentation of our Medicare Initiative to a group of senior government affairs staff from a diverse range of health professions, including the American College of Physicians (ACP), American Academy of Family Physicians (AAFP), American Osteopathic Association (AOA), and American Congress of Obstetricians and Gynecologists (ACOG).
Our efforts on Capitol Hill have yielded meaningful interest, particularly on the Senate side, from a bipartisan group of lawmakers who are considering introducing legislation on our behalf. The past year has also taught us some important lessons that pertain to both the strength of our initiative and the challenges we face in achieving legislative success.
Lesson No. 1: The policy of our proposal is fundamentally sound.
After a year’s worth of conversation on Capitol Hill, we can be confident that the structure of our Medicare Initiative, from a policy perspective, makes sense to Congress. Staff members in offices ranging from conservative Republicans to liberal Democrats agree that a comprehensive medication management (CMM) benefit delivered by qualified clinical pharmacists would enhance the quality of care available to seniors and improve overall health outcomes. Of course, agreeing with our policy proposal by no means directly translates into actively championing it or introducing legislation on our behalf. But we take encouragement from the fact that, to date, all the congressional offices to which we have presented have supported the substance of our initiative.
Lesson No. 2: The cost of our proposal remains a major challenge.
Almost all legislation enacted by Congress comes with a price tag attached. The Congressional Budget Office (CBO)—founded in 1974—is required by law to produce a formal cost estimate for all bills (other than appropriations measures) that are “reported” (approved) by a full committee of either house of Congress. The agency is strictly nonpartisan and conducts objective, impartial analyses, but it does not make policy recommendations on the legislation for which it develops cost estimates, commonly called budget “scores.”
Of importance, the agency does not engage in “dynamic scoring,” the process of incorporating the macroeconomic effects of a proposal into a budget estimate. In other words, the agency does not score potential savings that might accrue from a policy proposal.
Therefore, a CBO analysis of ACCP’s legislative initiative would estimate only the upfront cost of paying clinical pharmacists for their direct patient care services under the Medicare program—and would not incorporate the overall savings that such services would accrue as a result of “getting the medications right.”
Although there is a general consensus that establishing a Medicare CMM benefit would generate significant savings elsewhere in the Medicare program by averting hospitalizations, emergency department visits, and other costly encounters, the “score” or price tag attached to such a bill would include only the cost of delivering the CMM service.
In what is clearly a difficult budgetary environment and amid the ongoing debate on tactics like sequestration, gaining support for an initiative that would, at least from the perspective of the CBO accountant, increase Medicare costs is a significant challenge. However, ACCP believes there is a growing willingness in Congress to look beyond the confines of the CBO score alone and seriously examine opportunities to contain Medicare program costs by improving the overall quality of care delivered to America’s seniors.
Lesson No. 3: Support from the other health professions is critical.
Our Medicare Initiative is based on the ability of CMM, provided by qualified clinical pharmacists working as formal members of the patient’s health care team, to significantly improve clinical outcomes and enhance the safety of medication use by patients. It is therefore reasonable for lawmakers to expect that other members of the health care team will support our initiative, in the interest of improving the quality of care delivered to patients. Several congressional offices have emphasized the need to secure the support of other health professionals, particularly physicians. Accordingly, ACCP has been resolute in its outreach to organized medicine.
We are confident that the underlying structure of our Medicare Initiative will help secure the support of other professions on the health care team. For example, the requirement that, to deliver care under our proposal, qualified clinical pharmacists must have in place an active collaborative drug therapy management (CDTM) agreement not only ensures that the necessary systems are in place to facilitate the process of care and optimize efficiency, but also reassures physicians that the initiative does not inappropriately encroach on their practice as diagnosticians and prescribers. Fully using the qualified clinical pharmacist’s knowledge and skills to coordinate the medication use process through CDTM agreements allows other team members to be more efficient in their own patient care responsibilities and frees up other team members to practice at the highest level of their own scopes of practice.
Recent developments in California also provide encouragement that we can gain the support of organized medicine. When the California legislature was considering legislation to recognize pharmacists as health care providers, the California Medical Association (CMA) revised its earlier opposition to the bill and adopted a “neutral” stance on the legislation. This decision was made partly because direct patient care services would be delivered by pharmacists with the appropriate education and training to attain the designation of Advanced Practice Pharmacist, which requires certification in a relevant area of practice and completion of residency training. Similarly, under our proposal, qualified clinical pharmacists must be certified or eligible for certification in a pharmacy practice specialty recognized by the Board of Pharmacy Specialties (BPS).
Lesson No. 4: Delivery of care must be compatible with evolving delivery and payment models.
As Congress considers legislation that would formally repeal the SGR (sustainable growth rate) mechanism and reform Medicare physician payment policies, lawmakers on both sides of the aisle have made it clear that there is no interest in simply expanding the current Part B fee-for-service model. Any new Medicare benefit must be compatible with the evolving payment models already being tested, such as those adopted by accountable care organizations (ACOs) and patient-centered medical homes (PCMHs).
ACCP’s Medicare Initiative is based on the CMM process of care, which is endorsed by the Patient-Centered Primary Care Collaborative (PCPCC). The PCPCC represents more than 1000 stakeholders dedicated to advancing an effective and efficient health system built on a strong foundation of primary care and the PCMH. The PCPCC resource guide, developed with major input from ACCP, provides a framework for integrating CMM into clinical practice in the PCMH and advocates for the need to include payment for CMM as an essential professional service for effective integrated care.
ACCP has made it clear in our discussions on Capitol Hill that until Medicare payment systems have fully evolved into these integrated systems, some degree of fee-for-service payment must exist to facilitate CMM delivery in the short term. But we have also emphasized that our proposal is not only fully compatible with integrated delivery models, but that the inclusion of CMM in order to “get the medications right” is an essential requirement as well to achieve the outcomes and cost savings these evolving models promise.
Lesson No. 5: Our success will require the participation of ACCP members.
As stated earlier, no congressional office has disagreed with the substance of our proposal or disputed the value that a CMM benefit could bring to the quality of care for Medicare beneficiaries. Yet agreeing in principle with an initiative and being willing to introduce legislation to advance it are two very different considerations. All members of Congress want to see backing from their home district or state for any proposal they have been asked to support.
The political reality is that a legislative initiative cannot move forward purely on the strength of its own merits—grassroots advocacy and financial contributions are key to showing support for an initiative from districts and states well beyond the Beltway. ACCP calls on every member of the College to contribute to the ACCP-PAC.
If most ACCP members were to participate in the PAC, it would send a very powerful message to candidates for office who ask for evidence of the level of support from the clinical pharmacy profession for our Medicare Initiative. We urge all ACCP members to make a contribution to the PAC, however small. A big war chest is always important when it comes to political contributions, but a PAC is not measured just in terms of dollars—participation is also important, and we call on all of our members to participate.
Only ACCP members are eligible to contribute to the PAC. With more than 14,000 ACCP members, our organization is positioned to become one of the most prominent pharmacy PACs in Washington. To do this, we need the widespread support of the ACCP membership.
All ACCP members should consider making a donation. CLICK HERE to support the PAC today!
Medicare Initiative Advocacy Materials
As a reminder, two important resources related to our Medicare Initiative are available online. Please take some time to familiarize yourselves with these documents, which will guide your communications with Congress related to the initiative and help ensure we deliver a consistent message around how CMM helps “get the medications right” and why Congress should enact legislation to achieve this.
Click here to access the Medicare Initiative Congressional Issue Brief.
Click here to access the Medicare Initiative Data Document.
To learn more about ACCP’s advocacy efforts in general, please visit our Medicare Coverage Initiative Web page, where you can access more resources and details about how individual members can become involved. For more information on any of ACCP’s advocacy efforts, please contact:
John K. McGlew
Associate Director, Government Affairs
American College of Clinical Pharmacy
1455 Pennsylvania Ave. NW
Suite 400
Washington, DC 20004-1017
Telephone: (202) 621-1820
E-mail: [email protected]