Introduction

As the health care reform process moves out of congressional committees and onto the floor of the House and Senate, policy-makers face the daunting task of resolving a host of controversial issues – and of facing a divided electorate.

Recent polls show support for the current proposals at 46% and opposition at 50%, yet these numbers need to be considered within a much broader context. Research shows that 54% of voters believe major changes are needed in the health care system, and 61% say it is important for Congress to pass health care reform this year.¹

To complicate matters further, the polls themselves reflect a general public that is often confused or even misguided over what is being proposed. Widespread fears over government-run “death panels” emerged from nothing more than a provision in the legislative language that would have, for the first time, paid for optional consultations with doctors about hospice care and other “end-of-life” services.

As former Senate Majority Leader Bill Frist was quoted as saying, “Clearly, the death panels and public plan arguments have been overblown.”² Although undoubtedly there should be concern and debate over any proposal that would affect people’s health as well as the economy, to the extent this issue does, the partisan rhetoric from both sides has served to muddy the issue rather than clarify it.

Status

All five congressional committees have passed legislation. Leadership in each house will now work to merge the language produced by the committees to allow consideration on the floor of each respective chamber.

Finally, conference negotiators representing both chambers will meet to reconcile the House and Senate language and produce a final bill that will be voted on and eventually sent to the White House for the President’s signature.

The five different congressional committees that share responsibility for the reform process are:

• Senate Health, Education, Labor and Pensions (HELP) Committee
• Senate Finance Committee
• House Energy and Commerce Committee*
• House Ways and Means Committee*
• House Education and Labor Committee*

(*The legislative draft release by the House of Representatives is known as the “Tri-Committee Bill.”)

In addition, the Obama administration is deeply invested – politically speaking – in the process and has made health care reform a centerpiece of its agenda.

Major Issues to Be Resolved

All the legislation sets out similar goals – to provide affordable, quality health care. Opinion remains divided over how to reach these goals, and several controversial issues must be resolved before the process is completed.

“Public Option” – Perhaps the most controversial issue in the debate. Although all committees would establish a health insurance exchange or gateway through which individuals could purchase coverage, the Senate HELP Committee and House Committees go as far as including a “public option” that would compete with private plans operating in the exchange. The Senate Finance Committee voted against this public option.

Financing – Early and incomplete Congressional Budget Committee (CBO) estimates score each proposal as follows:

• Senate Finance – $829 billion over 10 years
• Senate HELP – $645 billion over 10 years
• House “Tri-Committee” – $1.042 trillion over 10 years

The Obama administration has called for a bill that costs no more than $630 billion over 10 years.

Most of this spending will come from new taxes and savings to Medicare and Medicaid. Specifically, the Finance Committee calls for cuts in payments to Medicare Advantage Plans and for an excise tax on high-cost insurance plans that exceed $8000 for single coverage and $21,000 for family coverage. The House proposes a surcharge of 1%, rising to 5.4% on families with incomes above $350,000 and individuals with incomes above $280,000.

Senate HELP Committee Affordable Health Choices Act (http://help.senate.gov/BAI09A84_xml.pdf)

Provisions Affecting Clinical Pharmacists’ Services

(Section 212) Medical Home Model – Initiates a grant program to establish community health teams. Teams must receive the support necessary for local primary care practitioners to provide access to pharmacist-delivered medication therapy management (MTM) services, including medication reconciliation.

Under the proposal, health teams must provide 24-hour care management and support during transitions in care settings, including a transition care program that:

• provides in-site visits from the care coordinator; and
• assists with the development of discharge plans and medication reconciliation on admission to and discharge from hospitals, nursing homes, or other institutional settings.

The transition support must also ensure that postdischarge plans include MTM, as appropriate.

(Section 213) MTM Grant Program – Provides grants to eligible entities to implement MTM services provided by licensed pharmacists, as a collaborative, multidisciplinary, interprofessional approach to the treatment of chronic diseases for targeted individuals, to improve the quality of care and reduce the overall cost in the treatment of such diseases.

Services, based on the APhA/NACDS–developed Core Elements of an MTM Service Model 2.0, include the following: assessing a patient’s medication therapy, developing an action plan, working with the rest of the care team to implement the action plan, monitoring the patient, and providing education and training to enhance the patient’s understanding and appropriate use of the medications.

These services are provided to targeted individuals who take four or more prescribed medications; take any “high-risk” medications; have two or more chronic diseases; or have undergone a transition of care, or other factors, as determined by the Secretary of U.S. Health and Human Services (HHS), that are likely to create a high risk of medication-related problems.

(Section 216) Hospital Readmission – Creates a payment structure to prevent hospital readmissions by providing increased reimbursement or incentives for improving health outcomes, care coordination, chronic disease management, and medication and care compliance initiatives through comprehensive programs for hospital discharge planning and postdischarge by appropriate health care professionals.

(Section 220) Quality – Establishes a demonstration program to integrate quality improvement and patient safety training into the clinical education of health professionals. Entities eligible for the demonstration program include schools of pharmacy.

(Section 2707) Quality – Directs health insurers to develop and implement a reimbursement structure for making payments to health care providers. This structure provides incentives for the provision of high-quality health care in a manner that includes the implementation of case management, care coordination, chronic disease management, and medication and care compliance activities, including the use of a medical home model as defined in section 212 of the act.

(Section 411) Workforce – Establishes a commission to look at various workforce issues, including current workforce supply and distribution and health care workforce education and training. The section defines health care workforce as all health care providers with direct patient care and support responsibilities, including pharmacists. The section also includes “clinical pharmacist” in its definition of health professionals.

(Section 431) Workforce – Authorizes the Secretary to award grants or enter into contracts with entities that operate a geriatric education center. The center shall use the funds to offer courses focusing on geriatrics, chronic care management, and long-term care that provide supplemental training for faculty members in health profession schools including schools with programs in pharmacy.

Section 431 also directs the HHS Secretary to provide grants or to contract with individuals to foster greater interest among health care providers in entering the fields of geriatrics, long-term care, and chronic care management. Eligible individuals include pharmacists.

(Section 453) Workforce – Provides area health education centers grant monies to distribute to entities that initiate health care workforce educational programs. The grant money must be used for several things including conducting and participating in interdisciplinary training that involves various practitioners including pharmacists.

House Tri-Committee – America’s Affordable Health Choices Act of 2009 (H.R. 3200) (http://docs.house.gov/edlabor/AAHCA-BillText-071409.pdf)

Provisions Affecting Clinical Pharmacists’ Services

MTM Grant Program – An amendment introduced by Congressman Butterfield (D-NC) that is identical to the Senate HELP proposal.

(Section 1301) Medical Home Model – Establishes an accountable care organization (ACO) pilot program to test different payment incentive models intended to promote accountability, encourage investment in processes that result in high-quality and efficient care, and reward providers for high-quality, efficient care.

The community-based medical home model must employ community health workers who assist primary care providers in chronic care management activities such as MTM services. ACOs may involve services not currently compensated for by Medicare such as pharmacist services.

(Section 1305) Preventive Services Cost Sharing – Eliminates cost sharing for Medicare preventive services, including diabetes outpatient self-management training services, diabetes screening tests, and certain vaccinations.

Workforce Strategies – Congressman Braley’s (D-IA) amendment to Section 2211 – Establishes a new program, similar to the National Health Service Corps (which does not include pharmacists), to offer loan repayments to frontline health care providers, including pharmacists, who agree to serve 2 years in an underserved area.

(Section 1191) Quality – Expands tele-health services that allow access to care in underserved communities; may result in the ability of pharmacists and other health care professionals to provide remote “in-person” care.

Senate Finance Committee: America’s Healthy Future Act of 2009 (http://finance.senate.gov/sitepages/leg/LEG%202009/091609%20Americas_Healthy_Future_Act.pdf)

Provisions Affecting Clinical Pharmacists’ Services

(The proposal released by the committee is known as the “Mark” rather than the “bill” because the chair has not yet released legislative language.)

Medication Therapy Management – The HHS Secretary would be required to create an Innovation Center within CMS. The Innovation Center would be authorized to test, evaluate, and expand different payment structures and methodologies that aim to:

• foster patient-centered care
• improve quality
• slow the rate of Medicare cost growth

The Innovation Center would be required to conduct an evaluation of each model tested, including an analysis of the extent to which the model results in, among others, coordination of health care services across treatment settings.

The Center would be required to consider testing, at a minimum, models that achieve at least 1 of 13 criteria. One of the criteria includes “the utilization of medication therapy management services.”

Hospital Readmissions – The Mark includes “comprehensive medication review and management, including patient self-management, when appropriate” in the list of possible core intervention elements for care transition services. However, the Mark does not address the realignment of payments to increase access to these services or confirm that pharmacists may provide these services and that their services will be compensated through Medicare Part B.

Medicare Advantage MTM – The Mark includes MTM in a new bonus payment for care coordination and management activities that are conducted by Medicare Advantage plans: “Medication therapy management programs that focus on poly-pharmacy and medication reconciliation, periodic review of drug regiments, and integration of medical and pharmacy care for chronically-ill, high cost beneficiaries.”

Workforce – The Mark would establish a Workforce Advisory Committee, composed of external stakeholders and representatives of health professionals; schools of higher education for health care professionals; public health experts; health insurers; business; labor; state or local workforce investment boards; and any other health professional organization or practice the Secretary deems appropriate. These stakeholders would develop and present a national workforce strategy to the Secretary and Congress that would set the nation on a path toward recruiting, training, and retaining a health workforce that meets the nation’s current and future health care needs.

Medicaid – The Mark would make prescription drugs a mandatory benefit for the categorically and medically needy, effective January 1, 2014.

Prevention – The Mark would provide Medicare beneficiaries with access to a comprehensive health risk assessment based on guidelines developed by the Secretary in consultation with relevant groups and entities. The assessment would identify chronic diseases, modifiable risk factors, and emergency or urgent health needs, including a list of all medications currently prescribed and all providers regularly involved in the patient‘s care.

Conclusion

After a summer fraught with hysteria over health care reform, September saw the return of some stability to the process.

The passage of a bill through the Senate Finance Committee was a vital step. Of importance, the nonpartisan CBO determined that the bill would not add to the federal budget deficit but would dramatically reduce the number of uninsured Americans.³ This favorable CBO “score” is vital to securing the support of Republicans and moderate Democrats.

Yet difficult negotiations lie ahead. House Democrats remain divided over the controversial “public option,” and senior citizens across the country continue to voice their concerns over proposed Medicare cuts.

ACCP continues to work with its pharmacy stakeholder colleagues to develop a strategy to ensure that the provisions affecting clinical pharmacists’ services remain in the bill during the process of merging and reconciling the language. As the process moves onto the House and Senate floor, a comprehensive grassroots response will likely be called for to protect these important provisions.

ACCP members are reminded to visit the College’s Legislative Action Center to communicate directly with elected officials on the importance of protecting the provisions that allow access to vital clinical pharmacists’ services.

References

1. Rasmussen Reports Opinion Poll. Available at View Website. Accessed October 5, 2009.
2. Time Magazine. Available at View Website. Accessed October 5, 2009
3. Washington Post article. Available at View Website. Accessed October 7, 2009.