As the calendar winds down in 2009, we can begin to reasonably reflect on a year that will surely stand out as a main turning point for the nation’s health care system. Will patients, health care professionals, and the nation’s overall health status, both clinical and financial, soon begin to reap the anticipated benefits of efforts to deliver on the long “wish list” of improvements to our health care system? Will this wish list, discussed and sought after for almost three decades but stymied repeatedly by the sheer magnitude of the necessary changes and an insufficient national political will, finally be delivered?

Most of us have had the personal experience, particularly when we were younger, of putting together our holiday wish list. Then, on the big day, we realize that we either did not get a key wished-for item or perhaps unwrapped something similar to what we had put on our list but did not quite meet our expectations. Often, however, usually with use and experience, the gift turned out to provide both the pleasure and the benefit we had hoped for. We may not always get what we want, but we often end up getting what we need. That may prove to be one of the principal lessons learned from this round of health care reform. Moreover, it is a certainty that the current effort will not accomplish all that it should to improve the availability, quality, and cost-effectiveness of needed health care services, including those provided by clinical pharmacists.

As this column goes to press, the U.S. Senate remains in session to meld the work of the committees on Finance and Health, Education, Labor, and Pensions into a single piece of legislation for a vote by the full Senate before adjourning for the holidays. Although many differences exist between the two measures, the final bill will undoubtedly result in changes that will bring the following outcomes. (1) Expand access to both needed care and insurance coverage for millions of currently uninsured and underinsured Americans. (2) Require substantial reforms in the private health insurance industry’s approach to preexisting condition exclusions and coverage cancellations, among other reforms. (3) Promote and support innovations in health care systems delivery and care processes, particularly with respect to primary care and team-based care delivery. (4) Bring reform to payment policies and coverage within the Medicare and Medicaid programs. Still unresolved is whether some form of “public option” for insurance coverage that would compete with private health insurance plans will be an element of the final Senate language.

The House of Representatives passed similarly sweeping reform legislation on November 7 by a vote of 220-215. The Affordable Health Care for America Act (H.R. 3962) expands coverage to 36 million Americans. This additional coverage creates an insurance exchange that offers private plans as well as a public insurance option, provides premium subsidies to help individuals and families purchase coverage, broadens the Medicaid program, and implements a series of insurance market reforms such as a ban on discrimination based on preexisting conditions. The Congressional Budget Office estimates the price to be $1.05 trillion in the first 10 years of implementation.

Despite its prodding and urging of the Congress, the Obama administration is likely to see its goal of signing health care reform legislation into law before the end of 2009 deferred to the early part of 2010. Even with the Senate’s anticipated passage of a final bill before the holiday recess, the work of resolving the differences between the House and Senate versions of the mammoth legislation in a conference committee, followed by final votes in both chambers on the conference committee report, will move the process several weeks into 2010. Even the president of the United States cannot always get what he wants … but he will probably get what he needs as an important first step in his administration’s agenda to achieve comprehensive health care reform as a centerpiece of his presidential and political legacy.

Parallels exist in clinical pharmacy’s health care reform wish list. For the past decade, ACCP’s advocacy efforts have focused directly and strategically on recognition of and payment for pharmacists’ clinical services within Medicare and other insurance programs, particularly efforts to cover such services under the traditional fee-for-service payment model that has been the hallmark of the Medicare Part B program covering physicians’ and other providers’ professional services. Through periods of limited progress early in the decade as well as subsequent strategic “detours” created by the establishment of the Part D outpatient drug benefit with its very basic medication therapy management services requirement, the advocacy efforts of ACCP have remained at the top of clinical pharmacy’s wish list. So far, we have not been very successful in getting either what we want or what we need.

But 2009 and the expansive, multi-stakeholder discussions around the needed changes in the nation’s health care delivery system have opened many doors for dialogue, and ACCP has actively walked through many of those doors throughout the year. These discussions include ACCP’s active involvement in the Patient-Centered Primary Care Collaborative advocacy for the patient-centered medical home model (and the inclusion of team-based medication management involving pharmacists in that model). As well, the Institute of Medicine’s Best Practices Innovation Collaborative, focused on improvements in chronic care management and coordination, is included in these discussions, as is the unified message from the full spectrum of the pharmacy profession with respect to key principles for health care reform related to professional services, payment reform, infrastructure support, and health information technology.

Through these collaborations and discussions, we have gained a much better appreciation for the health reform wish lists and concerns of most other key stakeholders in the process—patients, other providers, employers who are purchasing health benefits and services, insurers, and, of course, government. In fact, there may be many more concerns in common among us all than we have realized. A prime example is the growing recognition across a wide spectrum of interests, particularly among the primary care medical community but also among purchasers and employers, that the dominant model of payment for professional services that relies exclusively on a fee-for-service framework to practitioners must undergo reform. Indeed, the predominant payment model for such professionals working within their isolated silos must be substantially reformed (if not abandoned entirely) if the goals of patient-centeredness, enhanced quality based on evidence-based practice, and continuous, coordinated care are to be achieved. Evidence that care provided by interprofessional teams of providers enhances clinical outcomes, patient satisfaction, and cost-effectiveness has been generated despite the misalignment of most current payment methodologies that do essentially nothing to support the delivery of interprofessional care.

The good news is that key provisions of both the House and Senate bills support the expansion of the patient-centered medical home practice model and call for the inclusion of pharmacists and comprehensive medication management services as essential components of grant programs to support the development and maturation of this and similar models of care. The bills recognize the critical importance of quality medication management services, particularly for patients with multiple chronic diseases, patients with multiple care providers, and patients who undergo transitions from one care setting to another. Enhanced support for interprofessional health professions education programs is also contained in both the House and Senate measures. These concepts have received strong bipartisan support throughout the committees’ work and the floor debates, despite substantial disagreement over the few highly charged political issues that have drawn much of the media’s coverage of health care reform. However, many challenges remain to be addressed, especially with respect to how payment policy and procedures can be changed to support the actual flow of dollars to practices that provide the services of a truly integrated and interprofessional team of providers, particularly in conjunction with smaller medical practices, smaller communities, and rural areas.

Nevertheless, these developments offer substantial promise for ACCP and its members. The theme of Dr. John Murphy’s just-concluded tenure as ACCP President has proved to be particularly enlightened—and valuable—throughout this year of health care reform discussions: “No Silos, No Boundaries.” We have used that message to substantial beneficial effect as we have expanded our engagement with colleagues in medicine, nursing, and other disciplines to provide our perspective, our ideas—and yes, our wish list—for integrating the patient care services of clinical pharmacists into the clinical and economic fabric of a reformed health care system. We are finding a consistently receptive audience for this message when we speak not of what we want, but of what patients and the health care system need that clinical pharmacists can provide within the framework of that interprofessional team.

It is possible that as the health care reform movement continues into 2010 and beyond, ACCP members, and the College itself, will not get precisely what we have had on our wish list for the past decade. Perhaps, instead, we will get something closer to what we need to be successful as true “providers” of care—a reformed delivery system that is both philosophically and functionally patient-centered and that supports collaborative and team-based care through education, practice model innovation, and payment policy reform. This could be an outcome that, when we look back years from now, proves to be a wonderful gift.

From the staff of the Washington office of ACCP, our best wishes to you and yours for the upcoming holiday season.