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ACCP Report - February 2013

Washington Report

Coverage for Clinical Pharmacy Services in Medicare: Understanding the Legislative Process

Written by John McGlew
Associate Director of Government Affairs



Until now, ACCP’s initiative to pursue recognition of the direct patient care services of qualified clinical pharmacists as a covered benefit under the Medicare program has focused on what Washington would call the “policy” side of the question. This discussion addressed the vital work of developing a consistent definition of direct patient care services (the “what”) and the credentials and experience necessary to ensure that a clinical pharmacist (the “who”) could competently provide direct patient care services in a collaborative practice structure.

But as we move forward with this effort, our focus is shifting toward a broader examination of the “political” side—the process of working with Congress to develop and pass legislation that would amend the Social Security Act to include coverage of clinical pharmacy services under Part B of the Medicare program.

Developing Our Message

It is no secret that lengthy, overly technical communications documents are neither welcome nor appreciated on Capitol Hill. Busy congressional staff need concise, direct issue briefs that clearly articulate the problem (in this case, that 13% of total health care costs are associated with managing drug-related morbidity and mortality)1 and the solution (amending the Social Security Act to include clinical pharmacists on the team of health care professionals).

Of course, brevity alone will not advance our initiative. We are fully prepared to explain and defend our proposal in a comprehensive manner and provide a variety of data and evidence to illustrate that engaging pharmacists to deliver direct patient-centered, team-based care will improve outcomes and lower costs. But to launch our initiative on the Hill, it is vital that our message be clear, succinct, and easily understood.

Message Alignment

It is also important to align our political message with the legislative priorities of the current Congress and administration. In the area of health care, these might include the following:

  • Affordable Care Act Implementation. After the struggle to secure passage of the Affordable Care Act (ACA) through Congress and the judicial system, overseeing its full implementation is a clear priority in the 113th Congress, at least for the Obama administration and congressional Democrats. Although much of the focus will be on big-ticket provisions such as the establishment of state-based exchanges and enforcement of the individual mandate, there are opportunities for ACCP to align our initiative with the team-based integrated-care models that the ACA embraces.
  • Medicare Payment Reform. There is not much Democrats and Republicans in Washington can agree on at the moment. But that Medicare, in its current form, is fiscally unsustainable has been widely acknowledged on both sides of the aisle. Admittedly, there is a lack of consensus on a solution to the crisis—Democrats have provided little in the way of concrete reform proposals, and Republicans have offered the controversial option of a block grants approach to the program. Nevertheless, reforms that could help secure the long-term future of Medicare by improving quality and outcomes—without simply cutting provider payments or reducing benefits to seniors—should be of interest to lawmakers across the political spectrum.
  • Demographic Challenges to the Health Care Delivery System. Under the ACA, up to 30 million Americans will soon have access to health insurance coverage. Meanwhile, during the next 18 years, members of the baby boom generation will turn 65 and qualify for Medicare at a rate of 8,000 per day.2 It is unclear how the health care delivery system, particularly at the primary care level, will cope with this demographic burden. ACCP’s initiative—consistent with accountable care organizations or patient-centered medical homes in a reformed, consolidated health care delivery system—offers the promise that by ensuring the medication component of a patient’s care is safe, appropriate, and therapeutically optimal, other members of the health delivery team will be free to focus on the areas where they can have the greatest impact, practicing at the top of their licenses, to collaboratively achieve the goal of better care, better outcomes, and lower costs.

Identifying Political Champions

In seeking to identify potential champions to advance our initiative in Congress, we need to identify elected officials who share our vision of a more patient-centered, team-based, and quality-focused approach to Medicare who also sit on the congressional committees of jurisdiction over the Medicare program itself.

In the House of Representatives, jurisdiction over Medicare is shared between the Energy and Commerce Committee and the Committee on Ways and Means. In the Senate, the Finance Committee oversees Medicare issues. Members who sit on these committees are best placed to introduce legislation on behalf of ACCP and work to ensure its passage into law.

  • Click here to view the members of the Senate Finance Committee.
  • Click here to view the members of the House Energy and Commerce Committee.
  • Click here to view the members of the House Ways and Means Committee.

In addition, legislation would ideally be introduced in a bipartisan manner, meaning a Republican and a Democrat from a committee of jurisdiction would work together to cosponsor a bill on our behalf. Although we acknowledge the challenge of identifying bipartisan cosponsors from the key committees of jurisdiction, we have taken care to ensure our legislative proposal is entirely nonpartisan and have focused on the issues that members from both parties can agree on—improving quality and lowering costs in the Medicare program.

To determine whether your elected officials sit on a committee of jurisdiction, visit our Legislative Action Center and enter your zip code to view your congressional delegation. Check your work zip codes as well as your home address—especially if you practice in several sites. Members of Congress will be interested to learn about innovative, cost-saving care delivery going on in their district, even if you are not a constituent residing in that district.

Navigating the Congressional Budget Office Challenge

The Congressional Budget Office (CBO) is the federal agency 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 chamber of Congress. The CBO is strictly nonpartisan and conducts objective, impartial analyses but does not make policy recommendations on the legislation for which it develops a cost estimate or budget “score.”

Of importance, the agency does not engage in “dynamic scoring,” which is 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 only estimate the up-front cost of paying clinical pharmacists for their direct patient care services under the Medicare program, not the overall savings these services would produce as a result of “getting the medications right.”

In the current fiscal environment, Congress is understandably reluctant to adopt measures that come with a CBO price tag. However, the existing Medicare fee-for-service structure that rewards volume rather than quality is no longer viable. Faced with the prospect of slashing payments to providers or reducing benefits to seniors, Congress is already considering proposals that will fundamentally change the way Medicare pays for care. ACCP believes that our proposal can be incorporated as part of this broader payment reform discussion.

In addition, the CBO recently released a report on the Medicare Part D prescription drug program that shows a link between changes in prescription drug use and changes in the use of and spending for medical services, even though the CBO’s cost estimate for the Medicare Modernization Act of 2003 (which established the Part D benefit) did not include an offset, nor did its estimates of the cost of the ACA (which includes provisions closing the Part D coverage gap).

The report found that a 1% increase in the number of prescriptions filled by beneficiaries would cause Medicare’s spending on medical services to fall by about one-fifth of 1%.3

The release of this report should not imply that the CBO plans to change the methodology it uses to score legislation. But it does provide a timely reminder to lawmakers that expenditures in one area of the Medicare program can yield even greater savings in other areas.

Advancing Provider Status Through Grassroots Action

It is no exaggeration to say that without the active participation of ACCP members in the advocacy process, this initiative cannot succeed.

We believe that our investment in our Washington office and advocacy activities during the past 12 years leaves us well placed to move our initiative forward. But our success ultimately lies in the engagement of ACCP members to help their elected officials understand the importance of “getting the medications right” as part of patient-centered, team-based models of care delivery.

With more than 13,000 members, not to mention their professional colleagues and patients, ACCP has the potential to exert a considerable influence on Capitol Hill. But to realize this potential, we need the active participation of all of our members as grassroots advocates.

ACCP’s Step-by-Step Guide to Hosting a Visit of Elected Officials to Your Practice Setting

A key element in the internal ACCP discussion leading up to the launch of our legislative initiative was around the need to develop a consistent, standardized process of patient care—recognition that clinical pharmacists’ contributions to patient care are often difficult to define could act as a barrier to achieving recognition and payment for those services.

If this definitional question persists even within the health care community, it is understandable that lawmakers in Congress might struggle to grasp what we are proposing when we call for coverage of direct patient care services by qualified clinical pharmacists.

Hosting a visit of your elected officials to your practice is perhaps the single most important thing you can do to help lawmakers understand what team-based, patient-centered clinical practice is all about—and to generate their support for recognition and payment for clinical pharmacists’ services.

A visit also serves as a means to establish an ongoing constructive dialogue with your congressman or senator, and his or her staff, on issues important to the delivery of team-based, patient-centered care.

A comprehensive guide to inviting a member of Congress to tour your practice site is available on our Legislative Action Center. If you would like to discuss the process of hosting a lawmaker at your practice site, please contact John McGlew at (202) 621-1820 or jmcglew@accp.com.

All ACCP members are urged to consider inviting their elected officials to learn more about their practice through a tour of their practice site.

Advancing Provider Status Through the ACCP Political Action Committee (ACCP-PAC)

There is a widely used analogy of advocacy as a three-legged stool—with the three legs composed of direct lobbying, grassroots action, and financial support for candidates.

Political contributions are an essential component of our grassroots advocacy toolkit, helping to raise our profile on Capitol Hill and show our support for members of Congress who share our vision for clinical pharmacists in an evolving Medicare program.

A well-funded PAC can be used to demonstrate the support within the profession for our legislative initiative and the importance that ACCP members attach to moving it forward in Congress.

ACCP-PAC depends entirely on the support of ACCP members. Although several PACs represent various segments of the pharmacy profession, ACCP has the only PAC dedicated to advancing the practice of clinical pharmacy.

With more than 13,000 ACCP members eligible to contribute to the PAC, ACCP is in a position to become one of the most prominent pharmacy PACs in Washington. To do this, we need the widespread support of our membership.

If each ACCP member contributes just $25, ACCP-PAC will raise $300,000. All ACCP members should consider making a donation of at least $25 to ACCP-PAC. CLICK HERE to support your PAC today!

ACCP-PAC Governing Council

ACCP-PAC is directed by the PAC Governing Council, which provides oversight and strategic leadership for the operations of ACCP-PAC.

The ACCP-PAC Governing Council consists of the following ACCP members:

Chair: Leigh Ann Ross, Pharm.D., BCPS
Treasurer: Gary R. Matzke, Pharm.D., FCP, FCCP
Secretary: Michael S. Maddux, Pharm.D., FCCP
Member: Anna Legreid Dopp, Pharm.D.
Member: Terry Seaton, Pharm.D., FCCP, BCPS (Board of Regents Liaison)

ACCP funds the administrative expenses associated with operating the PAC, so all member contributions go directly to support pro-clinical pharmacy candidates.

CLICK HERE to support your PAC today!

Contact us! 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 Avenue NW
Suite 400
Washington, DC 20004-1017
(202) 621-1820
jmcglew@accp.com

References

  1. New England Healthcare Institute. Thinking Outside the Pillbox: A System-wide Approach to Improving Patient Medication Adherence for Chronic Disease. Appendix I. August 2009. Available here. Accessed February 7, 2013.
  2. AARP Article: As the First Boomers Turn 65, They Face Choices on Health Care, Retirement. November 10, 2010. Available here. Accessed February 7, 2013.
  3. Congressional Budget Office Report: Offsetting Effects of Prescription Drug Use on Medicare’s Spending for Medical Services. November 2012. Available here. Accessed February 7, 2013.