Doctors, nurses and patients will start to see changes take effect as a result of the federal health reform law that goes into effect in 2014. Pharmacists will also see lots of changes, and they need to know what to expect.
By Nancy Wang
Local pharmacists are sharpening their pencils and heading back to school to get ready for the changes coming to Medicare as the federal health reform bill kicks into effect.
About 45 pharmacists – mostly Triangle-based – sat through a two-and-a-half hour presentation in Durham earlier this month that covered all the things they need to know to comply with the law as it gets implemented over the coming year. Many of those pharmacists work with seniors who depend on Medicare, and they’ll need to be up to speed on changes to that program too.
Some of them appeared pretty dazed by the time it was done.
“It’s a lot for anyone to take in and keep straight,” said Gina Upchurch, the director of Senior PharmAssist, who taught the class. “And pharmacists don’t get paid a dime to deal with the headaches.”
Upchurch’s organization, Senior PharmAssist is a non-profit that helps Durham seniors get access to and learn about their medications. Upchurch held the continuing education session at the Durham Center for Senior Life, where her office is located.
The students were pharmacists from hospitals, independent and retail pharmacies and technicians. They gathered to learn about the upcoming changes to Medicare Part D, which deals with drug coverage and prescription plans for seniors and people with disabilities.
Since the Affordable Care Act, often referred to as Obamacare, passed in 2010, there have been many phases of change to health insurance coverage and reimbursements. Pharmacists, especially those who work with seniors, have to understand and explain the changes to their patients, many of whom have multiple health problems and may take handfuls of drugs every day.
Hospitals and corporations like CVS Pharmacy are holding training sessions to help their pharmacists, but independent pharmacists are expected to figure out the changes on their own.
“Initially there were some training programs for pharmacists who weren’t part of a hospital or bigger company, but there hasn’t been as much support since [2010],” Upchurch said.
All certified pharmacists in North Carolina are required to complete at least 15 hours of continuing education credits annually in order to maintain their state license, so Upchurch decided that this was a great way to pass on the information to independent pharmacists who may lack the resources otherwise.
Changes ahead
Starting in 2013, Medicare patients will get more government support when they fall in the insurance donut-hole, the gap in coverage that Medicare recipients experience after spending a certain amount out-of-pocket.
In the coming year, the donut hole will open up after patients spend $2,970 for out-of-pocket drugs, extending the coverage by $40 from this year. Discounts for certain medications will also be increased. Some brand medications will be discounted at 52.5 percent, up from last year’s 50 percent, and some generic drugs will be discounted at 21 percent, up from last year’s 14 percent.
But, these discounts may not offset rising drug prices.
The most recent AARP Rx Price Watch Report released in March found that prices for 469 prescription drugs on the market – including those that are the most used among the elderly – increased by 25.6 percent from 2005 through 2009. More recent data is not yet available but many pharmacists say they see increasing costs for their clients.
One attendee commented on his retired mother’s drug plan, noting that even with the increased discounts, the price of her drugs has gone up year after year.
Payments to be based on patient experience
This lag in the intended outcomes of the ACA and the current situation is not just limited to medication prices. Many pharmacists at the event also voiced their frustration over poor communication with physicians and other providers.
“I had an elderly patient who needed an antibiotic not covered by her plan and the doctor told me that she could either pay $100 now for the necessary antibiotic or $1000 later when she comes back to the hospital sick again,” said Darius Russell, an independent pharmacist at Durham’s Central Pharmacy.
“This patient has Medicaid and Medicare, so when I told her that the doctor wanted her to pay $100 for a seven-day course of antibiotics, she told me that she would just go without it.”
Such interactions with physicians are not rare.
“[Pharmacists] don’t have a unifying voice like the [American Medical Association] because there are so many different kinds of pharmacists who work in such different settings,” said Vincent Gaver, a pharmacist at CVS Caramack. “Because we are so fractionalized, it’s harder for us to fight for a seat at the table and to establish ourselves as a member of the health care team.”
Upchurch agreed, but said she believes the health care reform’s emphasis on outcomes over the traditional fee-for-service model will encourage providers and pharmacists to work together.
“You’re going to see this big tug-of-war between the hospitals and the insurers,” said Upchurch. “And if the hospitals play well in the community and engage community partners like pharmacists, it will help them get the outcomes they want.”
The focus on patient outcomes has already started to affect Medicare payments.
As of Oct 1, reimbursement payments to hospitals will be reduced by one percent for hospitals that have many patients who get readmitted within 30-days of discharge. That reduction will increase to two percent in 2014 and reach a cap of three percent in 2015.
Upchurch said even though that seems like a small amount, for hospitals with many Medicare patients, those are strong incentives to make sure patients stay healthy once they return home.
She said it’s systematic changes like this that has her optimistic about the future role of pharmacists and pharmacy technicians, an optimism she hopes catches on to others in her field.
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