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Community Pharmacy State of the Union

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ACA Repeal-Replace Does Not Deter 115th Congress from Introducing Important Legislation to Support Community Pharmacy

March 10, 2017

The start of the 115th Congress and President Donald Trump’s Administration has been nothing short of exciting when it comes to healthcare and health policy.  With both the House of Representatives and the Senate under Republican control as well as the White House, GOP lawmakers are under pressure to deliver on one of their signature campaign promises – repeal and replace the Affordable Care Act (ACA) or Obamacare.

At fifty days into the Trump Administration, it is clear that making changes to the ACA will be harder than expected.  Even President Trump stated that, “Nobody knew healthcare could be so complicated.”  From a grassroots standpoint, citizens concerned that they will lose or have an increasingly difficult time finding healthcare coverage are turning out in droves to town hall meetings and expressing their opinions to federal, state, and local elected officials.  Media, professional and patient advocacy groups have been quick to hold President Trump and Congressional Republicans accountable on their policy proposals, making it difficult to pivot from ideas that may not be politically popular.  While House Republican lawmakers have put forward their repeal and replace plan, the American Health Care Act (AHCA), some within the Republican Party—especially in the moderate and conservative wings—have expressed opposition to the proposal.  These concerns are rooted in numerous factors, including political ideology, re-election politics, state specific concerns, policy objectives and general procedural questions (repeal and replace simultaneously vs. repeal, delay and then replace) and have splintered the once unified message of get rid of Obamacare.

One area of focus within the context of ACA repeal and replace that has proven to be particularly thorny for lawmakers is Medicaid reform.  The ACA gave states the option to expand their Medicaid program in exchange for enhanced federal funds for the additional lives that the program would cover.  Over 30 states expanded their programs.  Under the House Republican legislation, the Medicaid expansion under the ACA would continue until 2020 but would shift to per-capita caps, which would cap federal funds per Medicaid beneficiary.  The fixed sum of money could cause financial constraints, especially for States that have received an increase in matching funds from the federal government as part of their decision to expand their Medicaid programs.  Consequently, under this proposal many of these states may have to limit the scope of services they provide.  Although pharmacy benefits are technically an optional benefit under the Medicaid program, all states provide for them.  Pharmacy benefits range from state to state and changes to the financing of Medicaid could affect the delivery of these services to patients.  The ACA also contained provisions pertaining to fee-for-service Medicaid reimbursement for covered outpatient drugs.  In January 2016, the Centers for Medicare & Medicaid Services (CMS) finalized these drug payment provisions when the agency issued the Covered Outpatient Drugs Final Rule.  This rule, which implements significant changes to pharmacy reimbursement, helped to ensure patient access to pharmacy services and prescription drugs.  The repeal proposal put forward in the House bill does not directly affect these provisions.  However, under per-capita caps and potentially less federal funding, states that operate under a fee-for-service system could decide to move to managed care in an effort to better manage costs.  The move to per-capita-caps and a subsequent move to managed care could result in less patient utilization of pharmacy services, fewer prescriptions, and further challenges to pharmacy financial viability, which in turn could impact patient access to care.

This is the very beginning of the legislative process and many aspects of the House bill could change as the health committees and the full House of Representatives debate it.  And, in the Upper Chamber, some Republican Senators have stated they would like to see changes to the bill, especially as it pertains to the Medicaid provisions.  This is a fluid process and what is currently proposed will likely change.

While the ACA repeal-replace debate has gone on Congress has been tending to other legislative proposals impacting retail and long-term care pharmacy.  In January, Senators Chuck Grassley (R-IA) and Bob Casey (D-PA) and Representatives Brett Guthrie (R-KY) and G.K. Butterfield (D-NC) re-introduced S.109/H.R.592 the Pharmacy and Medically Underserved Areas Enhancement Act.  This much-needed legislation would recognize pharmacists as providers of care under the Medicare program for a range of services as defined by state scope of practice laws, which would ultimately increase patient access to care in medically underserved areas.  The bill, which enjoys broad bipartisan and bicameral support, has over 30 cosponsors in the Senate and over 130 cosponsors in the House.   Over 30 pharmacy, patient, and consumer groups, including the National Community Pharmacists Association (NCPA), the National Association of Chain Drug Stores (NACDS), the Senior Care Pharmacy Coalition (SCPC), the American Pharmacists Association (APhA), as well as AmerisourceBergen have endorsed the measure.  

Additionally, Members in the House and Senate re-introduced legislation to address the proliferation of direct and indirect remuneration (DIR) fees.  The Improving Transparency and Accuracy in Medicare Part D Spending Act (S.413/H.R.1038) would effectively ban all retroactive DIR fees on clean claims.  The bill, which AmerisourceBergen, NCPA, and others have endorsed, is sponsored by Senators Shelley Moore Capito (R-WV) and Jon Tester (D-MT) and Representatives Morgan Griffith (R-VA) and Peter Welch (D-VT) and seeks to build off the growing attention that CMS and others have given to DIR fees by effectively assessing them at the point of sale.  Some groups have floated, but not formally introduced, other ideas to address DIR fees, such as increasing transparency of DIR fees by revamping reporting requirements to CMS, assessing quality measures and their applicability to certain pharmacy settings (specialty vs. retail), and a complete ban on fees.  During his confirmation hearing, Secretary of Health and Human Services, Tom Price, responded to a question from Senator Sherrod Brown (D-OH) that he would work with Congress on addressing outstanding CMS guidance with respect to transparency around DIR fees.  This issue will remain one of pharmacy’s top priorities in 2017 and more action is expected.

Finally, last week, Representatives Doug Collins (R-GA) and Dave Loebsack (D-IA) introduced H.R.1316, the Prescription Drug Price Transparency Act, which would require PBMs to update their Maximum Allowable Costs (MAC) lists for Medicare Part D, TRICARE, and FEHBP every seven days to protect competitive pricing and to preserve pharmacy access and choice for patients.  Other cosponsors include: Reps. Buddy Carter (R-GA), John Duncan, Jr. (R-TN), John Sarbanes (D-MD), Cathy McMorris Rodgers (R-WA), Rod Blum (R-IA), and Brian Babin (R-TX).  The Community Oncology Alliance (COA), the National Association of Specialty Pharmacy (NASP), NCPA, and SCPC have endorsed this legislation.

This article was originally published on Our Independent Voice which provides resources and information on the issues that matter most to independent pharmacists.

Over the coming weeks, Congress and the Trump Administration will continue to move forward on ACA repeal and replace proposals and other health care agenda items. AmerisourceBergen will continue to monitor these activities and is committed to working with our coalition partners to ensure continued patient access to community retail pharmacy.   Please stay tuned to OurIndependentVoice.com for the latest updates on pharmacy related issues.

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