Policy Analysis: Pharmacy and Medically Underserved Areas Enhancement Act

Policy Analysis: Pharmacy and Medically Underserved Areas Enhancement Act

By Ryan Mills

Overview of the Health Problems

While the Affordable Care Act (ACA) provided health coverage for more Americans, it also increased the demand for health services. Despite the implementation of the ACA, over 20% of Americans do not have access to primary care physicians (PCPs) largely due to the fact that the current supply of PCPs does not meet the market’s demand, especially in rural areas. In the rural North Carolina county of Columbus, for example, the County Health Ranking report states that the ratio of PCPs to patients is 2,620:1. (1) According to Health Workforce Analysis conducted by Health Resources and Services Administration (HRSA), the projected shortage of PCPs will be 20,400 in 2020. (2) Of note, this is the national average and does not account for the disparity between rural and urban areas. The supply of PCPs in rural areas is forecasted to be well below the national average. Due to the aging of the baby boomer generation and the implementation of the ACA, the demand for primary care services will sharply increase through 2020. The HRSA projects the demand for care will be far greater than the supply of PCPs and increased optimal use of non-physician providers can help mitigate the PCP shortage and bridge the gap in care for patients. Pharmacists are an integral part of the healthcare team, and when integrated, patients, providers, community, and healthcare systems all benefit. (3) Granting pharmacist’s provider status in medically underserved areas is one way of increasing access to care. H.R. 592 and S. 109 seeks to amend the Social Security Act in which Medicare would recognize pharmacists as healthcare providers enabling coverage for pharmacist-provided clinical services. Passage of H.R. 592 and S. 109 into law would mean pharmacy services consistent with state laws, provided to Medicare beneficiaries in medically underserved areas, and would be reimbursable under Medicare Part B.

In North Carolina, pharmacists can administer most vaccines designated by the CDC without a prescription. North Carolina pharmacists, with appropriate training and experience, can obtain their Clinical Pharmacist Practitioner (CPP) credential and enter into collaborative practice agreements with physicians, whereby the physician grants authority to the pharmacist to provide specific patient care services. Physician-pharmacist collaborative practice authority has been used in North Carolina since 1998 as a means to provide improved care for patients with conditions such as diabetes, hyperlipidemia, hypertension, hypothyroidism, osteoporosis, chronic pain and smoking cessation. (4)

Severity of the Health Problem

Access to PCPs is vastly different in rural communities in comparison to urban areas. Rural communities across the U.S. face many contributing factors that create disparity in the delivery of healthcare. According to the National Rural Health Association report, living in remote areas correlates with poorer health due to social and economic factors such as educational shortcomings, health behaviors, and lack of access to care. Table 1 illustrates the disparity between urban and rural areas in the US. The increasing demand for healthcare services coupled with the vast difference in the percentage of physicians in rural compared to urban areas magnifies the importance of passing H.R. 592/S.109.

Health Snapshot (1)

Percentage of USA Population Percentage of USA Physicians Number of Specialists per 100,000 population Population aged 65 and older Population below the poverty level Average per capita income Population who are non-Hispanic Whites Adults who describe health status as fair/poor Adolescents (Aged 12-17) who smoke Male death rate per 100,000 (Ages 1-24) Female death rate per 100,000 (Ages 1-24) Population covered by private insurance Population who are Medicare beneficiaries Medicare beneficiaries without drug coverage Medicare spends per capita compared to USA average Medicare hospital payment-to-cost ratio Percentage of poor covered by Medicaid

Rural Urban

20% 79% 10% 90% 40.1 134.1 18% 15% 14% 11% $19K $26K 83% 69% 28% 21% 19% 11% 80 60 40 30 64% 69% 23% 20% 45% 31% 85% 106% 90% 100% 45% 49%

Overview of the Bill

In 2018, House Bill 592 and Senate Bill 109 was reintroduced and assigned to a congressional committee who will decide if the bill will be passed in the House and Senate. Sponsors of this bill are Sen. Charles Grassley (R-Iowa), Rep. Brett Guthrie (R-Kentucky), Rep. G.K. Butterfield (D-North Carolina), Tom Reed (R-New York), and Ron Kind (D-Wisconsin). The probability of these bills being enacted as standalone bills is 3%. (5) Both bills are titled “The Pharmacy and Medically Underserved Areas Enhancement Act” and follow 2014 House Bill 4190. The scope of the bill would serve to recognize pharmacists as providers under Medicare Part B. The patient populations targeted include those in Medically Underserved Areas, Health Professional Shortage Areas, and the Medically Underserved Populations. The reason this bill is limited to only medically underserved communities is that it fulfills a nationwide gap in medical care. Pharmacists have the appropriate education and training to help fill this void and focusing on this gap is a means by which pharmacists can draw attention to the need for our profession to be included as physician extenders. Nurse practitioners and physician assistants used similar approaches to gaps in care when seeking their provider status designation.

Reimbursement, as established by the Social Security Act, would be consistent with Medicare’s payment for nurse practitioners and physician assistants. The rate is 85% of a physician’s fee. The authorized pharmacy services would be in accordance

with the state’s scope of practice laws. If passed, the bill would increase patient access to quality care by allowing pharmacists to render services consistent with their level of education, training, and licensing. Most importantly, the legislation would not expand the scope of pharmacy services, but it would allow services to be rendered that are already authorized under state laws.

The bill is a cost-effective solution to health care by increasing patient access to care. It offers the opportunity for early intervention, such as drug therapy management, to help minimize long-term cost.

Proponents

The Patient Access to Pharmacists’ Care Coalition’s (PAPCC) is an inclusive multi-stakeholder group that represents a wide range of pharmacy professionals and other stakeholders who want to improve access to patient care services offered by pharmacists in the outpatient settings. Medicare Part B already encompasses all outpatient settings in which pharmacists work, such as medical homes, hospital clinics, physician offices, health systems, urgent care centers, community pharmacies, and other ambulatory care settings. Also, national pharmacy associations such as the American Pharmacy Association (APhA), American Society of Health-System Pharmacists (ASHP), National Community Pharmacy Association (NCPA), and the National Association of Chain Drug Stores (NACDS), support this legislation. The “provider status legislation” is the one issue in which all of pharmacy has rallied to support as one collective voice.

This legislation has tremendous bi-partisan support as well. H.R. 592 / S.109 currently has 282 cosponsors (165 Republicans/117 Democrats) for the House bill and 52 cosponsors (28 Republicans/25 Democrats/1 Independent) for the Senate bill. Both North Carolina Senators have endorsed their support of S. 109. In the House, 11 of our 13 Representatives endorsed H.R. 592. The two remaining NC legislators in need of signing on are Rep. Virginia Foxx (R-District 5) and Rep. Patrick McHenry (R-District 10).

The PAPCC is also implementing long-term strategies to educate the public on the pharmacy profession’s potential to improve medication therapy outcomes and overall public health. The most recent initiatives include an advertisement campaign targeting seniors about the role of the pharmacist, providing education to House and Senate members, and including the bill in the opioid legislation to improve the likelihood of approval.

Opponents

H.R. 592 or S. 109 as written still have many hurdles to overcome with competing priorities. The main challenge the bill faces is the cost to the Medicare program. The PAPCC is working on that issue, and although better medication use will save the healthcare system money in the long run, convincing the Congressional Finance Committees will be difficult. One of the reasons the earlier House Bill (HR.4190) did not pass is that it did not have a Congressional Budget Office (CBO) “score.” In the current session, the CBO has not scored the bill, but additional cost analysis based on a score produced during the previous 114th Congress has projected the cost to be less than $1 billion per year over the next ten years.

Congress is looking at the parallels between provider status and fee-for-service. They are primarily focused on cost savings rather than new additional costs. Data analysis to show future cost savings by improving population health will increase the probability of approval. In addition, data showing how this legislation can help with the opioid epidemic is likely to also be viewed favorably.

Concerns voiced by members of the House and Senate are centered around the position of the American Medical Association (AMA), the cost of the bill, and level of support. At this time, the AMA neither opposes nor supports the bill and bipartisan support in both the House and Senate are strong. Furthermore, physician members in the House of Representatives, Roe (R‐Tennessee) and Bera (D‐California), are cosponsors of the bill.

Unintended Consequences

Since the bill focuses on the underserved and is not viewed as

an attempt to compete with other health professionals, it is hard to argue against the proposed legislation; however, two potential problems with this bill have been identified. First, there could be an increase in cost of Medicare Part B which could increase premiums for beneficiaries. Second, the AMA could oppose the legislation because as the supply of providers increases, the demand for services may decrease which could threaten provider salaries and wages.

The cost of Medicare Part B is the biggest hurdle, but limiting pharmacy provider services to the medically underserved areas will limit the rise in costs billed to Medicare. Moreover, experts forecast a reduction in the costs to Medicare Part A (hospital coverage) because of preventive care. Data collected over the first few years can determine if a new bill to grant broader coverage into other healthcare areas would be beneficial.

Historically the AMA has opposed nurse practitioners and physician assistants practicing medicine without physician supervision. The AMA’s position has been to “oppose legislation allowing non-physician groups to encroach on the practice of medicine without physician (MD, DO) training or appropriate physician (MD, DO) supervision; and (we) continue to encourage state medical societies to oppose state legislation allowing nonphysician groups to encroach on the practice of medicine without physician (MD, DO) training or appropriate physician (MD, DO)

supervision.” (6)

A Call for Action:

Widespread action includes joining and supporting your state association such as North Carolina Association of Pharmacists (NCAP) because the enacting of services at the state level will be critically important. NCAP is the only organization in North Carolina whose primary focus is the profession of pharmacy; it is affiliated with national associations as well.

In order to gain passage of the Pharmacy and Medically Underserved Areas Enhancement Act (H.R. 592/S. 109) increased outreach efforts by pharmacy advocates is necessary. If you live or work in either Representative Foxx or McHenry’s districts, you should write to encourage them to sign-on to support H.R. 592. All others should write your Representative and thank them for their support and encourage their action on moving the H.R. 592 or S. 109 forward. Many national associations have predrafted letters that can be used by pharmacists and student pharmacists to facilitte a message to your legislator. Click on the “Take Action” hyperlink (below) for quick access to ASHP’s online advocacy center that has a pre-drafted letter that is connected to your elected officials based on your zip code.

TAKE ACTION

References 1. North Carolina. (2018). Retrieved from http://www.countyhealthrankings.org/app/northcarolina/2018/overview 2. Projecting the Supply and

Demand for Primary Care

Practitioners Through 2020. (2018). Retrieved from http:// bhpr.hrsa.gov/healthworkforce/ supplydemand/usworkforce/primarycare/

3. Choucair, J. (2015, January 28).

PAPCC Applauds Introduction of H.R. 592. The Patient Access to Pharmacists’ Care Coalition (PAPCC). Retrieved from http:// pharmacistscare.org/papcc-applauds-introduction-of-h-r-592

4. Clinical Pharmacist Practitioners. (2018). Retrieved from http://www.ncbop.org/pharmacists_cpp.htm

5. H.R. 592: Pharmacy and

Medically Underserved Areas

Enhancement Act. (2018).

Retrieved from https://www. govtrack.us/congress/bills/114/ hr592

6. Allen, R. (2018). Physician and

Nonphysician Licensure and

Scope of Practice. Retrieved from http://www.ama-assn.org/ meetings/public/interim00/reports/rcc/cme1i00.rtf

7. The American Society of

Health-System Pharmacists (ASHP). (2015). Retrieved from http://connect.ashp.org

8. What’s Different about Rural

Health Care? (2018). Retrieved from http://www.ruralhealthweb. org/go/left/about-rural-health

Ryan Mills, PharmD, MBA, MHA, BCPS, is the Pharmacy Manager at Novant Health in Kernersville, NC. rsmills@novanthealth.org