The United States has one of the least universal and most costly health care systems in the world. Over the last century, several “patches” have been put into place to address the increasing need for health care delivery, which has left us with a fragmented system. In today’s system, access to appropriate health care is a multi-factorial challenge.
There is the question of financial barriers where some individuals receive too little care because they are uninsured or under-insured, some Medicaid beneficiaries cannot find physicians that will access their coverage, while other individuals receive too much care that may be harmful, excessive and costly to the health system.
There is also the question of non-financial barriers to care such as language, literacy, cultural differences, factors of gender and race and lack of prompt access due to limited availability of appropriately capable facilities and primary care providers.
Today, four basic modes of paying for health care exist: out-of-pocket payment, individual private insurance, employment-based group private insurance, and government financing. Out-of-pocket payment was the foundation upon which the country started, with individuals paying cash or bartering for health care.
The unpredictable need and cost of care gave rise to individual private insurance companies, namely Metropolitan Life and Prudential. As the costs of hospital care rose in the U.S., the development of employment-based private insurance came to fruition and grew rapidly in the 1950’s, helping working people and their families afford health care.
However, the poor and the elderly were usually unemployed or in jobs without the fringe benefit of health insurance and could not afford the premiums. This gave rise to government-financed health care, which eventually gave rise to the enactment of Medicare and Medicaid in 1965. Medicare Part A is a hospital insurance plan for the elderly financed largely through social security taxes from employers and employees.
Medicare Part B insures the elderly for physician services and is paid for by federal taxes and monthly premium from beneficiaries. Medicare Part D was enacted in 2003 to offer prescription drug coverage and is paid for by federal taxes and monthly premiums from beneficiaries. Medicaid is a program run by states that is funded by federal and state taxes, which pays for the care of certain low-income groups.
Health insurance was originally an attempt to solve the problem of unaffordable health care under the out-of-pocket payment system, but as health care became more affordable two new problems arose: individuals used more health care services since they no longer had to pay out-of-pocket and providers could charge insurers rather than patients, and thus more easily raise prices. Thus, the solution of insurance fueled the problem of rising costs.
To combat these rising costs, new methods of reimbursement have been tried as one way of lowering the growth rate in health care costs. In the outpatient setting, units of payment range from fee-for-service, physician diagnosis-related-groups (DRGs), capitation and salary while hospital-based payment systems including fee-for-service, daily per diem, hospital DRG, capitation or global budget payments.
With the growing rate of uninsured and under insured individuals and the rising cost of health care, the subject of national health insurance has seen various periods of intense legislative activity alternating with times of political inattention over the last century.
Since the 1965 expansion of coverage to the elderly and poor with Medicare and Medicaid, the greatest change in the expansion of coverage was seen with the implementation of the Patient Protection and Affordable Care Act (PPACA) of 2010 which is estimated to extend health care to over 30 million uninsured people. The triple aim of health care reform consists of: achieving better population health, improving individual health and reducing health care costs.
The Affordable Care Act (ACA) has four main components: an individual mandate for all U.S. citizens and legal residents to have insurance coverage meeting a federally determined essential standard; an employer mandate for those with 50 or more full-time employees to face a financial penalty if their employees are not enrolled in an employer-sponsored health plan meeting the essential benefit standard; Medicaid eligibility expansion by eliminating the categorical eligibility requirement; and insurance market regulation that will eliminate the caps on total insurance benefits payouts, prohibit denial of coverage based on preexisting conditions, and limit the extent of experience-rating premiums (individuals considered more likely to use the health care system are charged more than individuals considered to be healthy and less likely to use the health care system) within the benefit package.
As an estimated 30 million Americans gain access to health care and the aging population continues to grow, we will continue to see the need to achieve better quality and improve outcomes while also decreasing costs.
It is estimated that 75-80% of the cost of health care in the U.S. is for the management of chronic diseases and their complications. Medication therapy represents 80% of chronic disease management and thus is a great opportunity to improve patient outcomes and control costs.
In 2009, the medical management of chronic medical conditions cost the U.S. health care system $1.7 trillion annually. The U.S. health care system sees approximately 1.5 million preventable medication-related adverse events annually and incurs nearly $290 billion dollars annually in avoidable costs to treat these adverse events.
Additionally, medication non-adherence alone results in $100 billion each year in excess hospitalizations. Pharmacists have comprehensive and unique expertise in the use of medications for the treatment, management and prevention of disease.
One strategy various professional pharmacy organizations are advocating for in an effort to improve outcomes and decrease costs is the recognition of pharmacists as direct patient care providers with a clearly defined process of care under Medicare Part B under section 1861 of the Social Security Act (SSA).
Within health care reform, priority is given to coordinating care among practice settings, using a team-based approach to improve outcomes and decrease costs through patient-centered medical homes (PCMH).
By becoming members of the PCMH and working under collaborative practice agreements with physicians and other members of the patient’s health care team, pharmacists can provide comprehensive medication management (CMM) services to address inappropriate medication use, work to identify and document medication-related problems, manage drug therapy to resolve identified problems and achieve medication-related outcomes, and educate patients and families to ensure full understanding of their medication regimen.
In order to make this pharmacist included team-based approach of PCMH possible, proper provider status recognition and payment models are necessary to ensure patients have access to these pharmacists’ services. Some ask why the provision of medication therapy management (MTM) as a patient care service under Medicare Part D is not sufficient.
The answer is that the benefit seen with MTM is more administrative rather than clinical and cannot achieve the full potential of CMM. Additionally, 30% of Medicare seniors are not enrolled in Part C and lack access to MTM.
One significant challenge faced by professional pharmacy organizations advocating for recognition of pharmacists as providers of direct patient care CMM under Medicare Part B is the concern of rising health care costs. The Congressional Budget Office (CBO) is the federal agency required to produce a formal cost estimate for all bills. Unfortunately, when estimating the costs, the agency does not score potential savings that might accrue from a policy proposal.
Therefore, the cost analysis would only estimate the up-front cost of paying pharmacists for their direct patient care services under the Medicare program, not the overall savings these services would produce. Thus, many legislators are proposing pharmacists see reimbursement underneath the umbrella of payment provided to current direct patient care providers.
Collaborative practice agreements are essential to ensure team based care, and under these agreements, pharmacists would receive payment as part of the integrated health care team rather than under a fee-for-service model. While the value of improved access, quality, and cost is readily recognized within pharmacy organizations, credibility will be increased if produced or validated outside of the profession.
The profession of pharmacy has made considerable progress in the efforts to express the importance of recognizing pharmacists as direct patient care providers under Medicare Part B and outlining the process of care of CMM.
However, we have considerable ground to cover in the future. This requires active involvement and advocacy on the part of each pharmacist nationwide. Recognition under section 1861 of the Social Security Act is just the first step, with the need to justify benefits to private sector insurers on the horizon.
Bethany A. Kalich, PharmD, BCPS