CONGRESS PASSES SWEEPING OVERHAUL OF HEALTHCARE
Some Pharmacy Related Provisions Still Intact, But Fight Far From Over

A sweeping overhaul of health care passed the U.S. House of Representatives late Sunday by a seven vote margin after more than a year of partisan debate. But critics say the fight is far from over with controversy over a reconciliation package still to be resolved in the Senate and threats of a lawsuit by several states, including Texas, over the cost of Medicaid expansion under the bill.

That cost has caused a majority of states, including Texas, to threaten to challenge the legislation in court as unconstitutional. Texas Attorney General Greg Abbott announced late Sunday that Texas and other states will challenge the legislation in court. “The federal health care legislation passed tonight violates the United States Constitution and unconstitutionally infringes upon Texans’ individual liberties,” Abbott said in a statement.

The bill approved by both the Senate and the House included numerous pro pharmacy pieces but even that hasn’t guaranteed the support of health care providers, including pharmacists, in a controversial struggle that has divided a nation. In the vote for the health care legislation, all 178 Republicans in the U.S. House were joined by 34 Democrats in voting against the bill. It is the biggest expansion of federal health care guarantees since the enactment of Medicare and Medicaid more than forty years ago.

A separate compromise package of changes expanding the reach of the measure was also passed by the House after its vote on the Senate bill. That reconciliation bill will advance to the Senate. If the Senate approves the reconciliation bill, it goes back to the House, and then to the President to be signed into law.

The issue for pharmacy now becomes preserving important pro pharmacy issues as the reconciliation package moves to final passage in the Senate. The National Community Pharmacy Association took the lead on the pharmacy portion of the legislation assisted by groups such as PBA Health and TrueCare in trying to get the best possible bill for pharmacy passed.

“We salute NCPA for their hard work in protecting the issues important to pharmacy in the health care reform package,” said Texas TrueCare Government Affairs Director John Heal.

“We are also grateful to our Texas pharmacies who have reached out to the Congressional members who have supported pharmacy in this fight.”

Health care reforms that will affect pharmacy include:

EXPANDED MEDICAID: Medicaid will be expanded significantly. More lower-income individuals under the age of 65 will be covered by Medicaid. Under the new rules, households with income up to 133 percent of the federal poverty level, or about $29,327 for family of four, will be eligible.

CHANGES IN MEDICARE: The bill cuts projected Medicare spending by roughly $500 billion, in part through reductions in the Medicare Advantage program. It also promises to eliminate the “doughnut hole” – a expensive gap in coverage that affects millions – by 2020. Seniors who hit the gap will receive a $250 rebate immediately. In 2011, they will receive a 50 percent discount on brand-name drugs.

The bill also increases Medicare payroll taxes on families making more than $250,000. Starting in 2013, it also imposes a 40 percent tax on insurance companies providing expensive “Cadillac” health plans valued at more than $8,500 for individuals and $23,000 for families.

Other pharmacy related provisions that will be watched as the bill moves through the final part of the process include those pushed by NCPA and other pharmacy groups, including:

MEDICARE DMEPOS ACCREDITATION EXEMPTION: The bill modifies the DMEPOS pharmacy accreditation

PHARMACY PROVISIONS IN HEALTH CARE BILL Pharmacy provisions advocated by community pharmacists and included in the measure passed by the House were: A series of grant and pilot programs that include medication therapy management (MTM); improvements to the Medicare Part D MTM benefit; reductions in the patient-care-jeopardizing cuts to Medicaid pharmacy reimbursement under the average manufacturer price (AMP) model; and conditional exemption for pharmacies from the durable medical equipment (DME) Medicare accreditation requirements.

requirements which currently reduce beneficiary access to important health care products because of redundant and costly accreditation requirements. Under the legislation pharmacies are exempted from accreditation if their total Medicare DMEPOS billings are 5 percent or less of their total prescription sales. It also exempts all pharmacies from the accreditation requirements until 2011, giving pharmacies flexibility in the types of items they could provide to Medicare beneficiaries and sets a reasonable DMEPOS accreditation threshold.

PHARMACIST PATIENT CARE SERVICES: Expands the patient care role for pharmacists through the delivery of medication therapy management (MTM) services and coordination of care with other health care providers.

PHARMACY REIMBURSEMENT: Reforms the Medicaid Average Manufacturer Price (AMP)-based reimbursement system for generic drugs that was originally enacted in the Deficit Reduction Act (DRA) of 2005. These reforms, which have important bipartisan bicameral support, are critical to ensuring the continued dispensing of lower cost generic medications and the viability of small independent community pharmacies.

PBM TRANSPARENCY: Language begins the process of creating transparency requirements for pharmacy benefit managers (PBMs) that are used by health insurance plans in the exchange and in Medicare Part D. Having this important information will empower plan sponsors to make sure that PBMs are putting the best interests of the plan sponsor and its enrollees ahead of the self-serving financial interests of the PBMs.

The President is expected to sign the bill in the next few days, after which the lawsuits by he states challenging the constitutionality of the new law will begin to be filed.

 

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