Pharmacists Urge Passage Of Bills Requiring Faster Payments, Higher Reimbursements Under Medicare Rx Benefit, USA

Main Category: Medicare / Medicaid / SCHIP
Also Included In: Pharmacy / Pharmacist
Article Date: 24 May 2006 - 2:00 PDT

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Lobbying groups representing independent pharmacy owners from across the country are calling for the passage of legislation that would require "prompt pay" for pharmacists participating in the Medicare prescription drug benefit and would establish new rules governing pharmacists' involvement and reimbursement for "medication-therapy management," CQ HealthBeat reports (Carey, CQ HealthBeat, 5/22). The pharmacist groups say payments from pharmacy benefit managers under the drug benefit are too slow and too small for community pharmacies to cover their expenses, the Atlanta Journal-Constitution reports (Lipman, Atlanta Journal-Constitution, 5/23). The National Community Pharmacists Association is sponsoring a conference in Washington this week to lobby for such legislation (Young, The Hill, 5/23). On Monday, the Association of Community Pharmacists Congressional Network held a news conference to call for the passage of such legislation, which it says is needed to hasten reimbursements to pharmacists from PBMs. (Atlanta Journal-Constitution, 5/23).

Bills, Congressional Action
The legislation the groups are supporting includes a Senate bill (S 2563) by Appropriations Committee Chair Thad Cochran (R-Miss.) and co-sponsored by Health, Education, Labor and Pensions Committee Chair Mike Enzi (R-Wyo.) and 14 other senators. In addition, a House companion bill (HR 5182), sponsored by Reps. Walter Jones (R-N.C.) and Marion Berry (D-Ark.), has been referred to the Ways and Means Committee and the Energy and Commerce Committee (The Hill, 5/23). The Cochran-Enzi bill would require pharmacists to be reimbursed within 14 days of filing electronic claims and within 30 days of filing paper claims under the drug benefit (CQ HealthBeat, 5/22). The House bill also would require PBMs to pay claims within 14 days, according to the Hill. Both bills would give pharmacists a larger role in medication-therapy management, which is designed to help patients with multiple medications better manage their illnesses (The Hill, 5/23). According to the Journal-Constitution, the measures are two of at least five similar bills that have been proposed in the House and Senate (Atlanta Journal-Constitution, 5/23). In addition, the House Energy and Commerce Subcommittee on Health on Tuesday is holding a hearing on the drug benefit's effect on pharmacists (The Hill, 5/23).

Pharmacists' Comments
ACPCN President Bill Rustin and Mike James, vice president for governmental affairs, said PBMs are delaying payments for as long as 45 days (CQ HealthBeat, 5/22). Rustin said, "If something's not done, community pharmacies may be out the door." Georgia Pharmacy Association Executive Vice President Buddy Harden, who will testify before the House health subcommittee Tuesday, said, "For the last three months, pharmacists have been borrowing money to pay the bills." Mary Ann Wagner, senior vice president of the National Association of Chain Drug Stores, said chain drug stores also have been hurt by slow payments but they receive much of their revenue from sales of nonpharmacy items (Atlanta Journal-Constitution, 5/23). Charles Sewell, vice president for governmental affairs at NCPA, said, "The difference between us and [PBMs] is we're health care providers. They're corporate middlemen" (The Hill, 5/23).

PBM Response
The Pharmaceutical Care Management Association, which represents PBMs, says claims are processed in a timely manner and the reduced payment levels are the result of market forces that have lowered costs under the drug benefit (The Hill, 5/23). PCMA President Mark Merritt said PBMs currently pay claims within 30 days. He said adding electronic payment systems would increase costs and create other concerns that aren't included in current PBM bids. PCMA released a study on Monday finding that the Senate legislation would increase the cost of the drug benefit to beneficiaries and to Medicare by at least $9 billion over 10 years, primarily because of increased payments for medication-therapy management (CQ HealthBeat, 5/22). Merritt said, "I haven't seen any independent study corroboration" of the pharmacists' concerns (The Hill, 5/23). "We've been surprised at how little attention these provisions are getting," Merritt said. He added that he does not think the Senate measure will pass because "there's not much of a stomach to pass legislation that will increase costs to the Medicare program" (CQ HealthBeat, 5/22).

The study is available online. Note: You will need Adobe Acrobat Reader to view the report.

Political Implications
The New York Times on Tuesday examined how Republican and Democratic parties both believe their "candidates will benefit in a big way from Medicare's new prescription drug coverage." The Bush administration and most congressional Republicans "acknowledge no fundamental flaws or weaknesses" in the drug benefit, but "they tend to overstate enrollment, which is widely viewed as a measure of popularity and success of the program," the Times reports. Democrats, on the other hand, "cite every mix-up and mistake ... as proof that private insurers are less efficient and less reliable than the government" in administering Medicare benefits (Pear, New York Times, 5/23).

Additional Coverage
USA Today on Tuesday profiled five beneficiaries affected by the Medicare drug benefit: an Ohio couple who represents "the poster children for the benefits of the new program"; a dual eligible in California who cannot afford his medication costs since his coverage was transferred from Medicaid to Medicare; and a couple who delayed signing up for several months but then chose a plan shortly before the May 15 enrollment deadline (Wolf, USA Today, 5/23).

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