Expansion of Medicaid brought in many people with new needs for education, counseling, ad intervention from pharmacists.
Pharmacists may need to increase their education, counseling, and intervention efforts to better serve the patients who now have health insurance through the Medicaid expansions.
As a result of health reform, more Americans have medical and pharmacy benefits. According to the Henry J. Kaiser Family Foundation, the number of uninsured nonelderly Americans went down from 44 million in 2013 to 28 million in 2016.
Many who became eligible for Medicaid through expansions under the Affordable Care Act (ACA) may never have had health insurance before. They have a distinct set of needs and often require a more hands-on approach from pharmacy. Pharmacists will be the most frequent point of contact for new Medicaid patients within the health-care system, which gives both community and hospital pharmacists opportunities to play a greater role in improving patient outcomes.
Pharmacists can adopt new strategies that lower overall drug spending or that put the patient in a better position to improve their health, whether by creating comprehensive medication lists, improving adherence, or collaborating with physicians.
“This could be a great opportunity for pharmacists to demonstrate their value as a patient-care provider,” said Joseph Hill, Director of the Government Relations Division for ASHP.
States that chose to expand Medicaid as part of health-care reform are seeing more significant jumps in coverage, but this increased coverage comes with increased responsibility for health-care providers.
“The good news is more people are covered under Medicaid, the bad news is we don’t have enough money to pay for everybody to get everything, so we have to ration health care for Medicaid recipients,” said Perry Cohen, PharmD, CEO of The Pharmacy Group. “Pharmacists have to manage the cost like never before and not just be passive dispensers blaming the third party for the cost.”
Growing in Numbers
After the ACA (Obamacare) went into effect, 32 states plus the District of Columbia chose to expand Medicaid.
The Henry J. Kaiser Family Foundation released a brief in September summarizing the findings of 153 studies that examined the impact of the Medicaid expansions.
The expansions resulted in significant gains in coverage and reductions in the uninsured rates in those states, according to the brief. For example, according to a 2017 report from the Louisiana Department of Health, the state of Louisiana provided coverage for more than 433,000 residents who previously had lacked it.
Amy Shin, CEO of the Health Plan of San Joaquin, said the two counties her health plan covers in California saw tremendous growth after the expansion.
“Both at the federal and the state level, they completely underestimated the number of people who qualify,” she said, adding that many estimates were inaccurate because there was limited data to guide projections.
The Health Plan of San Joaquin serves only Medicaid patients, with about 350,000 members in San Joaquin and Stanislaus counties in California. The plan tries to have a telephone wait time of less than 30 seconds for its members, but after the expansion, wait time initially shot up to 30 minutes, Shin said.
“That was the kind of experience almost every health-care industry organization had because of the expansion,” she said. This increase in volume was also probably felt at the pharmacy level as more patients gained access to pharmacy benefits, she added.
Medicaid patients have different and unique sets of needs as a population. Before the expansion, many in the industry divided Medicaid patients into two groups: Temporary Assistance for Needy Families (TANF) or Aged, Blind, and Disabled (ABD).
TANF Medicaid patients are younger families who typically use less pharmacy prescriptions and medical services than the ABD group (called Seniors and Persons with Disabilities in California). The ABD group typically includes older adults with more complex health-care needs.
Expansion, Shin said, introduced a third group. Health plans have learned that this expansion group falls somewhere in the middle, with higher prescription drug utilization than the TANF group.
Ken Perez, Vice President of Healthcare Policy at Omnicell, said data already shows hospital utilization increased since implementation of health-care reform, in part due to Medicaid expansion. But while use has increased, one of the challenges is that patients aren’t always seeking the most appropriate levels of care, often turning to emergency rooms for care that could be more appropriately and more cost effectively provided at alternate sites of care, he said.
For pharmacists, increased hospital use means an increase in the drug volume used at hospitals. Inpatient drug spending has seen tremendous growth. Perez pointed to the results of a recent survey of 712 hospitals done by NORC at the University of Chicago that found that, between fiscal years 2013 and 2015, inpatient drug spending at U.S. community hospitals increased 23.4%. The average inpatient drug spending grew 38.7% during that period.
“The Medicaid expansion, because of the nature of the Medicaid population socioeconomically and in terms of behavior and the growth in use of drugs, is now highlighting the importance of pharmacy and medication as a percentage of a portion of costs,” Perez said.
The Role for Pharmacists
Medicaid users, including those who entered under expansion, often require more touch points and more assistance navigating the health-care system. Many of these individuals had little or no experience with health care before and may have complex needs or disease states that were not properly addressed before they had coverage. They need education and counseling and both health-system and community pharmacist are situated to supply it.
“I think it’s incumbent on the pharmacy provider, the pharmacist, to reach out and make sure that a patient understands the benefit as well as the risk,” said Tom Bizzaro, Vice President of Health Policy and Industry Relations for First Databank. “We’re always counseling about adverse events, that’s something that we do,” he added. “I’d like to see us also change that counseling to be one that reinforces the reasons and benefits of taking those drugs to a patient.”
Brad Arthur, RPh, co-owner of two independent pharmacies in Buffalo, NY, said the Medicaid patient population his pharmacies serve are typically some of his most complex patients, with multiple disease states and multiple health-care providers.
“In my community, there is not a single private-practice physician, they are all clinic-based, so the population typically is going to multiple places to receive care,” he said. “There’s very little coordination of their care, so the pharmacy has a unique opportunity to be that point of coordination and contact.”
Compliance and adherence issues are also typically issues with these patients, many of whom may live alone or have a disability that could make them more susceptible to gaps in care or treatment, Arthur said. In urban areas, “the patient is left on their own in having to do these things, so there’s a lot of opportunity for us to interact with them.”
His pharmacies offer medication synchronization services and adherence programs, along with free delivery. “A lot of my folks are shut-in and if I can’t get the prescriptions to them, they are just not going to take them,” he said.
Pharmacists’ frequent access to Medicaid patients has positioned them to play a more central role in care for them.
“I think [pharmacists] can be a great source of preventative care services, so everything from testing for certain conditions, A1c levels, blood pressure, bone density, things of that nature to providing immunizations, being that front-line preventative health-care provider,” Hill said.
Most Medicaid health plans do not use mail-order pharmacies for traditional medications due to eligibility issues, which means that the majority of Medicaid patients will be regularly visiting a pharmacy for their medications. Plans tend not to not use mail order because a patient’s eligibility for Medicaid may change from one month to the next, Shin explained. The exception is for specialty medications which may have to come through the mail because of their high cost of inventory at traditional pharmacies.
Lowering Drug Spending
More people having health insurance coverage has meant higher health-care costs to the system. Now more than ever, the health-care industry is looking for new strategies to limit costs. Pharmacists can help lower health-care costs and further demonstrate their value on the health-care team. In community and hospital settings, pharmacists can achieve this by dispensing generics and calling the prescribing physician if a high-cost medication has a lower-cost alternative, Cohen said.
“These regional Medicaid programs, we’ll call them managed Medicaid, need the help of the pharmacist who is there on the streets,” he said.
For health-system pharmacists, this also means taking a more active role in cost management. Perez believes pharmacists can reduce drug spending costs by working with health-system chief financial officers to evaluate physician prescribing habits and medication use within the system to identify areas to reduce costs.
One area of particular value from pharmacists is in opioid prescriptions. Three out of every 10 nonelderly adults who have an opioid addiction are covered by Medicaid, according to the Kaiser Family Foundation.
“Increases in inpatient volumes, rapidly rising drug prices, and the opioid abuse epidemic constitute challenges as well as opportunities for pharmacy to contribute positively to patient care, hospital finances, and public health,” Omnicell’s Perez said.
Reimbursement for Services
Pharmacists can provide tremendous value for Medicaid patients, but one of the biggest challenges to assuming a greater role for these patients is reimbursement.
With Medicare, pharmacists can be reimbursed for providing medication therapy management services, but Medicaid programs are run at the state level, so there is no comprehensive national program that provides similar reimbursement.
Shin says that this doesn’t mean that a health plan can’t develop its own reimbursement plan; plans are looking for a good partner who can help address gaps in care, Shin said. They have to consider the value a pharmacist can provide and the health plan’s own financial limits before these type of reimbursement programs can be launched, but pharmacists need to begin to demonstrate their value.
Cohen said health care is entering a new era where “no outcomes, no incomes” reigns supreme. If pharmacists want to be reimbursed for the services they provide, they’ll have to demonstrate that they improve outcomes.
“I just think the future is very bright for the practice of pharmacy but we need to have different models on how to provide pharmacy services and manage patient care,” Cohen said.