Why Essential Health Benefits Matter to Pharmacists

Ensuring patient access to community pharmacists is going to be an important part of health care reform.

Lonny Wilson, DPh, NCPA president and pharmacy owner

While the Affordable Care Act (ACA) was enacted principally to ensure health coverage for all Americans, it obviously has enormous implications for pharmacists as well. One linchpin in the law’s effort to provide affordable insurance options for the uninsured is its directive to states to establish health exchanges where consumers can purchase insurance. Billed by supporters as a “Travelocity” for health insurance, the exchanges don’t start until 2014, but critical decisions are being made today that will govern these patients’ interactions with pharmacists and their access to pharmacies.

One example of this is what’s known as “essential health benefits” (EHBs). The law outlines 10 categories of health benefits that health plans included in these exchanges must cover. The National Community Pharmacists Association (NCPA) supported, and Congress ultimately included, prescription drugs and chronic disease management among the 10 categories of EHBs.

Although prescription drugs and chronic disease management are treated as separate categories, both can be addressed by ensuring that patients have access to independent community pharmacies. Independent community pharmacists promote proper adherence to medication and face-to-face consultations with pharmacists, both integral components to properly manage chronic disease.

But how do you define “access” under the ACA? That’s one of the issues that Congress left to the Department of Health and Human Services (HHS), which in turn has now indicated that EHBs will be defined by a “benchmark” health plan selected by each state. The selected benchmark plan will serve as a reference plan, reflecting both the scope of services and any limits offered by a “typical employer plan” as required by the ACA. In our view, the states in selecting their benchmark plan should not equate the ability of patients to obtain prescription medication solely through the mail as adequate “access” to pharmacy services. Although some patients may prefer mail order as an option, it should be the patient’s choice.

There are a myriad of reasons why mailorder pharmacy is simply not appropriate for all patients or their medical conditions. Mail-order pharmacy is not appropriate for certain patient populations, such as many seniors, or for medications that are designed to treat acute conditions, or are temperature-sensitive. Furthermore, there are additional risks to patients that they could be delayed in receiving their mailorder medication, causing them to go without for a time. Once the prescription is processed, there are outside factors that could further delay delivery to patients, such as processing time at the mail center. The US Postal Service is actively seeking to implement changes that could slow parcel delivery, further muddying the outlook. Whatever the reason, patients not receiving their medication on time and in some cases receiving the wrong medication altogether face serious health risks and could ultimately need to seek out costlier options.

Ensuring that patients have adequate access to the pharmacy of their choice, including independent community pharmacies, mitigates these risks. Community pharmacists will often advise if a generic alternative to a name brand prescription is available, where appropriate, and coordinate with the patient’s doctor. Generic utilization saves both the patient and their health plan significant sums, and community pharmacy has the highest rate of generic dispensing.

Protecting the patient’s choice of pharmacy also dovetails with the ACA’s requirement on chronic disease management. The pharmacy practice is expanding to more pointedly address effective medication use and achieve optimal patient outcomes. In addition, community pharmacies represent the most accessible point in patient-centered health care, with 92% of Americans located within 5 miles of a retail pharmacy. Typically, consumers do not need an appointment to talk with a pharmacist in a community pharmacy about prescription medications, over-the-counter products, or any other health-related concern. The accessibility of the community pharmacist as well as the close tie that exists between many pharmacists and members of the community is critical, especially in rural or innercity areas where consumers may not have sufficient access to medical care.

Finally, we believe that the benchmark health plan selected by each state should include pharmacist-provided medication therapy management (MTM) under chronic disease management. The New England Healthcare Institute has estimated that medication-related problems including poor adherence impose as much as $290 billion in largely avoidable annual costs—that’s 14% of health care expenditures. These costs include emergency department visits, hospitalizations, and other preventable forms of care. Face-to-face MTM can reduce these costs by preventing many of these adverse effects and ensure that more patients with chronic conditions remain adherent to their recommended drug regimens.

We understand there are current legal challenges to the ACA that will be resolved in the coming months. However, at present, it remains the law of the land, and HHS and the states must take steps to ensure its smooth implementation. On behalf of our profession, NCPA will continue to urge the individual states to give serious consideration to the aforementioned recommendations when choosing their benchmark plan in order to ensure that patients have access to the best care available.

Lonny Wilson, DPh, of Oklahoma City, Oklahoma, the president of the National Community Pharmacists Association, has long been a fixture of Oklahoma health care and pharmacy circles. He is currently chief executive officer of the Pharmacy Providers of Oklahoma (PPOk). He has 30 years of experience in community pharmacy and currently owns and operates 3 pharmacies in eastern Oklahoma County—ValuMed Pharmacy of Fort Gibson, Midwest City, and Bestyet Discount Pharmacy of Harrah. Wilson also serves as chairman of Mirixa, a leading developer of innovative clinical solutions that facilitate pharmacist-based patient care services. Wilson is a graduate of Southwestern Oklahoma State University School of Pharmacy.