By: Stacey McCullough, PharmD, Chief Pharmacy Officer at NCODA
Medicare patients are some of the heaviest users of our healthcare system and require the most pharmacy support to manage both chronic and episodic health needs. According to the Kaiser Family Foundation analysis of National Health Expenditure data from CMS, Medicare’s contribution to total national health spending on prescription medications has seen a massive increase from two percent of the budget to thirty-two percent. These patients depend on their pharmacy team for counsel, care, and consistent access to essential medications and are often the most impacted and vulnerable members of our communities.
As pharmacists, the long-anticipated DIR fee transition is upon us, and much has been written about the potential impact on the financials and cash flow of pharmacies of all sizes serving Medicare patients. Whether you view this shift as the “DIR apocalypse” as some have called it or look at it as a step forward toward greater transparency, we should be considering the real-life impact on patients and maintaining our valued role in care delivery.
For oncology patients, the potential impact of any care change is even greater than for most Medicare patients. The volume of medications required, and the continual dose modifications and optimization, creates a scenario where having a consistent integrated team is critical to providing the best possible outcomes for these patients.
Delays in Treatment
Given the current confusion on changes in reimbursement for both patients and care providers, there is an increasing risk that reimbursement rates are not sustainable, making it untenable for pharmacies to sustain their operations or continue their participation in networks. This issue would result in patients being forced to identify and establish mail order pharmacy relationships rather than their previous pharmacy provider that understands their needs and can provide the trusted counsel that the medically integrated team has developed over time.. These delays can have significant impacts on compliance and patient safety whether for chronic conditions or the filling of acute treatments.
Continuity of Care
For patients that are dealing with more complex or challenging healthcare conditions like a cancer diagnosis, there is additional risk in coordination and the continuity of care that is critical to provide the best possible outcomes. Maintaining a steady, integrated approach to care including the coordination of medication delivery, adverse event management, dosing modifications, and compliance is a life-saving endeavor. If a patient is forced to move from the medically integrated pharmacy there is a greater risk of losing interdisciplinary communication and the appropriate care required for many oncology medications. A patient may be pushed, for financial reasons, to a specific pharmacy that does not have access to their full medical history and their care needs, nor offer the trusted counsel that their medically-integrated team has developed over time.
Accessibility to Treatments
As medically-integrated pharmacies are working to manage their revenue, absorbing reimbursement cuts can put them at risk for maintaining their financial viability depending on the mix of patients and prescriptions that make up their day-to-day operation and patient care responsibilities. This is especially challenging when dealing with specialty medications, a small percentage reimbursement loss is significant, and creates an increased likelihood that treatments will not be available in a manner convenient for patients in a timely manner.
What’s next? Right now, medically-integrated pharmacies are closely watching the impact of the Medicare and DIR transition in the first quarter and teams are working to find their own solutions as they evaluate the effect of these changes. The challenge of Medicare reimbursement is that the new payment structure has transformed pharmacy into a volume business in the hopes that your location can break even and maintain quality service to the patients you serve. Over the next few months, NCODA will be featuring discussions with members on their experiences and any learnings that can be applied to others.
As a professional who has been committed to the care of patients for years, I implore all of us within the industry (providers, payors, and legislators) to maintain a focus on the impact to patients in all we do. Working toward transparency is a wonderful thing but, as we manage this transition, it is imperative that we put patients first.
