Instructor: Sandra Andrews, CPhT
Obamacare, the Obama Health Care Plan, Health Care Reform Bill, Patient Protection and Affordable Care Act (PPACA) or simply the Affordable Care Act (ACA): no matter which name is most familiar to you or what your personal opinion is concerning this often controversial bill, one thing is certain, this piece of legislation will touch each and every American. Most would agree there is a need for health care reform in the United States; however, agreeing on how to go about completing the needed changes has presented more of a challenge. From the very mention of a nationalized health care plan, there was a call to challenge what some have suggested is socialized medicine and others have felt was a move in the right direction for all US citizens. Once again, this falls under the veil of personal opinion, but perhaps some of the most important questions we should be asking are; how will this change the tide of health care and how will the changes affect health care professionals? These are questions that require thorough investigation and meaningful thought. According to the US Bureau of Labor Statistics, in 2010 there were 274,900 licensed pharmacists working in the United States and that number is predicted to rise to 344,600 by the year 2020. Pharmacy technicians surpass the number of pharmacists by almost 20% with 334,400 technicians working in this country in 2010. Like the projections for pharmacists, the number of pharmacy technicians is expected to grow with statisticians predicting approximately 443,000 technicians by 2020. No matter how you interpret the numbers, by 2020 the number of pharmacists and pharmacy technicians will be over 750,000 strong, too large a number not to have a significant effect on the surge of health care changes we are now about to experience. In order to best understand the dynamics of the Affordable Care Act it is probably best to understand how the bill came about, what the bill entails and when the changes will be fully in place. President Barack Obama will most likely be remembered in history for several reasons, but perhaps his most considerable achievement is -passing- the Affordable Care Act. On March 23, 2010, President Obama signed ACA into law, holding to a significant piece of his campaign platform. Passage of the bill did not come without a fight, nor did it end when President Obama signed it into law. The challenge of implementing a national health care plan in the United States has not gone unnoticed. Generations of presidents and presidential candidates have run their campaigns on the promise of health care for the masses. In 1912, Theodore Roosevelt, who decided to make another run for the White House under the Bull Moose Party, touted a National Health Insurance as part of his campaign promises. In 1935 our nation was in the center of the Great Depression and President Franklin Roosevelt pushed for national health insurance, but had to abandon his aspirations in exchange for the Social Security Act. In 1945, President Harry S. Truman urged Congress to pass a National Insurance Program for anyone who was willing to pay a voluntary fee, but the American Medical Association felt this was a move towards socialized medicine and shut down Truman's intentions. In 1965, President Lyndon B. Johnson proudly signed an amendment to the 1935 Social Security Act, which created the Medicare and Medicaid programs. These two programs have experienced several changes throughout the years, but still retain a prominent place in the history of health care in the United States. The Nixon administration also sought to develop a national health care plan, requiring employers to cover their employees and allowing federal subsidies for those who bought private insurance, but the Watergate Scandal marred the administration and the initiative died almost immediately. An economic recession in 1976 forced President Carter to end his charge for a national health plan. In 1988 President Ronald Reagan signed into action the legislative rule, which required employers to offer the continuance of health insurance for up 18 months to employees who had left their positions. COBRA, the Consolidated Omnibus Reconciliation Act, required the employee to absorb the cost of the insurance, but allowed the employee a bridge from their prior employer's insurance benefits to their new employer's benefits. Further attempts to form a national health care plan did not develop until 1993, when President Bill Clinton appointed the First Lady, Hillary Rodham Clinton, as the chair responsible for formulating a universal health care plan. The plan, which not only required businesses to cover their workers, but also mandated health insurance for all citizens, hit hard opposition from Republicans and Democrats, as well as setting off a storm of criticism from the medical community. The plan eventually died on the Senate floor. However, in 1997, President Clinton was able to sign into law the workings of a State-Federal program that would be the vehicle for insuring a large number of moderate-income families with children, whose adjusted gross income made them ineligible for Medicaid. The Children's Health Insurance Program (CHIP) helped to insure millions of children who would have otherwise, fallen between the cracks. While President George W. Bush's administration did not advocate a national health care plan, he did champion the expansion of Medicare benefits by adding prescription drug coverage, one of the last significant changes made to Medicare. This, of course, leads to 2009 and the Obama administration, when President Obama and a Democratic-controlled Congress worked together to shape what is now known as the Affordable Care Act into law. The plan was met with opposition within hours of being signed into law. On the day that President Obama signed ACA, 26 States: Alabama, Alaska, Arizona, Colorado, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Louisiana, Maine, Michigan, Mississippi, Nebraska, Nevada, North Dakota, Ohio, Pennsylvania, South Carolina, South Dakota, Texas, Utah, Washington, Wisconsin and Wyoming, filed a lawsuit in federal court. Spearheaded by Florida, the states' lawsuit contended that the Affordable Care Act's mandate for individual health insurance and the expansion of Medicaid was unconstitutional in regards to the right of the individual citizens of the United States. The National Federation of Independent Business (NFIB) and other separate plaintiffs, who did not have health insurance, also filed suit. The courts elected to hear the cases together as one case, rather than two separate lawsuits. The Supreme Court would hear the history-making case and would need to make a decision on the constitutionality of the individual mandate and the expansion of Medicaid, two of the principal conditions of the bill. Settled with a monumental task, the Supreme Court would first need to decide if they indeed had authority to make a decision on the case. All nine justices decided overwhelmingly that they indeed did have jurisdiction over the case and the lawsuit moved forward, allowing both sides to present their arguments. The first element of the lawsuit revolved around the bill's individual mandate. This part of the legislation requires all individuals to have health care insurance or face the penalty of a fee administered as a shared responsibility payment. The United States Internal Revenue Service (IRS) would be accountable for assessing and collecting the penalty as reported on federal tax returns. The penalty, which is to begin in 2014, would initially be either $95.00 or one percent of income, whichever number is greater. In 2015 it increases to $325.00 or two percent of income and in 2016, $695.00 or 2.5 percent of income. After 2016, the penalty amount would be appraised to fall into conjunction with the cost-of-living. There are, however, those who are not subject to the individual mandate or the shared responsibility payment. Persons who are not subject to the individual mandate of ACA: Undocumented immigrants Religious objectors Those who are serving jail time Persons who are not subject to the shared responsibility payment: Those who pay insurance premiums, which are more than eight percent of their adjusted household income Any person who is a member of an American Indian tribe Those who apply for a financial hardship waiver Any person who was without insurance for less than three months of the year Any person whose income falls below the federal tax filing threshold The second challenge of the lawsuit, which would be known as National Federation of Independent Business v. Sebelius, was the expansion of the Medicaid program. Medicaid, which receives funds from both federal and state governments, is not a mandatory program, but most states do participate. Under the Affordable Care Act, states who participate in Medicaid would be obligated to increase coverage to include anyone who was 65 and under and whose income fell at or below the Federal Poverty Line (FLP), $14,856 per year for a single person and $30,657 per year for a family of four. While some state Medicaid programs already exceed ACA guidelines, the majority do not, covering only families with dependent children. Parents of children who participate in Medicaid are also covered, but at an income level that does not meet the new levels provided by the ACA expansion to Medicaid. In order to help states cover the cost of the Medicaid expansion, the federal government has promised to cover 100% of the state's associated cost. From 2014 through 2016 federal aid to state run Medicaid programs will remain at 100%, after 2016 the aid will slowly start to decline until it reaches 90% in 2020, where it will remain until further determination. On June 28, 2012, the United States Supreme Court delivered a decision on National Federation of Independent Business v. Sebelius. On a narrow vote of 5-to-4, the Supreme Court ruled that the United States Congress had the right to levy tax and that the penalties associated with violation of the individual mandate could constitutionally be considered taxes, since they fell under the responsibility of the Internal Revenue Service. There was somewhat of a smaller separation between the Supreme Court justices on the ruling regarding the expansion of Medicaid. So how does all of this affect us as pharmacy professionals? Actually, there are quite a few points of the Affordable Care Act which require substantial contribution from the pharmacy profession. The American Pharmacists Association (APhA) recognizes the involvement of pharmacy in the following areas: Medication Therapy Management (MTM) The Independence at Home Demonstration Project Accountable Care Organizations (ACOs) Electronic Health Record (EHR) incentives and e-prescribing MTM utilizes pharmacy services to develop a medication plan that is not only therapeutic, but also optimizes treatment in a way that offers the patient the best outcome. Several national pharmacy organizations such as the American Pharmacists Association, American Society of Health System Pharmacists, American Society of Consultant Pharmacists and American College of Clinical Pharmacy already advocate for the use of MTM. ACA charges the Secretary of Health and Human Services with awarding grants to chosen entities who meet the requirements necessary to perform MTM. MTM is an invaluable tool that requires the specific skills of a pharmacist. The Affordable Care Act mandates that MTM services must include the following: Initial evaluation of the patient and the patient's disease state(s) Assessment of the patient's medication plan as prescribed by the patient's physician, then producing a medication therapy plan based on this analysis Making adjustments or suggestions to the medication therapy plan through a cooperative effort made between the patient, the patient's physician and the pharmacist Once the medication therapy plan has been initiated, monitoring of the patient's response to therapy in order to appropriately evaluate the patient's response and benefit of medication therapy Documentation of all information regarding the patient's medication therapy management Providing patients and caregivers with easy-to-understand information concerning their medication therapy, as well as any training which may be necessary for administering the medication Providing patients and caregivers with information concerning additional MTM services that are applicable to the practice of pharmacy and are underwritten by other federal programs While the use of MTM is a service, which may have benefit for any patient who must use prescription medications to treat a disease state, the Affordable Care Act directs MTM services to those patients who are taking at least four prescriptions, taking medications considered to be high risk and have been diagnosed with at least two chronic diseases or are at a higher risk for problems with their medication therapy. Entities who are awarded grants for MTM through the Department of Health and Human Services must provide an analysis of the program's worth and in turn the Secretary of Health and Human Services will present the required reports to Congress. Another aspect of the Affordable Care Act that may require the involvement of pharmacy services is the Independence at Home Demonstration, a project under the Centers for Medicare and Medicaid Innovation. The Independence at Home Demonstration, currently in the testing phase, is a direct result of ACA. The premise of the Independence at Home Demonstration is to provide Medicare patients who have numerous, chronic disease states, home-based primary care in order to improve the patient's overall medical outcome and, in turn, ease the costs associated with that care. The Centers for Medicare and Medicaid Services (CMS) will then award physicians and nurse practitioners, the primary facilitators of the program, with incentive payments when they meet quality standards and decrease Medicare's cost. Home-based care, which is a large part of this service, allows the practitioner more assessment time with the patient in the patient's home, ultimately providing the patient with a more appropriate plan of care and a better quality of life. It is also assumed this will reduce the cost of health care, considering the patient would normally incur costs associated with an institutional or clinic setting. Primary care practice teams chosen by CMS will provide care to the intended patient for a period of three years. During this time the primary care team will report to CMS, tracking the quality of care the patient is receiving as well as measuring the benefit afforded to the patient from this type of care plan. Practices who wish to participate in the Independence at Home Demonstration will need to meet the following criteria: Are led by physicians or nurse practitioners Are organized for the purpose of providing physician services Have experience providing home-based primary care to patients with multiple chronic conditions Serve at least 200 eligible beneficiaries The primary care team may include physician assistants, pharmacists, social workers and other staff There are also specified criteria for the patient who may need to participate in the Home Independence Demonstration: Have two or more chronic conditions Have coverage from original, fee-for-service Medicare Need assistance with two or more functional dependencies (walking, feeding, etc.) Have had a non-elective hospital admission within the last 12 months Have received acute or subacute rehabilitation services in the last 12 months While it may still need to be determined to what extent pharmacy will play in the primary care team, it is certain that consultation and collaboration of pharmacy services will be key to the development of the patient's plan of care. Home deliveries of patient medications as well as thorough evaluations of patient medication therapy management are just a few of the services which can be offered by pharmacy through the Independence at Home Demonstration. As of April 2012, there were 15-individual practices that participated in the Independence Home Demonstration and as of August 2012 there were three consortia, a combination of several individual practices that participated in the program. As the Obama health care plan develops and the Independence Home Demonstration proves itself as a benefit, additional individual and consortia practices will be needed, which in turn will call for the need of extended pharmacy services. MTM and the Independence Home Demonstration will call for the collaboration of the pharmacist and the pharmacy technician. Pharmacists will be called upon for more advanced clinical duties and the pharmacy technician will be needed to complete tasks such as inventory management and filling of medication orders. Of course, the final check will always go to the pharmacist; regardless of how evolved the technician's tasks become. The Affordable Care Act is a collection of medical and legal jargon almost 1000 pages long. It can often be long on words and short on understanding. This is perhaps, one of the reasons it has been met with resistance. Accountable Care Organizations (ACO) is an avenue of the Affordable Care Act that has not only caused controversy, but confusion as well. An ACO is a system of physicians and health care institutions that agree to provide medical services, as a cooperative effort, for a minimum of 5,000 Medicare participants for a period of no less than three years. The idea behind ACOs is to bring together services, such as specialists, home health care services, pharmacy services and rehabilitation services. The thought is to create one connected continuance of care, providing the patient with integrated care and cutting cost to an already financially stressed Medicare system. While care of the patient should always be central to any health care service, HHS estimates ACOs could save the Medicare system up to 960 million dollars in just the first three years. ACOs save Medicare money by making providers and their service partners equally responsible for the health of the patient. Not only will cooperating partners be able to share patient information without effort, but joint accountability will decrease the incidence of unnecessary testing and procedures. Medicare operates on a fee-for-service basis, meaning physicians, health care institutions, and other service providers are paid based on the service or procedures they perform. The more services that are performed, the more fees are paid to the provider. This, along with the increase of Medicare beneficiaries, drives the costs associated with the Medicare system. ACOs, which are also paid as a fee-for-service model, offer a twist from the traditional Medicare fee-for service, by giving incentives and bonuses to providers who, not only meet the required benchmarks, but also help to cut Medicare costs by focusing on preventive care as well as overseeing the health of those with chronic diseases. A pharmacy's involvement in ACOs will again involve consultation and medication management services. Pharmacy technicians who work for organizations that participate in an ACO may be called upon to complete medication reconciliation, or perhaps in order to provide more extensive pharmacist services, be part of Tech-Check-Tech implementation. The extensiveness of pharmacy's involvement will depend upon the expansion of the program as well as state and federal regulations, but ultimately gives proof to the fact that ACA touches all facets of the health profession. Electronic health records (EHRs) and e-prescribing is the final pharmacy-based potential that has received attention. EHRs and e-prescribing are not new ideas; in fact, some institutions have had EHRs in place for several years. Electronic health records are just another indicator of the medical profession moving forward into the electronic age. Rather than have endless mounds of paper, EHRs allow the physician to not only see the patient's medical history much more completely, but also allow other health professionals, such as the pharmacist, to have expedited access to information that may be essential when formulating plans of care. The Affordable Care Act calls for mandatory use of electronic health records as well as e-prescribing. In the last several years there has been a push towards the use of these records. In 2009, approximately 16% of all hospitals and 17% of all physicians' offices implemented the use of electronic medical records (EMRs). In 2012 those numbers doubled, with 35% of all hospitals and 34% of all physician's offices employing the use of EMRs. ACOs, which we spoke about in previous paragraphs, will rely heavily on the use of EMRs in order to provide its professionals with a seamless system for accessing and validating patient medical information. E-prescribing, which actually works alongside EHRs, will also be an enforceable piece of technology under the Affordable Care Act. Electronic prescribing is just as it sounds: prescribing patient orders electronically through a computer system. The prescriber will initiate the medication order or prescription from their computer where it will then be transmitted to the pharmacy, either one associated with the institution or a mail order pharmacy. The pharmacist will be able to access the patient's records, including such information as the patient's allergies, current and past medication therapies and documentation concerning the progression of the patient's disease state(s). A final piece of legislation that we should mention, which does and will continue to have a great deal of impact on the practice of pharmacy is the Medicare Modernization Act of 2003. The Medicare Modernization Act (MMA), which actually went into effect in 2006, was the first piece of legislation that founded an outpatient prescription plan for Medicare patients. Medicare Part D, which as of September 2012, has over 32 million beneficiaries, is a completely voluntary process for most recipients. Those who fall out of the voluntary status are considered to be low-income recipients or who have dual eligibility, meaning they are covered under Medicare and Medicaid. Typically, these recipients are automatically enrolled in a prescription drug plan (PDP), unless they elect to choose their own PDP. There are two basic types of Medicare prescription coverage, Medicare prescription drug plans (PDPs) and Medicare Advantage plans, such as a health maintenance organization (HMO) or a preferred provider organization (PPO). In order to participate in a Medicare Advantage Plan (MA-PD) the recipient must also take part in Medicare Parts A and B. PDPs simply add drug coverage onto the original plan. Customarily, Medicare prescription plans have what is known as a donut hole, or a gap in coverage. This simply means there is a limit on what the drug plan will cover for the patient's medications. This gap in coverage is normally temporary and only lasts until the patient and their drug plan have spent a specified amount of drug cost. In 2012 patients who reached the coverage gap paid 50% of the cost associated with brand name drugs and 86% of the cost associated with generic drugs. In 2013 the gap decreases to 47.5% for brand name drugs and 79% for generic drugs. Under ACA, the coverage gap will continue to gradually decrease each calendar year, until it reaches 25% for both brand and generic drugs in 2020. ACA also seeks to keep monthly Medicare prescription plan premiums at a leveled price. In 2012 the average premium for a Medicare prescription plan costs the recipient $30.00 each month. In 2013 premiums are predicted to hold steady at $30.00 a month, due in part to the ACA's effort to decrease Medicare costs. In fact, in July 2012, Medicare and CMS reported that since the Affordable Care Act was put into law, 5.2 million Medicare recipients saved over three billion dollars on prescription drug costs. For example: In 2013, Medicare Part D pays 21% of Mr. Rooney's prescription as long as it is a generic and he has not reached the coverage gap. He goes to his regular pharmacy to have his lisinopril filled. When Mr. Rooney goes into the pharmacy the next day, the pharmacy technician rings up his prescription. If there is a $2.00 dispensing fee and the prescription costs $20.00, then the cost would be $22.00, but Mr. Rooney participates in Medicare Part D and only pays 79% of the cost associated with generic drugs. The pharmacy technician tells Mr. Rooney his prescription will cost $17.80: $15.80 is the amount Medicare does not cover and the $2.00 dispensing fee. Mr. Rooney, who has gotten the same prescription for several months, notices the prescription cost him less than it did when he had it filled in December. He asks the pharmacy technician to check the pricing to make sure she did not make a mistake. The pharmacy technician explains to Mr. Rooney that after the first of the year Medicare would be paying for more of his generic prescriptions. In 2013 Medicare will pay 21% of the cost associated with generic drugs. However, the pharmacy technician goes on to explain to Mr. Rooney that he will have to pay more for his brand name drugs, since the discount is at 47.5%. Mr. Rooney seems satisfied with this explanation and leaves the pharmacy with a more thorough understanding of his Medicare gap coverage. The pharmacy technician, who was keen enough to see that Mr. Rooney did not understand his Medicare prescription plan, helped eliminate the need for the pharmacist to be interrupted to speak with Mr. Rooney. This example shows how important a role the pharmacy technician plays and will continue to play in the practice of pharmacy. The technician made sure she was up-to-date on information she knew would affect her patients; in this case, it was understanding the Medicare Part D donut hole. Whether or not the Affordable Care Act will achieve all its intended purpose still remains to be seen. One certainty is contained in the changes the health care profession will undoubtedly face in order to accommodate the legislation. The practice of pharmacy will need to adjust accordingly, moving the pharmacist into a more progressive clinical consultation role and mandating roles for the pharmacy technician that allow the pharmacist to take on these necessary tasks. Pharmacy technicians should familiarize themselves with the language of ACA, in particular those changes dealing with medication management and Medicare Part D. A pharmacy technician who is able to comprehend the particulars of the Affordable Care Act is not only able to take on a larger role as a pharmacy team member, but also address misunderstandings, which might normally require the pharmacist's attention. Still, the pharmacy technician must always remember to stay within the legal definitions of their profession. Understanding the language of the Affordable Care Act can be overwhelming and often confusing. However, http://www.healthcare.gov/law/index.html is a user friendly website provided by the federal government, which may help to educate and answer any questions. Another website, http://www.healthcareandyou.org, is not sponsored by the federal government, but is useful in answering some generalized questions concerning ACA. Pharmacy technicians who need to have a greater understanding of Medicare Part D and the coverage gap can find more information at: http://www.medicare.gov or http://www.hhs.gov. Change, as many have said, is inevitable; being able to adapt with the change often decides the success of those associated with it. With change comes evaluation and implementation of the laws that govern and protect us. As the role of the pharmacy technician continues to evolve, the need to understand these laws will become increasingly essential. A pharmacy technician who realizes the importance of laws and actively seeks to understand them builds credibility for themselves and the pharmacy profession. References: A Guide to the Supreme Court's Affordable Care Decision, The Henry J. Kaiser Family Foundation, 7-2012, http://www.kff.org/healthreform/8332/cfm Accountable Care Organizations: Improving Care Coordination for People with Medicare, HealthCare.gov, 3-12-12, http://www/healthcare.gov/news/factsheets/2011/03/accountablecare03312011a.html Coster, J. Khani, J. Health Care Reform's Impact on Community Pharmacy, National Community Pharmacist Association, 4-10-12, http://www.ncpanet.org Gentiviso, C. Health Care Reform 2012: A History of US Efforts. Huffington Post, 6-23-12, http://huffingtonpost.com/2012/6/23/Health-Care-Reform-2012-History Health Care Reform- Implementation of the Affordable Care Act American Pharmacist Association, 8-12-12, http://www/pharmacist.com/health-care-reform-implementation-affordable-care-act Health Care Reform-The Affordable Care Act American Pharmacist Association, 8-16-12, http://www.pharmacist.com/health-care-reform-affordable-care-act Medicare and You: The Official U.S.Government Medicare Handbook 2013United States Department of Health and Human Services, 9-2012, pp.81-133 Medicare Prescription Drug Benefit-An Updated Fact Sheet, Q1Medicare.com, 2012, http://www.q1medicare.com/PartD-the-2013-Medicare-Part-D-Outlook,php Medicare Prescription Premiums to Remain Steady for Third Straight Year, Department of Health and Human Services, 8-6-12, http://www.hhs.gov/news/press/2012press/08/20120806.html Neyarapally, G. Affordable Care Act: Improving Public Health Through Pharmacists, The Network for Public Health Law, 7-26-12, http://www.networkforphl.org The Medicare Prescription Drug Benefit- An Updated Fact Sheet, The Henry J. Kaiser Family Foundation, October 2012, http://www.kff.org/medicare/7044cm-Oct2012 Vivian, J. Affordable Care Act (Mostly) Upheld, U.S. Pharmacist, 8-21-12, http://www.uspharmacist.com, Vol. 37(8): 73-74 Author Bio: Sandy Andrews lives in Chambersburg, Pennsylvania with her husband of 17 years, Rob and her two teenage sons, Joshua and Caleb. She will be completing her BA in English from Arizona State University in July and will be moving on to complete her Masters Degree in English from Northern Arizona University. Sandy has over 20 years of experience as a Certified Pharmacy Technician, primarily in institutional pharmacy. Recently, Sandy has had a career change and is writing educational material for pharmacists and pharmacy technicians. Sandy is hoping to continue the growth of this new career choice. Idea in Brief: The Affordable Care Act is a piece of legislation that has been plagued with controversy from its inception. The continuation of this legislation will lie in the hands of the next administration as well as representatives elected by the people. The language of the Affordable Care Act is long and may be confusing, but without a doubt this legislation will bring changes to the practice of pharmacy. This program will decode some of the confusion that surrounds the Affordable Care Act and give a clearer understanding of how the practice of pharmacy will be affected. Idea in Practice: As the Affordable Care Act is implemented in phases, changes to the practice of pharmacy will begin to occur. The pharmacist, whose time will be needed for more clinical tasks, will need to rely more heavily on the pharmacy technician. There are four programs under the Affordable Care Act that the American Pharmacists Association recognizes require direct pharmacy involvement. Pharmacy technicians should obtain an understanding of these programs in order to substantiate their role, not only as an essential member of the pharmacy team, but also as a key player in the continuation of safe and effective patient care as defined by the Affordable Care Act.