Statement of the American Society of Health-System Pharmacists, Bethesda, Maryland

The American Society of Health-System Pharmacists (ASHP) is writing to commend the chairwoman and members of the subcommittee for holding the March 27, 2001 hearing on Medicare reform and allowing the subcommittee to hear from a broad spectrum of interested parties. The hearing provided valuable information on devising a drug benefit that will meet the needs of all seniors and enhance their quality of care. ASHP hopes that the committee will continue to hear from interested parties, such as pharmacists, who will play a critical role in achieving this goal. We stand ready to provide any requested information.

ASHP strongly supports efforts to add a drug benefit and to reform the overall Medicare program. We take this opportunity to share with the subcommittee the pharmacists’ role in devising a rational and cost-effective benefit. ASHP is the 30,000-member national professional association that represents pharmacists who practice in hospitals, long-term care facilities, home care, hospice, health maintenance organizations, and other components of health care systems.

ASHP believes it is the role of the pharmacist to help patients make the best use of their medicines. The first step in this process is of course to ensure that beneficiaries have access to the prescribed dosage at the prescribed time; to ensure that beneficiaries are not splitting pills or skipping doses in order to make their supplies last. A true drug benefit, rather than mere price reductions, will go a long way towards achieving this goal.

Increasing access to pharmaceutical products however, is only part of the challenge. Assuring appropriate outcomes, preventing adverse effects and medication errors, and enhancing patient understanding and involvement in their drug therapy are equally important components of a successful Medicare outpatient pharmacy benefit. Simply increasing access, without taking this other piece into consideration, will not assure the safe and effective use of medications and could actually result in increased medication-related errors. This is particularly true for seniors who see several doctors or take multiple medications.

Pharmacists are the health professional uniquely trained and committed to assuring appropriate drug therapy regimens. Working in a true collaborative relationship with patients and the prescribing physician, pharmacists are the best ally for ensuring that medications are being used in a clinically appropriate, cost-effective manner, free from preventable side effects, drug interactions, and other medication-related problems.

As the November 1999 Institute of Medicine report, "To Err is Human: Building a Safer Health System" points out: "Because of the immense variety and complexity of medications now available, it is impossible for nurses and doctors to keep up with all of the information required for safe medication use. The pharmacist has become an essential resource . . . thus access to his or her expertise must be possible at all times."

Currently, the expertise and value that pharmacists bring to patient care is not widely accessible through Medicare. This is because pharmacists are the only primary health care professional not recognized under the Medicare program as health care providers. As a result, pharmacists are not eligible to bill Medicare for the services they provide to beneficiaries.

This lack of recognition for pharmacists is consistent with the lack of coverage for pharmaceuticals. Thirty-six years ago, when the Medicare program was established, both pharmacists and prescription drugs were a miniscule part of health care. Since then times have changed. Drug therapy has become the preferred method of treatment for most illnesses. According to a recent ASHP consumer survey, approximately half of the senior population is now taking 5 or more medications each day. At the same time, the pharmacist’s traditional role of ensuring accurate, safe medication compounding and dispensing has evolved into a more comprehensive set of clinical, consultative, and educational services.

Medicare must update its policy to be consistent with current health care practice. The new IOM report, "Crossing the Quality Chasm: A New Health System for the 21^st Century," recognizes that financial barriers embodied in both public and private payers payment methods create significant obstacles to high-quality health care. The report states: "[e]ven among health professionals motivated to provide the best care possible, the structure of payment incentives may not facilitate the actions needed to systematically improve the quality of care, and may even prevent such actions." Our members have increasingly reported this to be true for pharmacists. Health systems often, even when acknowledging the pharmacists specialized expertise, cannot afford to fully utilize the pharmacists’ services since they are non-revenue generating. This is especially contrary to modern practice in the Veterans Health Administration and the Indian Health Service where pharmacists are explicitly recognized as clinical specialists and are providing these services on a broad basis. But again, are not eligible to bill Medicare for the services they provide. Moreover, thirty states have authorized pharmacists to provide these patient care services in collaboration with physicians. Most other states are in the process of doing so.

Research has overwhelmingly demonstrated that quality improvement measures, such as the improved coordination and preventive care that results from pharmacists’ drug therapy management services, can translate into dollar savings. This is true for Medicare since it is already paying for the increased hospitalizations, emergency room and physician office visits, as well as nursing home admissions, that result from medication-related complications. According to a 1995 study published in Archives of Internal Medicine, drug-related morbidity and mortality in the ambulatory setting alone cost the nation $76.6 billion annually.¹ An updated analysis, projected this number to have more than doubled in the last 6 years to $177 billion annually.² According to the 1995 study, the addition of pharmacists’ collaborative drug therapy management services would reduce negative therapeutic outcomes by 53-63% and avoid $45.6 billion in direct health care costs.³

1. Johnson and Bootman. Drug-Related Morbidity and Mortality. Archives of Internal Medicine. 1995; 155:1949-1956.

2. Ernest & Grizzle. Drug-Related Morbidity and Mortality: Updating the Cost-of-Illness Model. Journal of the American Pharmaceutical Association 2001; 41: 192-199.

3. Johnson and Bootman. Supra. FN1.