The Affordable Care Act insurance marketplace reforms included a requirement that health plans in the individual and small group markets cover essential health benefits (EHBs) in 10 key categories:

• Ambulatory patient services
• Emergency services
• Hospitalization
• Maternity and newborn care
• Mental health and substance use disorder services, including behavioral health treatment
• Prescription drugs
• Rehabilitative and habilitative services and devices
• Laboratory services
• Preventive and wellness services and chronic disease management
• Pediatric services, including oral and vision care

Policymakers at the Centers for Medicare & Medicaid Services recently published a request for information (RFI) seeking input on how to enhance and modernize the EHB regulation across a variety of areas, including overcoming barriers to accessing services because of coverage or cost and addressing gaps in coverage.

Working with its partner organization, the Get the Medications Right (GTMRx) Institute, ACCP is leading an outreach to the Biden administration, calling for coverage of comprehensive clinical pharmacists’ services to help achieve medication optimization on behalf of patients with complex health conditions.

Background of Medicare Medication Coverage

The Medicare Part D drug benefit successfully expanded Medicare to include prescription medications in the early 2000s. Medicare Part B has long covered a small number of physician-administered medications. However, beyond the limited Part D medication therapy management service, Medicare beneficiaries still lack access to a meaningful benefit to ensure that expensive and complex prescription medications provide maximum value.

There is a broad, bipartisan consensus shared by the Biden administration and both parties in Congress on the need for prescription drug price reform and greater transparency in the pharmacy benefit manager market. But ACCP believes there is a need to look beyond the affordability of medications and truly examine the value of the medication therapies prescribed. Comprehensive medication management (CMM) delivered by clinical pharmacists is the best way to achieve this critically important goal.

ACCP’s Recommendation

Medication misuse and the adverse drug events that ensue is estimated to account for at least $528.4 billion in unnecessary health care spending annually. CMM has been shown to improve outcomes, increase patient satisfaction, alleviate physician “burnout,” and save money.

CMM is a well-established standard of care in the nation’s leading private sector health systems, including Geisinger, Kaiser Permanente, Mayo Clinic, and Johns Hopkins. Nationally, in the integrated Veterans Health Administration care system, clinical pharmacy specialists (CPSs) hold scopes of practices that confer medication prescriptive authority and the responsibility to modify, start, stop, and/or continue medications according to guideline recommendations, collaborative practice agreements, and the CPS’s clinical judgment. CPSs also perform associated physical assessments, order laboratory tests, and initiate consults for other services.

CMM provided by clinical pharmacists, in close collaboration with physicians, is a critically important step in helping to ensure that medication therapy is fully optimized, thereby contributing to better care, lower costs, improved outcomes, and enhanced equity.

• Click here to read ACCP’s statement in response to the EHB RFI.
• Click here to read GTMRx’s statement in response to the EHB RFI.
• Click here to read ACCP’s January 2023 letter to the Biden administration calling for the inclusion of comprehensive clinical pharmacists’ services in the 2024 budget request to Congress.