Pharmacy News

Health Care Reform Means Challenges, Opportunities in Rural Areas

January 15, 2011, AJHP News]

Kate Traynor

ANAHEIM, CA 29 Dec 2010—In rural America and elsewhere, health care reform is essentially about providing better, more cost-efficient care—issues that pharmacists are well qualified to address, said Brock A. Slabach, senior vice president for member services for the National Rural Health Association.

"You as pharmacists have a large part to play in how we can, basically, reduce our costs and increase quality," he told attendees at a December 5 session on health care reform at ASHP's Midyear Clinical Meeting in Anaheim, California.

Roles for pharmacists in the era of health care reform include ensuring the correct drug selection for patients, measuring quality outcomes, and using health information technology to track whether patient care is being delivered as intended, he said.

And, he said, health care reform may allow pharmacists to prove their worth as medication therapy managers in nontraditional venues supported by the reform legislation, such as medical homes and accountable care organizations.

He encouraged pharmacists to "become part of the medical home" model and, where possible, participate in medical home demonstration projects whose goal is to provide better care at a lower cost.

In particular, he said, "we want the rural pharmacists and the rural hospitals to be able to take advantage of these programs and demonstrate, hopefully, as a model for the rest of the country, how well these things can work and . . . how people can work together and get things done."

Reform in rural America. Slabach expects health care reform legislation to have profound effects on rural communities. Particularly troublesome are unknowns, such as whether reform will cost more than it saves or vice versa, the fate of health care exchanges, and whether the individual mandate to purchase health insurance will survive repeal attempts.

He said if the 5% of Americans who are predicted to remain uninsured despite the individual mandate all live in rural areas, punitive measures targeted at these people will hurt rural communities.

A week after Slabach spoke, a federal judge ruled against the individual mandate in response to a lawsuit brought by the state of Virginia. The ruling did not declare the Affordable Care Act, as a whole, unconstitutional.

Slabach had called such suits inevitable and predicted that the U.S. Supreme Court will eventually sort out the constitutionality of the act.

He said any reform provision that involves payment cuts will disproportionately affect the 62 million Americans who live in rural communities, where health care is the "fastest growing segment" of the economy.

He said hospitals are typically a rural area's largest or second-largest employer and account for up to 20% of the local economy.

"When you cut a dollar to Medicaid . . . or Medicare, it's going to be taking money out of the rural communities to be able to provide services in terms of medical care . . . and also the jobs associated with that," he explained.

But he said the current state of the U.S. economy means that cuts to health services are likely and will be particularly hard on rural communities that are home to many elderly and poor Americans.

Over the next few years, he predicted, states will face tough decisions about Medicaid cuts, and the federal government will scrutinize its payments for Medicaid and Medicare.

Slabach said it is important for legislators to know that maintaining or bolstering the Medicare budget for rural communities would not have a large effect on total Medicare costs, because hospitals of 50 beds or less, many of which are in rural areas, account for about 2% of Medicare's spending.

A positive note. Slabach said the Affordable Care Act brings positives to rural practitioners, like an expansion of the National Health Services educational-loan forgiveness program for pharmacists and others who commit to work in rural areas.

"This is an important program to take advantage of," Slabach said. "I would encourage you to investigate, in your communities, the option of using this" to expand the number of rural providers.

He was initially pleased with plans to expand the federal 340B drug-discount program through health care reform legislation. But a provision to allow the inpatient use of 340B prices was stripped from the final law, and a statement excluding orphan drugs from the discount program for certain hospitals was added.

The orphan drug exclusion, he said, "has had a huge impact on the ability for many rural hospitals to take full advantage of that program."

Several health care reform provisions that are now in place are likely to prove popular with patients, Slabach said. These include the creation of high-risk pools that allow otherwise uninsurable Americans to purchase coverage, the gradual closing of the so-called Medicare Part D doughnut hole, the ability of parents to retain coverage for their children up to age 26 years, and the abolishment of coverage denials for children with preexisting medical conditions.

These factors should help health care reform to survive in some form despite efforts to quash it, Slabach said.

"Basically what you see here is that all the positives have kicked in," he said. "And as these things start to take effect and people get used to it . . . repealing the whole bill may not possible, nor would it be very popular. Because if you're counting on some of these provisions, and now they repeal the whole thing, it gets a lot more complicated."


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