California Mulls Coverage of Comprehensive Medication Management
A bill to have the nation's largest Medicaid program cover comprehensive medication management (CMM) services by pharmacists and primary care physicians emerged from a committee hearing on April 5 with a unanimous round of ayes by state legislators.
"In the past few years, we have added millions of Californians into Medi-Cal, making the effective management of the quality and cost of care an absolute necessity," Assemblyman Jim Wood told fellow members of the state Assembly Health Committee.
"CMM is a smart, important innovation to help meet these goals," said Wood, who introduced the bill and chairs the committee.
Wood is a licensed dentist whose coastal district stretches from the Oregon border to Santa Rosa, encompassing four counties and part of a fifth.
"My goal is to partner with the pharmacists community and the individual plans to explore how best to make a CMM benefit a reality," he said.
Managed care health plans provide services to Medi-Cal beneficiaries after their initial 30 days of qualification for the Medicaid program. The initial 30 days are covered by Medi-Cal's fee-for-service healthcare delivery system.
"It's bills like this," said Assemblyman Sebastian Ridley-Thomas, whose district is in western Los Angeles County, "[that are] why many of us are here—to advance healthcare quality and access."
Assemblyman Tom Lackey, whose district is eastern Riverside County, praised the bill while noting it comes with costs.
"There are some fiscal concerns, clearly," Lackey said. "But I think that even if this ends up being adjusted to even a pilot program, this is very powerful for districts like mine that have a rural outreach and have the very unfortunate circumstances of being underserved for assistance."
"So I would even like to be included as a coauthor, if that's acceptable," he said.
CMM, according to California Assembly Bill 2084, is "the process of care that ensures each beneficiary's medications . . . are individually assessed to determine that each medication is appropriate for the beneficiary, effective for the medical condition, and safe given the comorbidities and other medications being taken, and [that] all medications are able to be taken by the patient as intended."
To further explain CMM and its benefits, Wood relied on Steven Chen, leader of the nearly completed federally funded project "Integrating Clinical Pharmacy Services in Safety-Net Clinics" (see story).
"Patients loved the service; physicians loved the service," Chen told the 15 legislators at the hearing.
Chen, chair of the clinical pharmacy department at the University of Southern California in Los Angeles, described a patient encounter he had years ago that exemplified the need to help patients correctly use their medications.
He had decided to visit an insulin-using patient at home to gain insight as to why the man had not met his diabetes treatment goals.
The man, Chen said, lived in a camper shell on an empty lot.
"When I asked him the next obvious question—What did you do with the insulin we asked you to store in your refrigerator?—he pointed outside to the empty lot. And there, in the middle of the lot, was a refrigerator—no door, not plugged in—and two bottles of insulin cooking in the sun in 100-degree heat, basically denatured and useless."
No one spoke in opposition to the bill.
Twenty-six members of the public voiced their support, including representatives of groups other than pharmacy associations, such as the California Chronic Care Coalition, Los Angeles LGBT Center, and California chapter of the National Association of Social Workers.
Among those 26 supporters were 5 members of the California Society of Health-System Pharmacists (CSHP): President Kethen So, President-Elect Vicky Ferraresi, Director Jim Walsh, Sandy Bardas, and Donna Fitzgerald.
The hearing, perhaps not by chance, occurred during the afternoon of the annual Joint Capitol Legislative Day held in Sacramento by CSHP and the California Pharmacists Association (CPhA).
"We had a Board of Directors conference call to review this bill [before Legislative Day], and the board approved [supporting] it," So said after the hearing.
CSHP and CPhA had been cosponsors of the 2013 bill that resulted in recognition of the state's pharmacists as "health care providers who have the authority to provide health care services."
Absent from the bill, however, was any requirement for Medi-Cal to pay pharmacists for providing healthcare services or for Medi-Cal managed care plans to credential pharmacists as providers.
Ferraresi described CSHP as "really excited" about the bill because members know that CMM benefits patients and health plans.
But CSHP, she added, expects some opposition to the bill when it goes before the Assembly Appropriations Committee.
"In order to save money, you have to spend a little money," Ferraresi said. "Governor Brown has made it really clear he doesn't want to increase any Medi-Cal spending this year, so that's what we're up against."
Wood, who is also a member of the Appropriations Committee and spoke to the pharmacists in the morning, told his Health Committee colleagues that he would consider a pilot CMM project before statewide implementation.
Recent retiree Bardas said she attended the April 5 hearing because of her experience as an emergency medicine pharmacist at Stanford Health Care.
"We found that medication misadventures were a large part of our emergency room practice, and it could have been avoided with better medication management," she said.
Bardas said the pharmacists' strongest support comes from the rural areas of California, where access to healthcare is more difficult than in the urban centers of the state.
Assembly Bill 2084 is sponsored by CPhA.
[This news story appears in the May 15, 2016, issue of AJHP.]