Pharmacists Eye Counseling Pay To Keep Diabetic Test Strip On Shelves

From: Inside Health Policy

As retail pharmacists brace for significant Medicare pay cuts for diabetic testing supplies, some in industry are looking to getting reimbursed for counseling diabetics as a way to keep test strips and other diabetic supplies on their shelves. Retail pharmacists say they will stop selling the supplies if CMS cuts payment anywhere close to the competitive bid price for mail-order supplies, but if Medicare were to pay pharmacists for counseling diabetics, that would both save Medicare money and provide pharmacists a way to continue selling supplies, industry sources say.

CMS officials said at a recent stakeholder meeting that if the agency does not use inherent reasonableness to reduce prices, the program will soon fall under the competitive bidding program for mail-order supplies. Either approach would lead to steep pay cuts, and brick-and-mortar pharmacies, especially small, independent pharmacies, say they would no long be able to afford to sell supplies. That would cause problems for diabetics who prefer buying from local pharmacies instead of using mail order, they say.

Some retail pharmacists testified at the CMS meeting in Baltimore that pay cuts would decrease the counseling that many pharmacists offer diabetics for free. Daniel Nam, an independent pharmacy owner, said he spends hours a day giving free advice. Face-to-face counseling is crucial to some patient populations, he said, particularly those for whom English is a second language. Richard Price, of the Advanced Medical Technology Association, also said it was critical that beneficiaries be able to buy supplies at retail pharmacies “where they can obtain both the in-person assistance and the brands of testing supplies that they and their physicians have determined are most appropriate for their needs.”

Mail-order pharmacies said retail pharmacies should take up the counseling-reimbursement debate outside of the debate over reimbursement for diabetic testing supplies. Sam Silak from Liberty Medical Supply and Jonathan Napier of CCS Medical suggested that pharmacists seek a reimbursement code for counseling. They said Medicare is paying for a supply, not a service, so counseling is separate and Medicare should pay the same for products sold retail and mail order.

A pharmacy source says industry is reviewing the idea of a separate code and there might be a precedent in the proposed Medicare Part B physician fee schedule for fiscal 2013 in which CMS would pay doctors a new fee to certify a face-to-face evaluation of a patient before ordering DME.

Such an approach could allow pharmacies to both continue selling supplies, at a lower cost, and continue providing counseling, which lowers costs by reducing hospitalizations and complications, industry sources say. It would be similar to what has been happening in Medicaid, they say. States have been shifting to average acquisition costs to reimburse for drugs, which has lowered drug reimbursements, while increasing pharmacists’ counseling and dispensing costs, the source says.

The problem, another industry insider points out, is that pharmacists are not considered providers under Part B. While medication therapy management, which often includes counseling for diabetes, can be reimbursed through demonstrations under Part D and is often recognized by private insurance companies, the corresponding ability under Part B does not exist. This could be tied to Part B modernization, and recognizing the changing role of the local pharmacist, the insider pointed out, but CMS could not make this change through regulation. It would require a change to the law.

But whether through Part B or Part D, there is a strong case for clustering diabetic supplies and services, the second insider said, and the impact would be an incredible saver for the Medicare program, as shown by the Ashville project and other diabetic counseling programs. There is a big focus on cutting reimbursement to pharmacies, but that is not looking at diabetes holistically. — Michelle M. Stein