COVID-19 is driving near- and long-term health care system changes, some examples of which include growing telemedicine options, disruptions to new and ongoing treatment, new patient affordability and access issues, and more. During a session at AMCP Nexus 2020 Virtual, Nick Diamond, JD, LLM, MBe, consultant; Daniel Nam, RPh, Esq, associate principal; and Margaret Scott, RPh, MS, MPH, associate principal, all of Avalere Health, discussed how the pandemic has influenced the scope of practice for managed care pharmacy and what a post-COVID-19 world may look like.
COVID-19 has shifted many patients into Medicaid due to unemployment, with a 4.8% increase in enrollment so far, said Dr. Scott. Elective procedures and routine care have drastically declined, “and this will continue to have [an] impact on the health care system,” she said. “This has been a problem for infrastructure, resourcing, and budgeting processes.”
“We’re seeing a reorganization of the provider landscape—digital health, digital therapeutics, telemedicine, remote monitoring services,” she said, “as well as a push for pharmacist provider status into scope of practice. Hopefully the reimbursement methodologies will follow along with that.”
Patient utilization of autoimmune and oncology treatments is down since the onset of the COVID-19 pandemic. According to Avalere Health Medicaid data, from Feb. to May, there has been a 54% decrease in infusion services for chemotherapy, a 64% decrease in injections of other drugs, and a 69% decrease in infusions of other drugs compared with this time period in 2019.
Additionally, about half of patients who lose employment lose insurance as well; these patients may then enter Medicaid or the health care exchange—or become uninsured—leading to changes in benefit designs and cost sharing. Reduction or loss of income translates to a higher burden associated with out-of-pocket costs. In addition to current limitations on provider access due to social distancing requirements, shifts in coverage frequently have led to changes in available provider networks.
Coverage flexibilities for telemedicine services aim to facilitate patient access to providers during the pandemic. For example, there is now a waiver of Medicare coverage and reimbursement barriers (e.g., non-rural areas, expanding eligible sites of care, technology, flexibilities, in-state care delivery, and use for initial/new patient visits and provider types). All 50 states and Washington, DC have expanded telemedicine coverage for Medicaid patients, and nine states have adopted state legislation. Most states have expanded coverage through waivers, amendments, emergency legislation, or executive orders to new populations, originating sites, provider types, and technologies.
“Which of these will stay in place after the pandemic ends?” asked Mr. Diamond, when discussing which telemedicine flexibilities might remain a broader part of health care post-COVID-19, including the geographic expansion, use of personal phones, coverage of initial visits for certain specialties, expanded ability to monitor patients remotely due to benefits, expanded provide types, care across state lines, and remote supervision of delivery of care. Flexibilities unlikely to remain available post-pandemic are expanded coding, reimbursement parity between telemedicine and in-person coding, and HIPAA non-compliance on platforms.
“Medicare Part B has opened up some flexibilities of home drug administration for infusions during the public health emergency,” said Dr. Scott, who mentioned that this is under the telehealth benefit because the physician must be available via telecommunications during therapy administration. A home health agency then provides the in-home treatment, and the claim is submitted and billed through the supervising physician; the home health agency receives their contracted amount from the payment. “Not quite a streamlined process, but it’s a little more flexible than Medicare Part B generally is for home infusion,” she said.
At the state level, there has been movement to expand the scope of pharmacist practice to aid in the pandemic response process. The U.S. Department of Health and Human Services (HHS) also issued a declaration that preempted state and local limitations on pharmacist-delivered COVID-19 diagnostic testing during the public health emergency. HHS also declared authorization for pharmacists to administer vaccines to children aged 3 to 18 years following declines in route pediatric immunization rates. With a potential COVID-19 vaccine on the horizon, HHS also declared that pharmacists can administer such a vaccine in patients as young as 3 years of age.
Despite the expanded scope of practice, Dr. Nam said that steep reimbursement challenges remain for pharmacists, including broad adoption by state Medicaid programs, pharmacist reimbursement for Part B vaccines, lack of provider status in Medicare, reimbursement for diagnostic testing, and broader adoption and innovative payments by commercial plans. “Is the amount that pharmacists are getting an adequate and appropriate level compared with what physicians and non-physician providers are getting?” asked Dr. Nam. Reimbursement will depend on several stakeholders, including the federal government, states, and health insurance plans/pharmacy benefit managers.
Presentation: L5 Scope of Practice for Managed Care Pharmacists in a Post-COVID-19 World. AMCP Nexus 2020 Virtual.