Current Issues in Pharmaceutical Reimbursement

01.15.2008American Journal of Health-System Pharmacists


Purpose. Six issues in pharmaceutical reimbursement arising from recent or proposed changes in Medicare rules or rates or the health care environment are described, along with possible strategies for addressing these issues.

Summary. Recent reductions in Medicare pharmaceutical reimbursement rates, increases in use of specialty pharmacies, proposed changes in rules for erythropoiesis- stimulating agent (ESA) reimbursement, increases in need for patient assistance programs, proposed changes in the clinical trial policy, and possible reductions in reimbursement for cases involving medication errors or other negative events as part of pay-for-performance initiatives are cause for concern. A multidisciplinary team approach to improving reimbursement can reduce institutional financial losses and increase options for Medicare beneficiaries. Health-system pharmacists can address concerns about the use of specialty pharmacies by collaborating with payers and specialty pharmacies on the development of workable models for safely obtaining, handling, and administering medications. Proposed rules for ESA reimbursement contain numerous flaws that could compromise patient outcomes. Pharmacists should provide the Centers for Medicare and Medicaid Services and their fiscal intermediaries with feedback on the potential impact of the proposed rules. The use of patient assistance programs can decrease financial losses associated with providing pharmaceuticals to underinsured or uninsured patients, but these programs can present pharmacists with logistical challenges. The proposed clinical research policy gives priority for research efforts and limited health care dollars to the health issues that are most important to Medicare beneficiaries, but details pertaining to implementation and funding have not yet been worked out. Pharmacists should voice opposition to pay-for-performance models that do not support a nonpunitive culture of openness in reporting quality indicators.

Conclusion. An understanding of issues in the current health care environment arising from recent and proposed changes in Medicare rules and rates for pharmaceutical reimbursement can help position pharmacists to manage these issues.