Madam Speaker, I have come down to this Floor many times over the past year and a half to share with my colleagues my profound concerns over the direction the Majority was taking with regard to health care reform. Regrettably, the…
Madam Speaker, I have come down to this Floor many times over the past year and a half to share with my colleagues my profound concerns over the direction the Majority was taking with regard to health care reform. Regrettably, the enactment into law of Patient Protection and Affordable Care Act--accomplished via an unprecedented and extraordinary misuse of budget reconciliation rules-- did nothing to alleviate my concerns. In fact, now that health care reform is law and the American people can finally see, in the full light of day, the law that the Democrat Majority wrote and jammed down their throats, a strong preponderance of Americans want this turkey of a law repealed.
I am firmly convinced that the credibility gap between what the Majority claimed its health care reform bill would do, and what all of the experts say it will actually do now that it is law, is a large part of why, according to the latest Gallup opinion poll, only 20% of Americans, a mere 2 in 10, have a favorable opinion of this Congress.
This Majority and this Administration has shown more disregard for the opinions and desires of the American people then any Congress and any presidential Administration, certainly of the modern age, if not history. It is time we listen to the American people; listen to the ordinary moms and dads and the small business owners who must live with the consequences--intended and unintended--of the laws that we pass.
To that end, I would like to share with my colleagues a letter I received from Pharmakon Long Term Care Pharmacy, Inc. and Pharmakon Pharmaceuticals; two Indiana corporations that provide pharmacy services to Indiana nursing and institutional facilities. Founded in 2003, these two companies have grown to over one hundred and fifty, 150, full-time employees serving more than six thousand, 6,000, people throughout Indiana and part of Illinois. I ask unanimous consent to include a copy of the letter in the Congressional Record after my statement.
I ask my colleagues to pay particular attention to the questions and concerns expressed in the letter about the Patient Protection and Affordable Care Act but I think it is also important to understand their observations about problems with Medicare and insurance billing as well as their concerns about DEA rules when it comes to dispensing medications; because these are the kinds of real world problems in our health care system that we should have been working to resolve if only we had been listening.
Letter to Congressman Burton on Healthcare
May 27, 2010
Congressman Dan Burton,
Rayburn House Office Building,
Washington, DC.
Pharmakon Long Term Care Pharmacy, Inc. and Pharmakon
Pharmaceuticals (d/b/a Pharmakon Compounding, Inc.) Inc. are
two Indiana Corporations founded by Paul J. Elmer R.Ph.
Pharmakon Long Term Care
Pharmacy, Inc. was founded in 2003 with the purpose of
providing pharmacy services to Indiana Nursing Facilities and
Institutional Facilities. Since its founding Pharmakon has
grown from 5 employees to a company with over 150 full time
employees; serving more than 6,000 individuals throughout
Indiana and part of Illinois. Carol and Paul Elmer, R.Ph.
founded Pharmakon Pharmaceuticals, Inc. in 2006 with the
purpose of providing medications to hospitals run by the
Department of Defense, throughout the United States.
Pharmakon Pharmaceuticals has a current staff of 25 employees
with an expected growth of over 100 within the next two
years. In the past 7 years, both Pharmakon LTC Pharmacy and
Pharmakon Pharmaceuticals have been able to provide jobs in
this rough economy and continue to grow and provide services
to our most vulnerable population, the elderly.
Currently, the Pharmakon Long Term Care Pharmacy, Inc.
experiences multiple barriers as a long-term care pharmacy. A
long-term care pharmacy differs from your local retail
pharmacy in that it is a highly specialized organization,
with the primary purpose of providing pharmacy services
(medications, medical supplies, consultant services, and the
such) to the elderly and institutional residents in nursing
facilities and various institutional facilities, such as
mental hospitals. Because it is a highly specialized
pharmacy, it faces multiple barriers daily, which make it
extremely difficult at times to provide the required services
to the most fragile population in the American Society. These
barriers are not challenges but are rather outright problems
that must be solved in order for these individuals to receive
the service and care they deserve. The following are examples
of some of our current barriers, none of which are addressed
in the current Healthcare Reform.
First, most pharmacy bills come due the 15th of the month
or the 30th of the month. The problem with this is that the
pharmacy is not paid on insurance claims for usually 30 days;
however, it is more common for the insurance company to take
up to 60 or even 90 days to pay the pharmacy. In addition any
claims submitted to Medicare Part B or D generally are not
paid to the pharmacy for 30 to 90 days. So while the pharmacy
must pay its bills when they come due, the insurance and
government plans generally do not pay within a timely
matter--this thus leaves the pharmacy with an ongoing debt.
Furthermore, another payment problem with Part D is whom
does the pharmacy contact when there are problems with Part
D? It would be beneficial for the pharmacy to know who holds
the position of managing the administration of the government
program. For example, when the pharmacy is not getting paid
on claims by Part D Anthem who can they contact to get this
resolved? The pharmacy, cannot continue to operate without
getting paid; we set out to create jobs in the community
while servicing some of the most vulnerable populations;
however, when the pharmacy is not being paid, we cannot pay
our bills or employees and thus those who need our services
cannot receive the services and goods they require in some
cases to continue living.
With that being said, another barrier the Pharmacy
continues to run into is Prior Authorizations. We, as a
pharmacy, have had to hire a nurse to work on prior
authorizations due to the fact that the nursing staff at the
facilities has no time to handle these and the doctors
generally refuse to do them. We must contact the insurance
company for prior approval for a medication. Generally, on a
good day, it is a 30-minute phone conversation with the
insurance company; however in some instances it may take up
to 72 hours for the insurance company to reply and say yes.
While we wait for the insurance company's reply, the
individual is suffering in pain waiting for their
medications. Because we must contact the insurance company
for a prior authorization this slows our ability to get the
medication to the individual, leaving them suffering in pain.
Additionally, many hours are spent handling, monitoring and
appealing insurance audits; rather than providing pharmacy
services. Insurance audits have become burdensome; we
understand the need for them; however, insurance companies do
not understand the Long Term Care Industry and the majority
of the time as it relates to these audits is spent on
educating the insurance company about this industry. Once
educated we usually win the audit; however, the time it takes
to reach this result, takes away from our primary purpose,
which is providing pharmacy services. Additionally, the time
frames set forth by the insurance company are not realistic;
they are too short for a pharmacy to return with proper
information and many times, we end up paying for something
that was originally covered and properly processed to begin
with.
Similarly, insurance formularies are not conductive to
residents in a Long Term Care Facility; for example, many do
not cover IV therapy, in which case we must get an override
in order to provide the necessary medication to the
individual and even with that we are audited for those
claims. It appears from our point of view that the insurance
companies do not grasp that these residents are cared for 24/
7 by healthcare professionals of many different
disciplines and when they are denied various medications
due to the formularies, they lay in pain suffering until
we can finally get the needed medications covered. These
individuals pay for plans to cover their medications, in
most cases these are expensive medications which the
individual themselves more than likely could not pay for
out of pocket. Additionally, we are not in the business of
providing free, expensive medications; as much as we would
like to, we cannot pay our employees while handing out
free medications. Since we cannot just give the
medications away, and since the patient cannot pay for it
and nor will the insurance; we are left in a difficult
position while the individual suffers.
Finally, one of our biggest barriers is the DEA not
treating nurses in long-term care facilities as agents of the
prescribing doctor when it comes to controlled substances.
There are times when a resident needs an emergency dosage of
a Controlled Substance, generally a Schedule II, and the
nurse must call a doctor who is generally not near a fax
machine. The nurse may not call in the prescription due to
the fact that the nurse is not considered an agent of the
doctor by the DEA and thus the pharmacy must attempt to reach
the doctor via phone before sending out the medication; which
can take hours; all the while the resident is agonizing in
pain. If the nurse would be permitted to be an agent of the
doctor this would reduce the time between when the order is
called in and when it is delivered to the individual.
How will the Patient Protection and Affordable Care Act effect Pharmakon Long Term Care Pharmacy and Pharmakon Pharmaceuticals, Inc.?
First, there are several sections that state the employer
must provide affordable coverage, but who is determining what
is affordable? In some instances, our hourly individuals may
want to opt out and purchase from the exchange because to
them they may find one a plan on the exchange more to their
liking and more what they deem affordable opposed to the plan
we offer. Why should we be punished for the decision that the
individual makes. We, as a corporation, cannot force our
employees to spend their hard earned wages toward something
they may personally decide either (a) they have no interest
in procuring from us (b) find that they just do not think
they can afford it or (c) they have no interest in purchasing
period from us or the exchange. The affordability is truly a
personal decision and should be left to the individual to
decide and the employer should not be punished for the
individual's decision. Furthermore, there is also the issue
that in some cases, our employees may choose just not to
purchase insurance from us or from an exchange and again we
cannot force them to buy it. We have many employees who just
choose not to buy the insurance we currently offer.
Additionally, the Bill states that the Employer is
responsible to cover 60% of all health care; for our
particular business this is a large sum that we just possibly
could not do and continue to pay our employees at their
current rates. If we are forced to cover 60%, there is a good
chance that we would have to lay off many employees in order
to be able to provide the required healthcare coverage.
Under this Bill, HSA cannot be used for over the counter
drugs, this seems to be counterproductive. The purpose of an
HSA is for the individual with a high premium to use those
monies for office visits, medication, and the such. In some
instances, why should an individual visit the doctor to
receive a prescription for Claritin-D just so that they can
use their HSA, now the individual will have to pay for the
office visit, which in the scheme of things may be more
costly than just buying the medication out of pocket. In all
reality this is the individual's hard earned money, the
government should not tell them how they may spend it;
especially when it comes to accounts set up just for health
care concerns. Yes, people may be irresponsible; but at some
point, the government needs to just trust that its citizens
will do the right thing and use their non-taxed dollars on
their health care. We at Pharmakon have HSA accounts due to
our high premiums; we believe that it should be the
individual's decision as to how to spend their monies and if
they choose to purchase Over the Counter medications, which
they need then they should be permitted to use their HSA
accounts.
The Class Act states that an employee can enroll and
disenroll but how will this affect the employer? If an
employee chooses not to enroll, will we the employer be
penalized? Again, we cannot force our employees to do
something they do not want; nor can we force them to spend
their hard-earned money on something they have no desire to.
Additionally what protections are there that we will not be
forced to enroll all employees in this when it becomes
apparent that it cannot support itself?
The Bill sets up Health Information Technology; however, it
is vital to ensure that Long Term Care especially the Long
Term Care Facilities and Pharmacies are brought to the table
in this process. We must realize that in a few years, the
baby-boomer generation will be the new class of residents in
these Long Term Care Facilities and with this increase of
resident population; we must look to the LTC community for
suggestions as it relates to Health Information Technology.
Many do not realize that while the pharmacies may be state of
the art, many of the facilities are not equipped with some of
the most basic technology; additionally most of the staff
would be in complete shock if they were just slammed with
this new technology; thus input from the LTC area is
extremely vital. Furthermore, the way things are done in a
doctor's office and hospital do
not always transfer as easily to LTC settings. HIT while
vital and extremely beneficial will be useless in the LTC
setting if LTC providers are not consulting in the
development of it. In additional the Pharmacy cannot be left
holding the price tag for updating LTC facilities when it
comes to this technology; there must be a way in which we can
encourage these facilities to update their own technology and
not depend on the Pharmacy to do it for them. Some of these
HIT grants should not only be given to LTC Pharmacies but
also the Facilities we service.
With the new Bundling system, the unanswered question here
is under the pilot program if one hospital receives a bid
will they determine which nursing facilities the individual
may use? One of the concerns with Bundling is what if the
hospital chooses to use nursing facilities which they own or
which are related in some manner to the hospital, will
patients have a choice as to which facility they want? If not
then the question becomes what will protect those facilities,
which are currently in business? Those facilities which are
related to the hospital may have the technology which non-
related facilities lack and then the question becomes who
is to provide the technology, across the board, most Long
Term Care Facilities are accustom to Pharmacies providing
all of their equipment needs, fax machines, med carts and
so forth. If and when this new technology is implemented
there will be a vast problem of who is to provide it and
furthermore uniformity. Pharmacies cannot bear the burden
of providing this to Facilities, and additionally neither
should hospitals.
The establishment of CMI within CMS aims to move the fee
payment from fee for service based reimbursement toward a
salary-based payment; however, providers are not defined, so
do Pharmacies fall into this? Additionally under CMS, there
is the Medicare Shared Saving Program, which sets up
Accountable Care Organizations--with the development of this
new organization the question becomes will pharmacies be a
group later determined by the Secretary to be part of this
process? If so or if not the question then becomes how will
these organizations effect our ability to procure business or
which homes may be able to willingly choose us for their
pharmacy services? All of these issues are left open and yet
to be determined, these are rather important issues; and
there are so many unanswered questions and with the
possibility of this new fee payment reimbursement, which may
affect LTC pharmacies.
Under the Medicare Shared Savings Program, subsection (b)
Eligible Accountable Care Organization. The payment would be
via shared saving; this section does not list pharmacies but
allows the Secretary to determine groups of providers and
supplies as appropriate. The big question is would this new
program affect how we as a pharmacy obtain new business and
in some cases keep current customers? Would this limit which
nursing facilities, institutions and so forth can utilize our
services?
Due to the fact that the bill does not address these above
stated questions, we are left wondering how these new
programs will affect the Long Term Care industry,
specifically the Pharmacies. While there is some concern
about how we will be paid, we are more concerned as to what
will happen to us and how these programs affect us. There is
a concern that because LTC pharmacies aren't mentioned by
name, we may not necessarily fall into one of these programs,
and under the guise of cost control our reimbursement fees
may be cut; which in turn will create a larger problem for us
as how to pay our employees and how to continue to provide
the services that we are do and that the facilities are
accustom to.
Our concern with Individuals at Home Demonstration Program,
specifically the payment methods governed by (subsection
(c)). The issue is the spending targets, which will be
determined on a per capita basis, what does that mean for
items covered under Part A and Part B and those cuts? While,
we agree that there is wasteful spending and that budget
controls are needed, we ask that those cuts to remedy the
increase in cost do not affect the Pharmacy. As a pharmacy,
there is only so much we can provide while not running at a
loss and if the spending targets reduce payments to the
pharmacy, there is a chance that the pharmacy will not be
able to provide to those who are most vulnerable and need all
the care we can give them.
While we at Pharmakon agree that Health Care needs to be
reformed, we believe that this current Reform Bill will
create more barriers in our ability to provide services to
the most vulnerable in our society and in addition as a
medium size business with mainly hourly employees, we feel
that many of these changes will affect our ability to
continue to employ many of our employees and will affect them
in their personal choices.
Sincerely,
Pharmakon Long Term Care Pharmacy, Inc.
Pharmakon Pharmaceuticals, Inc.