Long-Term Care Pharmacies are Essential in Supporting Individuals with LTC Needs, Regardless of Residence

DATE: November 2, 2021

Policy and Operational Barriers are Inhibiting Access to LTC Pharmacies Services in the Community

Washington, DC – While policymakers and thought leaders on Capitol Hill and across our nation continue to discuss bolstering home and community-based services, new original research and policy analysis  identified barriers to long-term care (LTC) pharmacy services for Medicare beneficiaries living at home or in the community (“community-dwelling”). Senior Care Pharmacy Coalition’s (SCPC) and ATI Advisory’s (ATI) latest report illuminates key operational and policy barriers that are preventing access to LTC pharmacy services outside facility settings. This is despite the fact that 75 percent of Medicare beneficiaries with LTC needs, such as requiring help with bathing, dressing, or eating, are living at home or in the community.

Among the three million community-dwelling Medicare beneficiaries with LTC needs, 65 percent use 10 or more prescriptions a year. However, a lack of policy specificity around LTC pharmacy dissuades PDP/PBM reimbursement for LTC pharmacy services outside facility settings. This results in an institutional bias that limits LTC pharmacy services to a small subset of Medicare beneficiaries in need.

SCPC and ATI identified key barriers including that LTC pharmacy is still not defined in statute. Other policy challenges reflect an emphasis on residence location rather than the individual’s LTC needs, with key beneficiary protections (such as network adequacy) focused only on beneficiaries living in facilities.

With the U.S. Department of Health and Human Services predicting that  70 percent of the U.S. population who reach age 65 will need LTC services, CMS and LTC pharmacies should be working lockstep to support Medicare beneficiaries. Prior SCPC and ATI Advisory research showed parallels in the needs of LTC patients regardless of where they choose to live. The prior analysis also identified that community-dwelling beneficiaries with LTC needs are more likely to be Black or Hispanic/Latinx, suggesting that this institutional bias in policy might exacerbate racial disparities.

“When policy treats LTC pharmacy like a medication delivery service, it minimizes the key role LTC pharmacies play in offering essential care required by people with LTC needs,” said SCPC President and CEO Alan Rosenbloom. “We need lawmakers who recognize that LTC pharmacy services cannot be limited to those who reside in facility and institutional settings.”

“Policymakers need to consider the LTC pharmacy needs of high need Medicare beneficiaries who choose to live at home and in their communities,” said Anne Tumlinson, CEO of ATI Advisory. “Our data show that many people with highly complex care needs live in the community. There’s no reason to support these needs in an institutional setting but not in the community.”

Regardless of where older adults choose to live, they should have access to Medicare services that address their needs. LTC pharmacies provide crucial services to complex, frail beneficiaries enrolled in Part D and should not be limited only to those living in facility settings.

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About Senior Care Pharmacy Coalition

The Senior Care Pharmacy Coalition (SCPC) is the only national organization exclusively representing the interests of LTC pharmacies, representing 75% of the sector overall. Its members operate in all 50 states and serve 850,000 patients daily in skilled nursing and assisted living facilities across the country. Visit seniorcarepharmacies.org to learn more.

About ATI Advisory

ATI Advisory is an advisory services and research consulting firm focused on transforming the healthcare delivery and financing systems for frail, older adults. ATI Advisory applies quantitative and qualitive research methods to identify opportunities to improve Medicare, Medicaid, and long-term care, and it stands by research and data as the foundation of quality. Visit ATIAdvisory.com to learn more.