Senior Care Pharmacy Coalition Provides Comments on Improving Care for Dually Eligible Enrollees

DATE: January 20, 2023

The Senior Care Pharmacy Coalition (SCPC), the only Washington-based organization exclusively representing the interests of long-term care (LTC) pharmacies, has responded to a Request for Information issued by a bipartisan group of Senators led by Senator Bill Cassidy (R-LA) regarding policy recommendations to improve care for enrollees dually eligible for Medicare and Medicaid programs (dual eligibles) and substantially reduce the amount of money both programs otherwise would expect to spend over time. Senators Carper (D-DE), Cornyn (R-TX), Menendez (D-NJ), Scott (R-SC), and Warner (D-VA) joined Senator Cassidy in this effort.

SCPC’s recommendations focused on the value of LTC pharmacy services to improving outcomes and reducing costs for dual eligible who need long-term services and supports (LTSS) living both in LTC facilities and in communities, and suggested policy changes to assure that this group of dual eligibles have unfettered access to LTC pharmacy services. 

Dual eligibles account for a disproportionate share of Medicare and Medicaid expenditures, and dual eligibles with LTSS needs account for a disproportionate share of Medicare and Medicaid expenditures for care of dual eligibles. Better care coordination and management not only between Medicare and Medicaid but also among various elements of each program focused on dual eligibles who need LTSS could significantly improve outcomes and reduce costs not only for this subset of dual eligibles but for both programs overall. A key – and often overlooked – component of such care coordination concerns use of prescription drugs. Medicare beneficiaries who need LTSS often are clinically complex and have disproportionately high drug utilization rates. For example, the typical Medicare beneficiary with LTSS needs living in the community takes fourteen prescription drugs on any given day.

Current research demonstrates the value of the enhanced clinical and specialized services that LTC pharmacies provide in improving outcomes and reducing health care costs for Medicare beneficiaries who need LTSS, particularly those living in the community. A key driver of these results is effective medication management for a population heavily reliant on prescription drugs, which necessarily obligates the LTC pharmacy to coordinate among all prescribers for each patient, thereby both directly and indirectly driving better care coordination for each patient.

Unfortunately, disconnected policies, both within and between the Medicare and Medicaid programs, limit patient access to LTC pharmacy services primarily based on the setting in which the beneficiary resides, rather than the LTSS needs of the beneficiary. Affording all dually eligible individuals’ access to LTC pharmacy services, regardless of the setting, would have significant positive effects on the health and quality of life of these beneficiaries, as well as the healthcare system overall.

SCPC’s believes LTC pharmacy clinical and specialized services be available to all dual eligibles who need LTSS regardless of where they live – federally defined LTC facility or community – and that the Medicare and Medicaid programs recognize the value of, and additional costs associated with those services through appropriate payment approaches. This type of policy would result in dramatic improvements in care coordination and better clinical outcomes and quality of life for dual eligibles who need LTSS while also reducing or at least slowing growth in overall health care costs for this population.

A necessary but not sufficient starting point would be to enact a statutory definition of LTC pharmacy to clarify the services essential to the LTSS patient population. The Long-Term Care Pharmacy Definition Act was introduced in both the 116th Congress and the 117th Congress and will be introduced in the 118th Congress as well. SCPC strongly encourages Congress to enact the bill this year. For more information regarding the need for a statutory definition of LTC pharmacy, click HERE.

SCPC is the only trade group in Washington exclusively representing the public policy interests of LTC pharmacies. Our members own and operate 325 LTC pharmacies in every state across the country, serving more than one million patients every day, including residents living in skilled nursing facilities, nursing facilities, intermediate care facilities, assisted living facilities, other congregate care settings, and at home.

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