From the blogs: TRICARE is being undermined by new policies
Sayings such as “cutting off your nose to spite your face” and “penny-wise and pound-foolish” aptly describe some of the government’s response to the rising costs of TRICARE. The taxpayer-funded military insurance program is stretched to the financial breaking point by aging baby boomer veterans and everyone who has served in our recent wars in Iraq and Afghanistan.
Pharmacists can play a vital role in reining in TRICARE’s spending. Whether it is their clinical expertise, their important interactions with patients, or their use of adherence programs like Simplify My Meds that lessen the approximately $290 billion being wasted annually in America on the improper use of medications, pharmacists help patients maximize the benefits of their drug regimens. Healthier patients are less likely to have expensive hospitalizations and other medical interventions that make expenditures soar. Unfortunately, TRICARE is undermining the level of assistance pharmacists can provide with several policies.
First, the Department of Defense (DOD) is understandably concerned about the skyrocketing costs of compounded medications, which according to a Government Accountability Office report, have risen from $5 million in fiscal year 2004 to $259 million in fiscal year 2013. Apparently, the biggest driver of this disturbing trend appears to be a small group of providers that have charged extremely high rates to TRICARE.
The DOD indicated to the National Community Pharmacists Association that it would focus on the isolated bad actors, while maintaining coverage for compounded medications. But then DOD abandoned that reasonable approach by scaling back its coverage of compounded medications prescribed by doctors and customized for individual patients.
The change was driven by effectively ending coverage of many ingredients in compounded drugs. As a result, many TRICARE beneficiaries are having claims denied and being thrown into a bureaucratic morass in quest of relief. Pharmacists must then spend more time finding work-arounds. This policy has been in place since last May.
Second, Congress, which sets the funding levels and policies for all government programs, is still debating whether to launch a small pilot program that steers TRICARE beneficiaries to “preferred pharmacies.” Many independent community pharmacies are excluded from “preferred” networks, forcing beneficiaries who want to use that pharmacy to pay more – or travel great distances to go to a “preferred” pharmacy. These exclusionary plan designs are rampant in Medicare Part D, which has led to the introduction of legislation that would allow pharmacies in medically underserved areas that are willing to accept all the terms and conditions of “preferred pharmacy” plans to be able to offer beneficiaries the lesser copay rates. The House version of the National Defense Authorization Act for Fiscal Year 2016 currently includes the aforementioned pilot program, but with important safeguards in response to the concerns NCPA has expressed:
TRICARE “preferred pharmacy” network participation rates for independent community pharmacies must mirror the current participation rates in the entire TRICARE retail pharmacy network.
The “preferred pharmacy” networks may comply with the current TRICARE pharmacy access standards, which is not the case with Medicare Part D’s “preferred pharmacy” plans.
Third, as of Oct. 1, all TRICARE beneficiaries will be forced to get their prescription drugs for chronic diseases such as diabetes, hypertension and high cholesterol from a mail order pharmacies. This means the face-to-face interaction between pharmacists and patients will be replaced by a conversation with an unknown pharmacist through a 1-800 phone number, which is not a recipe for greater medication adherence.
NCPA and the approximately 23,000 independent community pharmacies it represents stand ready to help DOD find effective cost-cutting strategies that do not further inconvenience TRICARE beneficiaries. For example, coordinated care models that better utilize pharmacies have been shown to improve health outcomes and reduce costs. We hope the ill-advised restrictions to compounding medications are rescinded, that an aggressive strategy to go after the bad actors is pursued, that any “preferred pharmacy” pilot program allows independent community pharmacies to participate in rates no less than they do today, and mandated mail order pharmacy usage for certain prescription drugs is reconsidered.
B. Douglas Hoey, RPh, MBA, is the CEO of the National Community Pharmacists Association.