ALEXANDRIA, Va. - As director of third-party and regulatory programs at the National Association of Chain Drug Stores, Roy Bussewitz currently has one overriding concern: the Omnibus Budget Reconciliation Act of 1990, or OBRA as it's commonly called.
Next year measures in OBRA affecting pharmacy service for Medicaid patients go into effect. And, since joining NACDS about a year ago, Bussewitz has been busy helping association members prepare for the various new requirements incorporated in the federal law. "I've been going out frequently to make OBRA presentations," he says. "I'm trying to make sure that everybody is up and ready to do it."
The act - which actually focuses on holding down government payments for pharmaceuticals under Medicaid - mandates that pharmacists more actively advise customers covered by the program.
As of January 1, 1993 this must be done by formally offering to counsel Medicaid patients on how to take their medications. In addition, pharmacists, in so-called prospective drug utilization review (or, pro-DUR), will be required to check for problems posed to patients by their prescriptions.
Because the measures pertain to Medicaid, explains Bussewitz, much of his involvement with NACDS members has been at the state level. The primary challenge there has been to prod through testimony state authorities to set OBRA-related regulations in a timely, notto mention, acceptable fashion.
Last November, for example, Bussewitz, who holds both law and pharmacy degrees, coauthored a model bill prescribing a method for patient counseling with Rite Aid Corp. vice president of government relations James Krahulec. The model's language, which gives ample latitude to the professional judgment of pharmacists, has influenced legislation in several states, according to Bussewitz.
On the matter of drug utilization review, he says, the biggest problem is that many states have been slow to form the DUR boards mandated by OBRA.
The state boards are responsible for, among other things, certifying pharmacy information systems for conducting pro-DUR. And drug chains are now adapting their electronic claims processing systems to facilitate the reviews.
But by January 1993 many pharmacy providers could be in a difficult position. "They very well may have uncertified systems - not because we haven't tried to get them certified," Bussewitz says, "but because a lot of states haven't formed those DUR boards in a timely enough fashion."
Bussewitz is working with NACDS members to nudge state authorities along. He also says much of the blame for delays in OBRA implementation belongs in Washington.
The Health Care Financing Administration HCFA), which oversees Medicaid at the federal level, is expected to give detailed guidance through published regulations to state officials for implementing OBRA. But to a large extent, says Bussewitz, it has failed to do so in a timely manner.
"If I were a betting man," he adds, "I would say that those regulations will not come out until after the elections."
In that case, says Bussewitz, it would be totally unrealistic to expect state authorities to follow up by year-end.
In his work, Bussewitz has considerable contact with officials at HCFA (a part of the Department of Health and Human Services), and he regards the staff as a very capable group. Nonetheless, he wishes that they would play a more assertive role in establishing national standards for services provided under Medicaid.
Uniformity in state Medicaid regulations, he says, is critical to cost-effective provision of pharmacy and other health care services. Efficiency suffers if, for example, a drug chain must conform to different pharmacy standards in each state in which it operates.
More often than not state agencies will go their own way, says Bussewitz, who once worked for Wisconsin's Medicaid bureau. "The attitude out there is, |Hey, if HCFA is not going to exert that kind of pressure from on high, then we can do what we want,"' he says.
Bussewitz, who at one time was on the staff of former Wisconsin Senator Gaylord Nelson, says that political pressure from elected officials may ultimately be needed to get a government agency to act. "That may be needed to encourage HCFA to act," he says.
If more is being expected of pharmacists, Bussewitz is not confident that additional financial compensation will follow.
Systems for documenting cognitive services provided by pharmacists are emerging, but it will be a very tough marketplace that decides on reimbursement. "Competition is really going to determine if cognitive services are going to be paid for," says Bussewitz. "And I'm not as optimistic as some that it's going to happen."
Bussewitz is concerned that third-party payers - both private and governmental - are shifting more administrative tasks to retail pharmacies. "There is a lot that we are asked to do that we aren't paid for," he says, "whether they are cognitive services or administrative services. "
Establishing national standards for pharmacy claims processing can help contain costs, and NACDS can work to that end. But in dealing with the demands of third-party payers, particularly in the private sector, there is little that the association can do, if only for antitrust reasons. "It is really a matter of individual business decisions," Bussewitz says.
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