Long-term care (LTC) pharmacies caring for this population face a myriad of unique obstacles, especially the regulatory framework surrounding them.
Although the coronavirus disease 2019 (COVID-19) pandemic has caused a sharp increase in at-home care, long-term care (LTC) pharmacies caring for this population face a myriad of unique obstacles, especially the regulatory framework surrounding them.
Although LTC pharmacies traditionally serve patients in assisted living, skilled nursing facilities, and group homes, the industry has seen a major shift to at-home care in recent years, pushed forward by the safety concerns of the COVID-19 pandemic. John W. Jones, JD, partner and chair of the health care transactions and regulatory practices of the health sciences department at Troutman Pepper, said that although he believes these inpatient facilities will always exist, he also thinks the trend of at-home care will continue.
“I think the goal is ultimately to care for these patients in the home more and more, and less in an institutional setting,” he said in an interview with Pharmacy Times®.
This population is often medically complex, with 8 or more prescriptions and 3 or more chronic diseases. They could also be transferred between a hospital and a skilled nursing facility before going home. Therefore, they require medication management assistance throughout the care continuum and for the rest of their life to avoid gaps in care. Although this type of care is common in inpatient facilities, not all patients require institutionalization and need this type of care at home.
Defining these LTC pharmacies presents a major challenge, however. Although they may co-exist in a retail pharmacy space, such as a combo shop, LTC pharmacies operate separately from the retail store and function very differently. Many medications for LTC patients are shipped, for example, but Jones emphasized that this does not make them a mail-order pharmacy. On the contrary, he said they are LTC pharmacies that deliver the medications to patients in their homes.
The various definitions result in a major problem for these pharmacies, including how they get paid. A payer’s first inclination is often to treat long-term care pharmacies that deliver to the home as a mail-order pharmacy, but this ignores the high-touch, complex services that they provide and that are required by patients.
“This is very different,” Jones said. “This is a high-touch pharmacy service for complex patients, so a lot of these services are regulated. There’s a lot of work that goes into managing the patients and improving outcomes.”
Even under regulations from the Centers for Medicare and Medicaid Services, Jones said the definition of LTC pharmacies is circular and unclear. It is currently defined by the facility that the pharmacy services or the location of the patient, which Jones said is largely irrelevant. Instead, he argued these pharmacies should be defined by the services they provide.
Those high-touch services include specialized adherence packaging, in-home visits, delivery of prescriptions to the home, patient monitoring, and a pharmacist on-call 24/7. These are only some of the requirements listed in the Medicare Part D Performance and Service criteria, however, and Jones said many LTC pharmacies provide additional wrap-around services required by these patients.
Despite the challenges, these pharmacies offer major benefits for patients and the health care system more broadly. Jones said these services result in government and sponsor cost savings, reduced readmissions to hospitals and emergency departments, and improved patient outcomes and overall health.
This system also benefits pharmacists by emphasizing their role in the care team. LTC pharmacies often have a global approach to patient care, requiring frequent interactions with physicians, nurses, technicians, and other care providers to provide holistic treatment plans.
“That’s what is great, is the pharmacist is an integral part of the care team,” Jones said. “That’s why you see these improved outcomes because of the patient oversight and care management.”
With these benefits and a greater push for at-home care during the COVID-19 pandemic, Jones said he sees a positive future for LTC pharmacies providing care to patients in the home. Even the challenges on the payer side are being more closely analyzed, he said, including a 2018 guidance from Medicare that encouraged payers to consider the substance of the pharmacy’s work before automatically classifying them as mail-order or retail.
Correcting the definitions based on patient residence is perhaps the greatest obstacle, Jones concluded.
“Let’s get away from reimbursing the pharmacies based on where the patient resides, because that’s not relevant,” he said. “Instead, let’s focus on the level of care need of the patient.”
Jones, J. Long-Term Care Pharmacy Services to At-Home LTC Patients [presentation]. Pepper Hamilton LLP.