OPINION EDITORIAL: PUNITIVE MEDI-CAL REIMBURSEMENT RULES POSE A PUBLIC HEALTH DANGER

March 12, 2020

By: Dr. Dana Gove

I decided to enter the pharmacy profession because of a strong personal commitment to take care of others; to give patients hope for a healthy life. One of the most important missions our pharmacy performs is to provide injection medications in San Jose and surrounding areas for low-income patients who struggle with behavioral health issues. Many are homeless and need help to stabilize their everyday lives. For these patients, the availability of these injections can mean the difference between life and death.

That’s why I am so alarmed by recently enacted bureaucratic rules from Sacramento that threaten the viability of this treatment program, as well as the progress we’ve made in improving the lives of a very vulnerable population. The reimbursement rates contained in these rules for the dispensing of these specialty medications are short-sighted and will have a catastrophic human impact. Patients are at risk of decline and death without access to the injections they need.

Independent pharmacies, like ours, go out of our way to provide these specialty medicines; providing not just prescriptions but also detailed counseling and instruction on their proper use.  That takes time, but we do that because we believe in our mission. Without that counsel and adherence to a regular monthly schedule of injections, we wouldn’t see the improvements that our patients need.

As a longtime community pharmacy owner, I want to do the right thing. But the rules adopted by the California Department of Health Care Services make that extremely difficult. For our pharmacy, the reimbursement cuts add up to approximately $250,000 annually. My team and I want to continue our commitment to the community and deliver these unique injection services. But it becomes a difficult call as we face a choice between continuing to lose money every single day and possibly closing, or continuing to provide services.

The problem is widespread. The state’s reimbursement rules add up to $67 million in cuts per year for pharmacies across the state. Even more alarming, the state Department of Health Care Services is going after pharmacists for back payments on Medi-Cal claims stretching back two years. It’s unreasonable to think that these independent pharmacies can come up with a collective $36 million in punitive paybacks for services that they have already provided when they are simply trying to keep the doors open and serve patients.

Pharmacists are committed to providing extraordinary care, especially in light of expanded coverage made possible by the Affordable Care Act. Roughly one in three Californians is now covered under Medi-Cal. But coverage has little meaning without genuine access to medicine, especially specialty drugs that are prescribed to treat a range of conditions and illnesses, including diabetes, high blood pressure and cancer.

California is obviously facing a homelessness crisis, and there is a strong intersection between these individuals and those struggling with some form of mental illness or a substance use disorder. Without proper medications such as those we deliver, there is little hope for these people to stabilize and engage in recovery. The bottom line is that these rules are creating a public health crisis in California.

I want to continue to provide compassionate care to my community. That’s why I’m so troubled by an unpalatable choice; either shut down the program, or stop taking care of Medi-Cal patients, who make up almost half of my business.

These rules were drafted by the previous governor’s administration. Governor Gavin Newsom, now in his second year, has the opportunity to stop the catastrophic effects that are coming, and reverse these rules. Fortunately, a new bill authored by Assemblymember Jim Wood (D-Santa Rosa) will do just that. The legislature must pass AB 2100 to stop these Medi-Cal cuts.

We can’t turn our backs on the most vulnerable among us – they are good people who deserve our help.

Dana Gove is a pharmacy owner in San Jose.

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