HR 4190: A Modest Proposal or Healthcare System Paradigm Shift?

The bill, its provisions, and the issues it raises
June/July 2014, Vol 2, No 3 - Inside Healthcare
Robert E. Henry

HR 4190 is a short legislative pharmacy bill that deserves a long look by retail pharmacists. Its significance rests not in its immediate provisions, but in what it is related to and what it suggests. This interesting bill provides a portal that facilitates entrance into vitally important topics, in particular, the expansion of the scope of practice of pharmacists and other nonphysicians, its impact (if any) on the declining physician workforce, the future division of labor of providers, and  the feasibility of interstakeholder collaboration, to name but a few.

Pharmacy associations everywhere are applauding HR 4190 as a progressive healthcare system measure that would help the process of expanding pharmacists’ scope of practice of primary care patient treatment. On the face of it, this is peculiar, as the bill makes no change in pharmacists’ scope of practice. But that does send a signal to look closely at the bill and think about its context.

Upon closer examination, it becomes apparent that HR 4190 in itself is a paradox: “a modest proposal” that pertains to matters anything but modest. The bill may not make provisions for expanding pharmacists’ scope of practice, but pharmacy association leaders use it to raise the issue, which has a long history and bright future. And although this bill goes no further than to correct an obvious flaw in the pharmacist reimbursement process for Medicare beneficiaries in underserved areas, it provides a portal into the matter of reorganization of healthcare providers’ responsibilities.

From here, the factors extend to several issues of significance: projected physician shortages; expansion of the scope of practice of nonphysicians; the vision of a new model for an integrated, interprovider team; new technology and research discoveries that make this team model possible and necessary; government legislative initiatives; and, finally, the challenge to make strategic changes to so many healthcare constants.

All signs ultimately point to a cohesive provider system, even if it will take considerable work to get there. This is what makes the examination of HR 4190 worthwhile. It provides real-
world interplay of issues: those that are gaining traction, those being opposed, and those being ignored or put on hold while stakeholders try to sort them out.

The goal that HR 4190 is pursuing through government legislation has its counterparts in physician legislation proposals, medical association position papers, and other initiatives.

The Facts of HR 4190
This pharmacy-related legislation is titled “HR 4190: To amend title XVIII of the Social Security Act to provide for coverage under the Medicare program of pharmacist services.” Congressman Brett Guthrie (R-KY) introduced HR 4190 in the House of Representatives on March 11, 2014, where it quickly gained bipartisan support and the applause of pharmacy associations.

The bill proposes to extend access to care to Medicare beneficiaries in areas underserved by primary care physicians, by establishing codes enabling pharmacists to receive payment for services they are already allowed to perform according to their state’s laws, but for which no reimbursement mechanism exists. Thus, the bill is an exercise in simple, Lincolnesque honesty and directness—a mere 300 words of legislation with no hidden traps or ambiguities. It does not expand pharmacists’ scope of practice, but that does not prevent its advocates from labeling it as a first step in that direction.

The bill was met with enthusiasm, optimism, declarations of commitment, and then lack of movement. Currently it is stalled in Congress, which must approve it before it adjourns at the end of 2014 to be adopted in its present form.

What Is Preventing Passage of HR 4190?
The first premise of understanding “Inside the Beltway” thinking is to appreciate that a bill entering the policy portal will be approached in cir­cumspect, systematic, political, and pragmatic ways.

Parsing this out a bit, a bill may be expedited if it does not offend any important group, if it is clear and unambiguous, and if it matters to a large constituency or otherwise has a major impact on society. Two major reasons suggest themselves: opposition, or more likely, the time and effort involved in passing a bill.

Congress’s overburdened agenda produces a constant backlog of bills. A second possible cause for the delay is opposition from one or more stakeholder groups that stand to lose from expanded pharmacist scope of practice—although this is less likely than in past years.

The only parties who may want its delay are physician organizations. However, the American College of Physicians and the Institute of Medicine both have a history of supporting the expansion of pharmacists’ scope of practice. Until recently, however, the American Medical Association regarded pharmacists as competitors for physician business and had taken steps to oppose it.

First Conclusions
The introduction of HR 4190 is akin to throwing a small pebble into a pond and watching the ripple effect. In healthcare and healthcare legislation, as in most of life, everything relates to everything else, making even the simplest bill subject either to intense scrutiny or strategic indifference.

In the case of HR 4190, there are some potent reasons why some stakeholders may regard it as crowding in on their turf, and other reasons why this might not hold any long­er. Supposition is deadly if it is used in place of the facts. But as a spur to thought and inquiry, it serves useful purposes.

Change is afoot, and healthcare mavens inside and outside of Congress know it. That is making some stakeholders very happy and others very nervous. Stalling HR 4190 is either opposition or, more likely, the time and effort involved in passing a bill.

Stakeholder Perspective
Factors Affecting the Passage of HR 4190
Kip Piper, MA, FACHE

HR 4190 is one of thousands of bills introduced in each session of Congress. As legislation goes, the 300-word bill is quite straightforward. However, to get to the President’s desk for his signature or veto, it will need to navigate the unique, rule-driven, and inherently political process of the US Congress.

The House and Senate have different processes, but, in general, a bill must be approved by the relevant House and Senate committees, with any differences in language resolved, and the identical language passed by votes of the full House and Senate. The bill is then sent to the President for his signature or veto. Bills can make it through this gauntlet as stand-alone legislation or similar language can be incorporated in a larger, faster-track piece of legislation—the latter being more likely for short Medicare-related bills like HR 4190.

Once the language is drafted, any Repre­sentative or Senator may introduce the bill in their respective chamber. The bill is then referred to the relevant standing committees for consideration. House committees often have subcommittees, so the appropriate subcommittee(s) considers the bill first.

HR 4190, with a bipartisan mix of 69 cosponsors, was referred by the House Speaker to the Ways and Means Committee and Energy and Commerce Committee, which share jurisdiction in the House for Medicare Part B. The bill was further referred to the Energy and Commerce Committee’s Health Subcommittee.

Prospects for passage of HR 4190 this year are low. In terms of the legislative process, several factors weigh in the bill’s favor. The policy has merit, the language is tightly focused, the bill has support from a mix of Republicans and Democrats, sponsors include members of key committees, outside support from pharmacists and pharmacies is strong, and the Medicare budget impact is likely modest.

However, only about 10% of all bills make it through committee in some fashion and only about 3% become law. The odds are lower for stand-alone Medicare bills, bills not essential to keeping programs and agencies running, bills introduced in only 1 chamber, and any legislation in an election year. Calendars are tight, gridlock is in high gear, and Congress faces a backlog of must-pass legislation, including appropriations. If HR 4190 is scored by the Congressional Budget Office as increasing Medicare spending, offsetting savings or revenues must be identified, further complicating passage. The bill also may be opposed by other provider groups.

The policy change in HR 4190 has a better chance of passage if it is bundled within a large Medicare bill, such as the next round of legislation on Medicare physician rates, which is expected by March 2015. If HR 4190 is not enacted before the 114th Congress takes office in January 2015, the bill can be reintroduced. Even the most meritorious policies can take years to gain sufficient support and find the right legislative vehicle.

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Last modified: May 21, 2015
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