Health Care Policy and Practice

Health Care Policy and Practice

Health policy has a significant impact on the way that health care is financed, organized, and delivered. Health policy is adjudicated by Federal, State, and local governments, as well as by health plans, pharmacy benefits managers (PBMs), professional organizations, professional licensing boards, and even employers. The Federal government’s actions say much about access to care for patients. There are many programs overseen by various agencies, including the Medicare and Medicaid programs administered by the Centers for Medicare and Medicaid Services (CMS). On a frequent basis, new budgetary and regulatory rules shape the way that these plans provide coverage for prescription drugs.

Medicare Part D was designed to provide drug coverage for Medicare beneficiaries on Parts A and B, as those programs do not include sponsorship for drugs acquired in the ambulatory environment. Selecting the best Medicare Part D option available to eligible beneficiaries can be quite confusing for them, as the basic structure of Medicare Part D can present a dizzying set of rules and tiers for varying levels of coverage and patient cost-sharing responsibility. CMS does provide a number of tools to help, including a user-friendly website ( and an internet-based decision support tool called Plan Finder. A study by McGarry et al found that while beneficial, the tool could be simplified for use by Medicare Part D enrollees.1 They found that reducing the amount of financial information displayed in Plan Finder results in the selection of lower-cost plans, with no accompanying decrease in plan quality.

Pharmacists and support staff are in a great position to assist patients navigate our complex health care system. Pharmacists have a responsibility to be familiar with patients’ pharmacy benefit coverage and formularies, along with common tools to help them maximize the benefits to which they are entitled or pay for. Pharmacists might not receive reimbursement directly for helping patients with these types of issues, but in addition to our ethical responsibility to practice altruistically, a little bit of help for a patient could go a long way toward developing a great relationship with them, reducing frustrations in the long-run, and promoting your pharmacy organization/employer.

Additional information about Impact of Health Care Policy on Health Care Delivery can be found in Pharmacy Management: Essentials for All Practice Settings, 4e. If you or your institution subscribes to AccessPharmacy, use or create your MyAccess Profile to sign-in to Pharmacy Management: Essentials for All Practice Settings, 4e. If your institution does not provide access, ask your medical librarian about subscribing.

1McGarry BE, Maestas N, Grabowski DC. Simplifying the Medicare Plan Finder Tool could help older adults choose lower cost Part D plans. Health Aff (Millwood). 2018;37:1290-1297.


Go to the profile of Shane Desselle
over 3 years ago

Have you offered to help a patient select a plan during open enrollment? Have you found loyalty to ensue from the help you provided?