The Evolving Role of Pharmacists in the Transformation to Payment for Quality and Cost-Effectiveness and the Attendant Legal Hurdles
The following article was published on October 17, 2016 by AIMM.
By Paul DeMuro, Ph.D., J.D., M.B.A., CPA and Yesenia Prados, Pharm. D.
The traditional role of pharmacists
When one thinks of pharmacists, one typically thinks of the individual in the retail pharmacy who fills his or her prescription that was “written” by a clinician. This traditional role of pharmacists was managing the production and dispensing of drugs. Pharmacists have only been considered dispensers, and not providers and thus their practice has been limited. Patients often viewed their pharmacists as businessmen and not as healthcare professionals. They thought their only role was to make a sale and patients were only there to make a purchase. Since patients often walked into a retail pharmacy where many things were being sold in addition to pharmaceuticals, this perception was probably not incorrect.
What pharmacists are doing today?
Today, the role of pharmacists is evolving such that pharmacists are much more involved in the management of patient care. Patients often see pharmacists as their go to health professional who is easily accessible. As pharmacists are now able to identify and meet a patient’s drug-related needs, they are attempting to lead the way and provide better patient care with their significant clinical knowledge, which has not been used to its full potential in the past. Pharmacists are now able to play an integral role in the healthcare system. The concept of clinical pharmacy has taken hold as the profession continues to move towards being patient-focused. In 2010, the Affordable Care Act identified pharmacists as medication therapy management (MTM) providers, allowing them to become formal members of the new integrated health care delivery models.
What pharmacists can be doing in the transformation to payment for quality and costeffectiveness?
As the payment system moves from a fee-for-service system to value-based purchasing and payment for quality and cost-effectiveness, and CMS begins to pay providers in accordance with new rules, that includes ACO participation and the Medicare Access and CHIP Authorization Act of 2015 (MACRA), pharmacists are becoming increasingly important because of their ability to assist in managing a patient’s care by helping improve outcomes. They can play a key role in specific quality measures being monitored by CMS such as medication review, medication adherence for diabetes, hypertension and cholesterol, use of high risk medications, and diabetic disease management. As the pharmacist is the one completing these measures the physician can be alleviated from those tasks and thus provide better patient care. Including pharmacistled MTMs in this model can also lead to providing patient education telephonically, reducing medication overuse or missing therapy, and also monitoring for adherence. The end result is to provide better quality of care at reduced costs.
Legal Hurdles that the pharmacists face in being as effective as they can be today?
It is often thought in health care that technology and advancements move much more quickly than the laws that govern the healthcare sector. Such is certainly the case in the pharmacy area. Often when one sees a chart noting a number of the stakeholders in the delivery of healthcare, the stakeholder mentioned related to pharmacists is “pharmacies.” Undoubtedly, this reflects the traditional role of pharmacists as noted above, and does not recognize their value in today’s evolving healthcare system. The care pharmacists can deliver to patients is constrained by certain laws and regulations that govern the scope of a pharmacist’s practice, which in many instances is quite limited. Furthermore, unless pharmacists are recognized as providers or suppliers who might be able to bill commercial and government payors for their services, they will not be paid for them. For example, Medicare Part B covers Medicare beneficiaries’ medically needed services (i.e. services that diagnose or treat a condition) and preventative services (i.e. vaccines and screenings). Although increasingly, pharmacists are Doctors of Pharmacy, who complete 10+ years of education with postgraduate training, and are qualified to deliver services such as disease state management, medication therapy management, immunizations and preventative health screenings, their profession is not mentioned as providers in the Social Security Act, and thus they cannot bill Medicare Part B. Given, that pharmacists cannot bill for their services, they must regularly provide services for free. Large chain pharmacies are at a disadvantage whenever an employee pharmacist spends time providing cognitive services to a patient, as the time they spend with a patient is less time they spend filling prescriptions. The providers in many ACOs are paid on a fee-for-service basis, although they may qualify for shared savings type incentive payments, pharmacists cannot be paid by the Medicare program. Although there is an increasing recognition of the value of pharmacist by Medicare, e.g. through the Enhanced Medication Therapy Management Program under Medicare Part D, progress has been slow. Recognition of the value that pharmacists bring to the management of patient care by recognizing them as providers and paying them for their services would bring another 300,000 or so mid-level providers into the healthcare system. These individuals can certainly help manage patients’ care in unique ways, particularly patients who have chronic diseases states that are being managed by in large part by medication therapy.