12/29/15, 12:08 PMPayment Reform for Pharmacists Remains Variable

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Payment Reform for Pharmacists Remains VariableNan MyersPublished Online: Monday, December 21, 2015

A shortage of primary care physicians (PCPs) is looming in many areas of the United States. However,although projections indicate this situation will get worse before it gets better, unexpected positive changesare happening for pharmacists. The Role of the Pharmacist Is ChangingTo meet the health care shortfall, which results partly from health care reform, pharmacists are taking onexpanded responsibilities. Most community pharmacists no longer stay exclusively behind the counter.Instead, they are developing new skills beyond the traditional prescription-dispensing function. Pharmacistsnow provide direct-care services, such as immunizations, point-of-care (the delivery of health care servicesto patients at the time of care), wellness and prevention screenings, medication therapy management,chronic condition management, patient education, and counseling. These roles are often part of team structures and are carried out in a much wider range of settings than thetraditional drugstore or hospital. These settings include inpatient facilities (hospitals, nursing homes, andrehabilitation centers); outpatient, urgent care, and ambulatory clinics; patient centered medical homes(PCMHs), and accountable care organizations (ACOs). The PCMH is a care delivery model whereby patienttreatment is coordinated through a patient’s PCP physician to ensure the patient receives the necessarycare when and where they need it, in a manner they can understand. ACOs are groups of doctors,hospitals, and other health care providers, such as pharmacists, who work together to offer coordinated careto their Medicare patients. The goal of an ACO is to ensure that patients, especially those who arechronically ill, receive the best care when they need it and avoid unnecessary duplication of services whichraises costs. Studies of pharmacists who provide medication therapy management (MTM) services show that suchservices can improve outcomes and reduce costs. These services are typically provided throughcollaborative practice agreements. In most states, pharmacists can modify prescriptions under acollaborative agreement that allows pharmacists to address drug-related adverse effects and improve

therapeutic outcomes for patients.1 The compensation model still mostly lags behind these newopportunities. How Can Pharmacists be Compensated for Providing New Services?Community-based pharmacists are considered to be among the most accessible health care practitioners.2

However, when they branch out from filling prescriptions, they find there is often a problem in obtainingreimbursement for these services. In the current environment, pharmacists can bill patients directly on acash-transaction basis, provide services under a third-party insurance-contracted service, or usepharmacist-specific current procedural terminology (CPT) codes. Medicare and Medicaid compensation policies also limit pharmacists’ ability to practice in new areas,particularly within integrated care teams. For example, under Medicare Part B, pharmacists are not includedin the statutory definition of providers and, therefore, cannot directly bill for patient care services. In addition,many state and private health plans align their payment policies with Medicare policies and, as a result, do

not allow pharmacists to bill directly for patient care services.3

These situations are not unusual. As we look to 2016, the hope is that as pressures continue to increase onhealth care providers, the value of pharmacist-provided services will be recognized and reimbursed. Some

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12/29/15, 12:08 PMPayment Reform for Pharmacists Remains Variable

Page 2 of 3http://www.pharmacytimes.com/publications/directions-in-pharmacy/2015/december2015/Payment-Reform-for-Pharmacists-Remains-Variable

change may happen as alternative payment models (APMs) and fee-for-service (FFS) quality initiativescontinue to take hold. In 2018, APMs and FFS linked to quality are forecast to hit 50% and 90%,

respectively, of reimbursements.4

Currently, pharmacists who practice in walk-in clinics, urgent care facilities, or inpatient or outpatientfacilities may be able to negotiate contracts with different payers or self-insured employers. There is also the“incident to” concept where a pharmacist bills services under a physician’s National Provider identifiernumber (issued by CMS). In this case, reimbursement is 100% of the Medicare fee schedule as opposed toonly 85% when the service is billed under the pharmacist’s number. Depending on the payer, a pharmacist may also use some CPT codes when seeking reimbursement. Threepharmacist-specific CPT codes (99605, 99606, 99607) were established for the delivery of medicationtherapy managed services. These codes are used by Medicaid, private health insurers, or Medicare. MTMfor Medicare Part D beneficiaries is among the most prominent types of direct patient care services that arereimbursed by payers today. How Does the Law Play a Role?States, too, are very slowing recognizing the value of pharmacists in direct care. The first to implementchanges are Washington, California, and Oregon. On January 1, 2016, Washington will enable pharmaciststo bill for their services just as a physician bills a patient for theirs. With such laws, these states lead the wayin requiring health insurers to consider pharmacists as health care providers alongside doctors and nurses.In California and Oregon, pharmacists will be able to prescribe contraceptives. After a brief screening thatwill include a questionnaire about the woman’s health and medical history, the pharmacists will assesswhether to prescribe birth control to her based on health history and lifestyle. Then the pharmacists willeither dispense the birth control or refer the woman to a physician. The pharmacists will be reimbursed bypayers if the woman carries insurance. As long as Uncle Sam does not widely recognize pharmacists as health care providers in federal programs,pharmacists will have to pick and choose opportunities to obtain reimbursement. This is, however, a paththat can lead to a better situation at the state level. Should the shortage of PCPs continue and affect morehigh population areas, state legislators, like those in Washington, California and Oregon, are likely toconsider efforts to give pharmacists the provider designation status, which should result in remuneration for

services.5-8

Nan Myers is a content strategist who works with health care clients to tell their stories through writing fornewsletters and published articles, while also coordinating media relations.

References:

1. National Center for Chronic Disease Prevention and Health Promotion. A program guide for publichealth: partnership with pharmacists in the prevention and control of chronic diseases. CDC website.http://www.cdc.gov/dhdsp/programs/spha/docs/pharmacist_guide.pdf. Published August 2012.Accessed December 1, 2015

2. Avalere Health. Developing trends in delivery and reimbursement of pharmacist services. NASPAwebsite. http://naspa.us/wp-content/uploads/2015/11/103015_Avalere_NACDS_WhitePaper_LP_Final.pdf. Published October 30,2015. Updated November 4, 2015. Accessed November 16, 2015.

3. Social Security Administration. Title XVIII—Health Insurance for the Aged and Disabled. SSA website.www.ssa.gov/OP_Home/ssact/title18/1800.htm. Accessed December 9, 2015.

4. Tefera L. Delivery system reform and the hospital value-based purchasing (HVBP) program.SlideShare website. www.slideshare.net/SAGES_Updates/dr-lemeneh-tefera. Published September 3,2015. Accessed December 9, 2015.

5. Maine LL, Knapp KK, Scheckelhoff DJ. Pharmacists and technicians can enhance patient care evenmore once national policies, practices, and priorities are aligned. Health Aff (Millwood).2013;32(11):1956-1962. doi: 10.1377/hlthaff.2013.0529.

6. Smith M, Bates DW, Bodenheimer TS. Pharmacists belong in accountable care organizations andintegrated care teams. Health Aff (Millwood). 2013;32(11):1963-1970. doi: 10.1377/hlthaff.2013.0542.

7. Yap D. APhA to HHS: lack of provider status a barrier. American Pharmacists Association. website.www.pharmacist.com/apha-hhs-lack-provider-status-barrier. Published November 4, 2013. AccessedJune 18, 2015.

8. Marotta R. Regional pharmacy trends: the state of provider status. Pharmacy Times website.www.pharmacytimes.com/publications/career/2015/pharmacycareers_february2015/regional-

12/29/15, 12:08 PMPayment Reform for Pharmacists Remains Variable

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pharmacy-trends-the-state-of-provider-status. Published February 16, 2015. Accessed June 18, 2015.

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