Currently, I am taking a class on the ongoing transformation in economic models of health care. While I will not discuss the intricacies of value-based payment models or accountable care organizations (ACO), what I will mention are take away messages I got from listening to financial people from New York City’s largest health systems. Indications on which reimbursement arrangement will best benefit health systems for patients, payers, and providers have not clearly emerged. 

Few clues can yet be found regarding the long-running question as to where pharmacists will fit in the equation of “mission vs margin.” As a pharmacist for 26 years, I have seen many attempts in our profession to not only elevate our contributions in the eyes of other health care providers, but to get paid fairly for these services. From my vantage point, Medicare reimbursement has been incremental but slow and expanded scope of practice has occurred in progressive states such as Iowa, Washington, North Carolina, and Minnesota.

In addition, I have been fortunate in my career to see how pharmacists work and how they have surprisingly similar battles with insurance companies and governments in Rwanda, South Africa, and Jamaica. Yet despite the disparities in resources, personnel, and facilities, patients in these countries have received remarkable care from pharmacists along with sustainable, consistent therapeutic outcomes.

On my first trip to Rwanda, I was listening in on a conversation between an epidemiologist, a social worker, and a physician with vast experience in treating HIV globally. They were discussing a strategy to reduce the impact of HIV in the country by various treatment and prevention measures. 

Naively, I said that is pretty ambitious; however, rather than admonishing me, they said something that stuck with me, “When you have bright, passionate people working on a problem, nothing is impossible.”

Five years later, I was speaking with an executive director of a prominent Rwandan non-governmental organization. She told me that in the past when they met with government officials, they outlined the HIV agenda for the year. Now, with HIV programs showing a positive effect, the Rwandans are now empowered to tackle other issues.

This is not to say that pharmacists in America working on vexing reimbursement problems are not bright and passionate, rather timing is everything—and with the chaos going on now in health care, this is a good time to refocus. When I was doing my BS Pharm rotation at the Jacobi Medical Center in the Bronx during the mid 1990s, my preceptor physician expressed frustration with the current status of the health care system.

He compared the system to a large sandbox in which health care dollars and revenue are being shifted from one part of the sandbox to another.

My current view is different than it was 20 years ago—there is a still a sandbox, albeit much smaller. The institutions and professions that stay in that sandbox have to understand and work with the new paradigm of delivering quality health care at a lower price.  

This is why I wrote earlier that large health care systems are searching for clues on which reimbursement arrangement will ultimately emerge. This reimbursement roulette is taking place in every state, municipality, city, and town.

Another key point gleaned from these classes is how the United States stacks up to other countries. An interesting dashboard compiled by Peterson-KFF (Kaiser Family Foundation) gives interesting comparisons that allows a review of various metrics pertaining to the health care environment. 

Health care institutions are also known as high reliability organizations (HROs). The military (think aircraft carriers) and nuclear reactors are also HROs. What they have in common is the goal of zero harm. To meet this goal, 5 things have to happen:  
 
  1. Everyone looks for and reports small problems
  2. Be preoccupied with failure
  3. Report even the smallest deviations
  4. Commit to resilience
  5. Defer to expertise1    

In this current chaotic environment of reimbursement that depends on quality and cost savings, pharmacists should increase their presence. Interested in hospital best practices? Then go to the CMS website, the most accepted scorecard for top hospitals.  

One of the tragedies and highest costs in US health care is marginalized populations lacking knowledge of access to their health care needs. How many of us working in community pharmacies have helped patients get the care they are entitled to?  

As part of our strategy to get our fair share of the reimbursement pie, make sure payors know of our activities.  Yes, there have been numerous studies and programs that demonstrate our contribution.  But I wonder how much of our day-to-day heroics go unnoticed?

Paul Batalden, MD, a health services researcher at Dartmouth, once said, “Every system is perfectly designed to get the results it gets.” 

In this new chaotic environment, pharmacists can be part of a new, better health care system for our country.

About the Author
Joel L. Zive, PharmD, AAHIVP, is a 2020 MPH candidate, Mailman School of Public Health, Columbia University.

Reference
  1. Chassin, Mark and Loeb, Jerod.  High-Reliability Health care:  Getting There from Here.  The Milbank Quarterly, Vol 91, No. 3, 2013 (pp. 459-490).