Expert Discusses Pathways of Pharmacist Payment for Patient Services

Melissa Somma McGivney, PharmD, FCCP, FAPhA, professor and associate dean for community partnerships at the University of Pittsburgh School of Pharmacy, gives a brief overview of the best practices when it comes to billing in a pharmacy.

Melissa Somma McGivney, PharmD, FCCP, FAPhA, professor and associate dean for community partnerships at the University of Pittsburgh School of Pharmacy, gives a brief overview of the best practices when it comes to billing in a pharmacy.

Q: What are some of the current pathways of pharmacist payment for patient services?

It's highly varied across the country. So, when we think about pharmacists’ payment for services, so much of it is local. The first thing is when we think about pharmacists in the community in particular, it's really about access. And so you're looking particularly focused on what is it that those people need in that particular community, and that often comes down to a state level.

So there's really five ways that pharmacists can get paid for services, as many of us are advocating for, we'd love to be providers under Medicare Part B, but until then, we have to advocate for the services that we provide.

So pharmacists can be paid for medication therapy management services under Medicare Part D, in some states that Medicaid plans, so those local plans have said, we want to make sure that our patients, our members, have access to pharmacist and the community. So, they've derived their own ways to contract with groups of pharmacies to pay for services or pay for patient access in a state Medicaid plan.Numerous examples of that throughout the entire country.

We're seeing a growth in employer plans as well. So, employers saying we want to keep folks healthy as part of having employees that's keeping them on jobs, keeping them healthy, wanting them to stay employed with us, and they're finding that connecting them with local pharmacies, because 80% of chronic disease management is actually drug therapy. When you realize that you realize, oh, having a drug expert, as a part of this really does make a difference, and so we're seeing a growth in employers, again, that local flair to what is happening.

We're also starting to see health systems, in some cases, connecting with local or regional pharmacies, because again, they want to keep people, once they're discharged from a hospital environment, they want to keep people at home, they don't want to see them circling back, and they're recognizing that some of the most significant issues upon discharge often revolve around drug therapy.

There's been an opportunity to do call-based and telephonic care, but there's still a subset of individuals that need higher intensity Person to Person Care, and in some cases, we're actually seeing health systems partnering with local pharmacies.

We can never forget that patients and caregivers can pay for services as well, and certainly that's been around for a long time.

Q: Can you give a brief overview of best practices when billing in a pharmacy?

When we talk about billing, I need to actually start with what happens before billing, because billing happens after the care, and it happens after everything has actually been designed in the pharmacy. So it’s the outcome? And in order to get to the outcome that we want is to be able to drop that bill. There are a few things that have to happen before that occurs, and some of it starts right in the pharmacy itself with systems in place to transition from a traditional dispensing only model, so product only model, to where you're actually taking care of the patient within that workflow. That includes some re designation of who does what within the pharmacy.

So, looking at the work that the technicians doing that cashier and the pharmacist, and are they all doing the work and at the most efficient at that top part of their skill set? So that's the first thing is looking at the redesign.

There's technology that's needed. We have to be able to have patients make appointments. We need to be able to have an electronic system that captures health information and can transmit those bills and can transmit that information. We have to be able to accept payments in new ways, from health insurers, and potentially from employers that don't necessarily come through the dispensing system.

We also have to have all of the tools in place in the pharmacy to be able to provide care. So, some of those things are relatively simple, you know, we want to have our blood pressure cuff, we want to have scales to measure people's height and weight, but we also have to apply for laboratory licenses. So there's a CLIA waiver that has to be applied for the state and the federal level. So you have to have all those things in place in order to provide the care in order to eventually be able to bill.

The other really best practice, which is a big part of what you asked, is having someone in the pharmacy or within the pharmacy team who has a designated responsibility for adjudicating billing and adjudicating claims and then looking at any rejected claims. So we're used to claims coming in a dispensing model all coming at us in a relatively standardized way. It doesn't work that way with patient care billing, so some things might come in electronically, some things might come in on paper and a whole variety and they come in in different timeframes.

Having someone within the pharmacy, or within the organization, that was responsible for making sure that the bills are coming in, and that you're getting paid for everything, or they can call or they can be able to work with the payer, if something did get rejected. Having a billing leader within the pharmacy or the organization is really, really very important as well.

Q: How can pharmacists prepare their practice for patient care payments?

The preparation is the key, as I was mentioning, there's 4 areas of preparation, and the first is really workflow design, and it first starts with a culture change of focusing on the whole patient versus the 1 problem that they might be having today when they're picking up their prescription. It's a change of anticipating patient needs thinking ahead, planning ahead, when they come versus reacting to whatever's coming. They'll always be some reaction, right, there's always going to be some patients who are going to need an acute medication for an acute need.

When we take a look, in general, about 80% of what happens in a pharmacy is about chronic medications, and about 20% of on the given day, it is acute, so the goal is to get that at present in a more predictable fashion. The way you can do that is through medication synchronization, planning out with the patient when they're going to get their meds and attaching what we call an appointment-based model to that. That transition from managing things just as they come at us to planning the care is the game changer. What it does is it helps plan out the work of the pharmacy team, and at the same time, it actually brings in oftentimes a more consistent flow of revenue, if you're thinking about it from a business perspective, for the dispensing of the drugs alone.

The appointment that medication synchronization helps the patient, the appointment helps the patient, and at the same time, it helps the business from a workflow perspective, and also, really from a financial perspective. When you transition to that appointment-based model, once you have the contracts in place, it's easier than to tag in those contracted services during those once-a-month appointments, helpful to that patient because they know what to expect. It's not coming at them randomly and helpful to the pharmacy team because they can plan out those things. So having this level of planned or anticipated care really helps to stabilize what's going on within the pharmacy.

The second thing is patient engagement, and 1 of the very first things that we encourage the pharmacy teams that we work with is to reintroduce themselves to their patients. Their patients have been used to a certain way of working and that's, you know, varied for any given pharmacy. But if they want to develop this in a new way, and to start taking care of the patient, they have to tell the patient and let the patient know this is happening and encourage that patient to work with them. This is the way welcome to my new practice.

We've actually seen a number of pharmacies do this, and some of them have gone as far as actually having the patient sign a contract with them. This is what you can expect from us. If you don't want this, here's the other thing that you can sign. So being really intentional about engaging that patient and letting them know, you know, what to expect that's different.

The other thing with patient engagement is to be really thoughtful about the staff that is working alongside the pharmacist, thinking about the work that the technician does, and some pharmacies are starting to change what a career ladder could look like for pharmacy technician. Perhaps they work as a pharmacy technician doing the work with regard to dispensing, and then, perhaps, that could be a patient care technician, where they're learning to engage the patient, perhaps they're the ones doing the blood pressure checks and the height and weight. There's a really interesting career ladder that can be built for the individuals that really create the entirety of the practice.

The other thing that we're seeing with patient engagement is that once you go to a patient care technician, the next level can be a community health worker. This is actually a training and a designation that is growing and communities all over the US, but we're seeing an opportunity for folks that really think about engaging the patient and connecting them to services in the community, and being a bit of a navigator for patients who need it so that they can get their totality of their care.

The third aspect of what has to happen in the pharmacy to prepare you for billing is really about looking at the way the whole practice is managed. I mentioned some technology things that need to occur; there's the need to have a scheduling system, there's a need for a patient care record, that we can adjudicate the claims, there's also a need to be able to communicate electronically with patients. In some cases, we're seeing that pharmacies are able to get into the electronic health records through a contract with local area health systems, so that they can actually engage in 2-way dialogue electronically with the prescribers. So there's a number of technology things that have to happen.

The other thing that we see in the practice management area is the ability, from a financial standpoint, to be able to take in the flow of funds from this new variety of different ways. Qhen we get into medical billing, so when we're taking care of patients, we often will need, through that contract, to actually be able to drop a medical bill. Money comes in in a different way, and so making sure that the pharmacy or the whole team is able to bring that money in in a different way is important.

It's really important personnel management changes, so people's jobs descriptions have to evolve, including the pharmacist, including the technician, including every person that's in that space, including delivery driver, you know, the delivery drivers have an incredible eye. They get to witness things that the pharmacist doesn't always see because they're driving to an individual's home and dropping it off, or sometimes they're invited into the home in ways that they understand the totality of the patient's experience, and then information has to come back to the pharmacist so we can think through how we can best help the individual. There's a lot of roles and responsibilities that end up evolving. When we transition to this patient care focused pharmacy, as you know, in instead of doing a traditional of dispensing only.

Finally, in practice management, you need to have some dashboards, you need to know how you're doing because what's so different when you're billing for patient care services is you don't know once you provide a claim to anywhere, you don't know if you're going to get paid the same amount, you don't know exactly the timeframe that you're going to get paid.

It's not like we do with drug dispensing where, you know, either right away, whether your claim has been accepted or not, and so you really need a set of dashboards to be able to know “Have I been able to take care of all the patients that I can in this contract? Where am I at?”

Some of the contracts allow you to see a patient every single month, some might be once a year, some might be 3 times a year, so you need a way to account for this variability between the contract. So really having dashboards created specifically for the work and the contracts that you have to serve people in your particular pharmacy becomes really important.

Finally, you know, business development. Patient care is a part of a whole community, making sure to know where the referral sources are in your community, reaching out whether it's the local doctors, offices, dentists, hospitals, but there's also the community organizations that are in the area that serve all kinds of needs that can also be referral sources in both directions. It’s really helpful to know what community resources are available.

Everything from what's going on at the local library to the local food bank to knowing where the Area Agency on Aging is, where's Meals on Wheels, all of those different types of services, and can be where we refer out from a pharmacy perspective, but at the same time, they could also be services that refer back to the pharmacy as well. So, it's a real holistic relook at the pharmacy when you start thinking about billing for patient care services.

Q: What are some patient care services that pharmacists can be reimbursed for?

It's a great question, and there's a lot of answers to it. I'll start with when we look at what pharmacists are paid for. It's always our expertise in looking at the patient's medications. And so when we start there, I'll tell you about a whole bunch of different services that we're seeing, but all of them are connected by that, you know, we're paid for that expertise that we have in being able to identify, prevent, and solve drug therapy problems that that's what we do, inherently.

The individual services since the early 2000s, it was medication therapy management, so you know, looking at a patient's holistically at their medications, certainly comprehensive medication reviews. We're seeing that really coming into the Medicaid space. So, while early 2000s, we're looking at Medicare, we still are, but now we're seeing in the Medicaid space, just how helpful pharmacists are able to be with individuals that are on multiple medications.

We're obviously seeing vaccines throughout the entire country. We're seeing point of care testing throughout the entire country, but we're also starting to see pharmacists, again, based on local and regional needs focused on caring for people with diabetes, focused on people who have asthma. We're seeing contracts for individuals who are pediatric patients, so pediatric asthma and helping them to manage keeping them in school. We're also seeing hypertension management. We're seeing pharmacists doing dis depression screenings. So when you think about the work that a pharmacist does, our access is really important, particularly in the community.

We have this expertise of drug therapy, and then we also walk in access, that becomes really important, particularly to individuals who may not already be connected to care. I think that's the other theme is that we have this opportunity to reconnect people to care. We can't take care of every single thing an individual needs, but as I mentioned earlier, 80% of chronic disease management is drugs, we can help with a drug therapy and reconnect back to the care that the individual needs.

Q: What is important for pharmacists to remember when it comes to billing, reimbursement, and payment?

That it starts before you drop the bill, and I think that's the hardest thing, you know, I've been at this for long enough where we just wanted to hurry up and bill and then, you know, you realize you got to change the practice, you've got to be set up, you have to be ready before you can actually be able to get that payment. I think that that's a really, really hard transition because you have to invest, first, in making the practice changes, so the practice changes the workflow redesign. That's why that medication, saying feminization, and they put in base model becomes so important because they help on the traditional dispensing side and they set you up for patient care, so that has to happen.

First, we have to rethink about the individuals who are within the pharmacy team and how we can use their skill sets at the highest level, so practice change happens before payment, contracting for patient care services happens before payment. There has to be a contract between the payer, whether that's a Medicare, Medicaid, employer group, and the group of pharmacies before you can submit a bill, and that's true for drugs and that’s true for any healthcare issue.

Again, we can't just submit a bill because we took care of the patient, we have to have a contract for that service, contracting for patient care services does become more attainable when you're part of a represented group, so what I mean by that, as you can imagine, a health care pair would rather contract with 1 place that can represent 150, for example, versus contracting with 150 individual pharmacists or pharmacies, and the health payers are really interested in how can I contract 1 way, but I can get a whole lot. We're seeing that happening more and more, where you have contracted entities, you need to have a baseline set of services that you're willing to offer. You have to have the technology in place to be able to make those services happen, and you have to have a payment infrastructure again, before billing can even occur because you can get to the bill.

But if you can't adjudicate that claim, you're not going to be able to get paid for the services. We're seeing that contracting often is meeting a local or regional need. There are some things that can happen throughout the country, but we're seeing some really interesting things that are happening regionally or locally, based on what the individuals need.

Then that's the access point. So, community pharmacies become an access point in addition to other places that folks can get receive care, and the moment is now we have demonstrated the collectively, the profession of pharmacy has demonstrated the value that we bring during this pandemic and how critical it has been to have access points in communities all throughout the United States. We've been able to demonstrate that we can get vaccine to the highest need individuals and that we can go outside of the walls of the pharmacy to be able to provide care in neighborhoods where care might not easily be accessed.

We've demonstrated that we can safely and effectively do point of care testing and we're able to get people access to their needed medications, even when other things have closed down. There hasn't been a more clear example of the value and what pharmacists can bring, and the public has said, we want you because they're coming in our doors.

The time to advocate, the time to step up and say we could do this and to create these changes is now and we're seeing that during the pandemic, and we've had a lot less chronic care management happening and so the need is even greater for so many individuals. I do think the time to step in and step up is right now, and we are seeing, from where I'm sitting in Pennsylvania, the number of patient care opportunities in pharmacies has grown significantly over the past 12 months, and it's really because of the work that pharmacists and teams have done in communities and demonstrated our value.