Pharmacists: Able, Accountable, Accessible: How About Reimbursable?

Resolving the issues surrounding reimbursement for clinical pharmacy services is a crucial step in health care reform.

An editorial by Judith Shinogle, PhD, MSc in the December 2011 issue of Clinical Therapeutics dissects the Patient Protection and Affordable Care Act and examines how it could expand pharmacists’ roles. Pharmacists are already active members of the medication care team, although some object to further expanding our roles because of the reimbursement issue.

Since the United States implemented the Medicare Modernization Act and the Medicare Part D prescription drug plan requirements for medication management, health plan sponsors must have medication therapy management (MTM) programs for certain patients. This includes comprehensive medication review by a pharmacist or other qualified provider at least annually and quarterly medication reviews under certain conditions. MTM is just one transformative health care innovation affecting pharmacy. Others include the patient-centered medical home and payment for performance programs.

Dr. Shinogle holds the same position as the National Community Pharmacists Association, which is to promote pharmacist involvement in accountable care organization (ACO) formation. To date, many ACOs do not include clinical pharmacists as part of the team. Adequate reimbursement for consultative pharmacy services is also a concern, and a longstanding concern at that. She indicates that pharmacists need to present business plans and demonstrate value in the provision of pharmaceutical care and medication management. Dr. Shinogle also discusses the strengths and limitations of randomized controlled trials, pharmacoeconomics and pharmacoepidemiology needs, real-world effectiveness, and surrogate measures for pharmacy interventions.

A recent report from the US Public Health Service suggests that pharmacist involvement in these new health models will only be sustainable when reimbursement for advanced services becomes a reality. Currently, some states do reimburse pharmacists for patient care services, but the report notes that the level of reimbursement varies greatly, which could lead to major inequities in care. Among other topics, the future of the health care system of the United States, the shortage of primary care options for patients, and the effects of an aging population requiring chronic care are discussed in the 95-page report.

In a letter supporting the report, US Surgeon General Regina Benjamin, MD, MBA, said, “[It] demonstrates through evidence-based outcomes that many pharmacy practice models improve patient and health system outcomes and optimize primary care access and delivery. It also provides the evidence health leaders and policy makers need to support evidence-based models of cost effective patient care that utilize the expertise and contributions of our nation’s pharmacists as an essential part of the healthcare team.”