Payment Models
Lauren Howell, PharmD
This is part one of a three-part series on financial reimbursement for pharmacists.
Pharmacists at Fairview Health System in Minnesota provide comprehensive medication management (CMM) services under a collaborative practice agreement, which allows them to manage around 20 conditions in the primary care clinics and is specific to the specialty area for those in specialty clinics.
But the health system has also found a way to allow its pharmacists to perform CMM and get paid for it. Pharmacists have the training and ability to manage patient medication therapy needs and improve outcomes. However, the need for payment for services by state and commercial payers can prevent pharmacists from functioning in an expanded role, as can a lack of designation as a legal health care provider and Pharmacy Practice Act scope of practice limitations.
The CMM services Fairview pharmacists provide are billed through MTM CPT codes. These codes allow them to bill for the initial 15 minutes of an MTM service for a new patient, the initial 15 minutes of an MTM service for an established patient, and an add-on code that is used to report additional 15-minute increments beyond the initial 15 minutes.
Pharmacists providing CMM services are credentialed and enrolled with health plans for their services.
“This doesn’t just magically happen,” said Amanda Brummel, PharmD, vice president of clinical ambulatory services at Fairview. “Without having some outcomes behind our work, I don’t know that we’d be in the same place.”
Brummel spoke about their model during a May 2025 presentation at Innovations in Pharmacy Training and Practice to Advance Patient Care: A Workshop.
Outcomes
Pharmacists at the Fairview Health System aren’t just performing CMM and getting paid, they are having a significant impact on patient outcomes. There has been a 33% reduction in readmissions for patients receiving MTM services. Additionally, the percentage of patients with diabetes optimally managed was 45.5% among MTM patients and only 21.5% among non-MTM patients.
The reduction in total annual health expenditures was found to exceed the cost of providing MTM services by more than 12 to 1.
In a patient satisfaction survey, 96% of respondents agreed or strongly agreed in recommending the pharmacy services. Among providers, 87% strongly agreed or agreed that clinical pharmacists reduced their workload by working directly with patients and the care team, improved overall medication use, helped patients meet goals and quality measures, and overall helped them manage their panel of patients.
The Fairview model
Fairview Health System is comprised of 12 hospitals and medical centers with 5,000 system providers and over 34,000 employees. Their CMM service allows pharmacists to provide care to patients with multiple conditions that are not at goal, patients during transitions of care, and patients who are prescribed high-risk medications. While pharmacists within the health system also operate in other roles and services such as disease and therapy management, community pharmacy, and clinical decision support, the CMM service is primarily the one for which Fairview has had success billing.
“We look for patients who have gaps in care, high risks for readmission, and those on specific specialty medications that we want to make sure are managed appropriately,” said Brummel.
The CMM service that started in 1997 now has a network of 70 pharmacists in 65 different locations and saw over 25,000 patients with over 57,000 encounters in 2024.
While most of the CMM services are embedded within primary care clinics, there are also some in specialty clinics that focus on specific patient populations and disease states such as HIV, pediatric transplant, psychiatry, pain management, and dermatology.
Each full-time equivalent pharmacist has a 600 to 700 patient panel, and each clinic site has its own patient care schedule. Visits are available both in person and via telemedicine.
Fairview is also involved with accountable care organizations and value-based care contracts. All the coding and claims submissions for these CMM services take place in a business office that is specific to the CMM program. “When payers have a mass of people that are providing a consistent service, it is a lot easier for them to pay,” said Brummel.
Fairview’s model is just one example of how pharmacists can be paid for patient care services they provide. ■