Brigid K. Groves, PharmD, MS, Vice President, Professional Affairs
In recent years, the role of pharmacists has evolved significantly, expanding beyond traditional dispensing duties to encompass a wide range of patient care services. Recognizing this shift, APhA has been conducting efforts to support members as they deliver patient care services and prepare to bill for service delivery under a patient’s medical benefit, regardless of practice setting.
Recently, APhA convened a group of thought leaders to discuss the successes, challenges, and barriers in scaling pharmacists' patient care services covered under health plan medical benefits. The outcome of these discussions is a set of comprehensive recommendations aimed at fostering collaboration between health plans and pharmacists to advance coverage of and reimbursement for pharmacists' services.
One of the primary recommendations is to widely promote the impact of pharmacists on patients' access to care, health, wellness, outcomes, and health care expenditures. Despite a robust body of evidence demonstrating the positive impact of pharmacists, we remain underutilized. Marketing efforts with consistent messaging and contemporary data are essential to raise awareness and interest in partnering with pharmacists to address access to care issues and medication-related problems.
For equitable patient access to care, the pharmacy profession must advocate to state legislative bodies and regulatory agencies to align pharmacists' practice authorities with their education and training. Standardizing pharmacists' scope of practice nationwide through state-level legislative and regulatory advocacy efforts will enhance health plans' ability to cover services that meet member needs and provide pharmacists with the opportunity to deliver them.
To expand and sustain patient access to pharmacists' services nationwide, pharmacists must achieve recognition, coverage, and reimbursement under the medical benefit in both Medicare and Medicaid programs. Federal legislative and regulatory advocacy is necessary to include pharmacists' patient care services in the Social Security Act, enabling us to bill for services directly through Medicare Part B. Similarly, state-level advocacy is vital to recognize pharmacists as providers under Medicaid, ensuring equitable access to care for vulnerable and underserved populations. Commercial health plans and employer groups have the latitude to cover and reimburse pharmacists' patient care services without legislative or regulatory mandates. Collaborating with pharmacists to provide covered patient care services under the medical benefit can improve care and lower costs regardless of coverage type.
Pharmacists should be prepared to evaluate and engage in multiple types of payment models, including fee-for-service, hybrid models, and value-based models. Understanding the benefits and risks associated with these payment models is crucial for exploring coverage and reimbursement opportunities for patient care services under the medical benefit. Check out APhA’s certificate training program to gain the knowledge on how to evaluate payment models and ultimately, get paid for pharmacists’ clinical services. Additionally, health plans and pharmacists must collaborate with health plan accreditors to support the integration of pharmacists as a clinician type into their accreditation processes and communications to overcome barriers related to pharmacist inclusion in health plan networks.
Successful billing processes under the medical benefit are essential for sustaining pharmacists' services and scaling payer coverage. Health plans should standardize and align pharmacists' billing processes with those of other provider types, allowing pharmacists to use their preferred documentation and billing software systems.
APhA’s recommendations offer a roadmap for advancing coverage and reimbursement for pharmacists' patient care services under the medical benefit. By promoting pharmacists' impact, advocating for standardized practice authorities, achieving recognition in Medicare and Medicaid, partnering with commercial health plans, exploring multiple payment models, collaborating with health plan accreditors, implementing successful billing processes, and embracing value-based payment programs, health plans and pharmacists can work together to improve patient care and outcomes.
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