The health care system appears to be moving from fee for service to pay for performance with emerging models of care such as patient-centered medical homes and accountable care organizations (ACOs). Many pharmacists are providing medication therapy management (MTM) in these new models, based on data in the 2013 Medication Therapy Management Digest: Pharmacists Emerging as Interdisciplinary Health Care Team Members, released in March.
Because pharmacists aren’t recognized as providers in Medicare Part B, patient access to pharmacists’ patient care services in a time of rapid change is limited. To guide a multiyear, multifaceted, multimillion-dollar effort to pursue provider status for pharmacists, national pharmacy organizations are close to finalizing a set of principles.
While provider status would help in efforts to include pharmacists in these new team-based models of care, pharmacists should not wait for provider status to make the leap, because these new models are forming now. Following are perspectives from three pharmacists on their respective ACO and/or medical home, barriers they’re experiencing, and what provider status could do.
Sandra Leal, PharmD, MPH, FAPhA, CDE, currently is the clinical pharmacy director for El Rio Community Health Center in Tucson, AZ, and the medical director for El Rio’s Broadway Clinic, which serves primarily homeless and mental health populations. El Rio is a National Committee for Quality Assurance (NCQA) level 3–accredited patient-centered medical home that in April 2012 joined the Arizona Connected Care ACO. The medical home has eight clinical pharmacists who are salaried.
“Historically, for [pharmacists] to be able to grow our services and to be able to sustain the model, we really had to document performance outcomes,” Leal told Today. “We weren’t getting reimbursed for seeing patients on a fee for service because we’re not recognized health care providers. But now, a lot of the accountable care quality measures and the patient-centered medical home audits really rely on interventions and outcomes that are measurable,” she said. “This environment now is very conducive to us working and contributing into a model that is now … providing revenue back to the organization to be able to more readily justify our services.” Meanwhile, she added, pharmacists who assist providers such as physicians and hospitals in reaching the meaningful use stages in electronic health record implementation and getting incentive bonuses aren’t recognized as providers.
Leal, who started the Change.org petition for provider status in late 2011, sees that pharmacists need provider status because not all of El Rio’s patients are ACO patients or Medicare patients. Most patients have Medicaid or third-party plans, or are uninsured. All of these programs use the language within the Social Security Act as an enabler or a barrier. “The biggest challenge is just not having recognition [as providers of patient care services] from our state Medicaid plan,” she said. “For the majority of the cases, I’m still struggling to try to figure out a way to have a sustainable impact,” at least until reimbursement associated with health outcomes becomes more widespread. “I think it’s getting there but I don’t know how long that’s going to take.”
Ashley Branham, PharmD, BCACP, works as Director of Clinical Services at Moose Pharmacy in Concord, NC, and as a preceptor for the University of North Carolina Eshelman School of Pharmacy Community Pharmacy Residency Program. Branham is one of four pharmacists embedded in a clinic with seven providers and five family medicine residents called Cabarrus Family Medicine, which is an NCQA-approved medical home. She explained in an interview that the medical home grew out of relationships between the pharmacists and the providers that stretch back several generations.
“We all come together to discuss complicated patients and figure out what expertise we can lend to resolve this patient’s problem,” Branham said. “We have to work as a team. That’s how we find out the missing pieces of a patient’s story.”
Of the four pharmacists embedded in the clinic, one full-time pharmacist is directly employed with Cabarrus, Branham is employed through a contractual agreement, and the other two are faculty with schools of pharmacy and funded by their universities. About three-quarters of Branham’s work is focused on patient education and assessment, and the remaining quarter of her time is spent offering provider assistance. “When or if pharmacists achieve provider status, it may slightly change the dynamics at our practice, but my responsibility really will not change.”
Describing two types of barriers that provider status would help with, Branham said, “There is a need to financially justify the value of our services. And to do that in my medical home can be difficult with limited payment mechanisms. … On a health care level, it’s really a goal to also justify our time by demonstrating quality, positive outcomes.”
Amanda Brummel, PharmD, is Director of Clinical Ambulatory Pharmacy Services with Fairview Pharmacy Services, LLC, part of Fairview Health Services in Minneapolis—a Pioneer ACO with approximately 15,000 patients and many different types of pharmacists, including 24 MTM pharmacists. The MTM pharmacists focus on medication use as part of the care team. Under collaborative practice agreements, they initiate, modify, or change drug therapy and order lab work. Patients are referred from their physician or because they were identified as high-risk.
“An ACO gives the right environment for everything to happen but … it definitely didn’t change our practice model,” Brummel told Today. What changed was “a bigger shift in general to the health of a population. I wouldn’t say that’s unique to pharmacy. I would say that transcends across the whole care team.” Pharmacists and the other health care providers document in the electronic health record, using Epic (the brand name). Fairview’s population health tool pulls data from Epic and other systems. Pharmacists can look up patients individually or across a clinic population.
“Obviously, we’re functioning without provider status,” and there is a question of whether the health care system is moving away from fee for service, Brummel said. But “without provider status, without me being able to put in a claim for what I’m doing, or some sort of recognition for what I’m doing on a per-patient basis,” CMS has no idea how pharmacists are helping in these populations, she continued. The agency “could be looking at the Pioneer ACOs right now” and seeing whether integrated pharmacists make a difference, “but there’s no way for them to even know that because we can’t submit anything to them to show that we’re taking care of these patients,” Brummel said. “We just want to be recognized as someone who is contributing to the care of the patient.”
This profile of Rep. Austin Scott (R-GA) is part of an occasional series in Pharmacy Today on Members of Congress who are champions of pharmacy. Scott is the new Co-Chair of the Congressional Community Pharmacy Caucus. Following are his responses from a recent e-mail interview:
My father was a small-town doctor during my childhood in rural south Georgia. Growing up, I saw local community pharmacists play a major role in rural health care delivery. In my area, the town pharmacists are often a fixture in the community. In areas where a doctor can be many miles away, local pharmacists deliver flu shots, give advice on over-the-counter drugs, and help with those late-night drugstore runs for a sick child. Many people see their pharmacists much more often than their doctor and there is a very personal relationship between pharmacist, patient, and physician. In my view, we should strive to encourage this experience in as many communities as possible, whether they are rural, suburban, or urban.
I majored in risk management at the University of Georgia and spent over 20 years in the health insurance business. With that background, I was able to gain a base knowledge of the issues to bring to policy debates. I was also in the state legislature for 14 years in Georgia. During that time, we worked on many state policy issues that affected pharmacists. For instance, I worked to require all pharmacy benefit managers [PBMs] to acquire a state license. [PBMs] control a large portion of our prescription drug dollars, but very few people are aware of the role they play. My view is that licensing is the first step to transparency.
Our main goal with the [Congressional] Community Pharmacy Caucus is to raise awareness of the critical role pharmacists play in their communities. We hope that our June 6 briefing will be a good introduction for both Members [of Congress] and staff to the concerns of pharmacists, as well as a path to action to make sure that pharmacists remain important figures in their neighborhoods. While I think that many members are aware of the issues facing pharmacists, it is the finance issues and issues like PBMs that I try to help explain a little more about.
We’ve just voted to repeal the Affordable Care Act [ACA]. I would like to see it replaced with common-sense, market-based reforms that really do lower health care costs, expand access to care, and improve the quality of care. We want to ensure that pharmacists can continue to play an important role in a health care system where patients can have access to affordable and safe drugs. We also want to make sure that pharmacies, many of them small businesses, can survive and thrive in communities across America. We need to remove the unnecessary burdens and regulations on small businesses like local pharmacies that have grown as a result of legislation like the ACA.