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The law of unintended consequences applied to pharmacist services
Michelle Powell 1464

The law of unintended consequences applied to pharmacist services

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Association Perspective

Michael D. Hogue PharmD, FAPhA, FNAP, FFIP Executive vice president and CEO of APhA

Like many kids who grew up on a farm, I learned to drive a tractor and lawnmower  as soon as I could reach the pedals. One day as I was mowing the back yard, I looked up to see that the storm door glass was shattered in my grandma’s mobile home. I panicked, shut down the mower, ran to grandma’s house, and called out her name to see if she was okay. Thankfully, she was.

Unbeknownst to me, there had been a metal bar lying in the weeds where I was mowing. The mower had picked up the bar and slung it across the yard, through grandma’s door, landing on her dining room table and breaking a few items in its path. Grandma had been at the other end of the home and was safe.

I learned valuable lessons that day: Beware of what is hiding in the weeds. Check twice before you end up with unintended consequences. And don’t take shortcuts. I had taken a shortcut by mowing the clippings toward the house when I should have been oriented away from the house. This was a huge rookie mistake, and it could have cost me a lot more than it did.

We are faced with some pretty deep weeds right now in the profession. The problems in front of us are challenging. I don’t need to restate them here—you all know them as well as I do. Everyone wants solutions and wants them instantly. However, I am concerned that some of the solutions that are being proposed for the problems we face may have unintended consequences that haven’t been fully considered. We can’t plan for every eventuality, but we must think carefully about our actions and the consequences—both positive and negative—of those actions.

We’ve been fighting for pharmacists to be paid for their care services in the outpatient setting for decades. Recently some PBM companies have suggested that they can cover pharmacist services and manage these services as part of the pharmacy benefit. On the surface, it makes complete sense. Pharmacies don’t have full medical models of billing nor revenue cycle management implemented, so reverting to creation of false National Drug Code (NDC) numbers or use of billing codes which can be instantly adjudicated through the PBM for pharmacist services seems like the path of least resistance.

On the plus side, this method costs very little for pharmacies with dispensing systems to implement. It also creates a more rapid revenue stream for services at a time when community pharmacies are cash constrained. This can also create advantages for pharmacies in knowing the patient’s coverage, copay, and deductible instantly—something our physician colleagues envy!

The negatives, however, are that pharmacists who provide outpatient services in environments not tied to dispensing would continue to have no path for billing—this includes some of the most rapid-growing segments of our profession in specialized care (e.g., oncology, psychiatric care, pain management) and medical clinic–embedded pharmacist practice. The biggest negative of all is that this model further carves out pharmacist providers from all other providers and treats our profession differently from others in the medical system.

Currently evidence suggests that this negative is real—take billing for the service of administering a vaccine. When pharmacists bill Medicare Part B for influenza or pneumococcal vaccine they get paid the same rate for administering the vaccine as all other providers. However, when pharmacists bill Medicare Part D for respiratory syncytial virus (RSV) or Tdap vaccine, many pharmacies get nothing at all for the service, or a small fraction of the fee other providers would be paid under major medical. Can you imagine the consequence of doing the same thing with more complex clinical services? The short- and long-term implications of this carve out could be as devastating to our profession as carving out drug benefits was in the 1970s and 1980s.

Payment for pharmacist services must happen through traditional medical models of billing. Yes, this means our profession will need to evolve in how we execute the business functions of pharmacy practice, particularly in the community pharmacy setting. Yes, it may mean financial investments to support those systems. Yes, it may mean delayed gratification. But it is the only way that pharmacists will be treated as equals, as providers, on the health care team. There are other pathways that can be complementary to a medical model of billing for care services, such as partnering with pharmaceutical companies to compensate pharmacists for ensuring clinical outcomes are reached with expensive prescribed therapies. Yet, there is no shortcut to pharmacist service payment.

Just like that metal rod lurking in the weeds of my backyard, let’s look first and avoid shattering the glass of future pharmacy professionals by settling for the easy way of paying for pharmacist services through PBMs. Let’s stick together as a profession and push for payment systems that treat pharmacists as equals to physicians, and partner for a sustainable future that avoids unintended consequences. Let’s all work together to more rapidly implement back-end infrastructure changes to support the revenue model.

For every pharmacist. For all of pharmacy. Won’t you join us? ■

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