The term pharmaceutical care was introduced by Hepler and Strand in 1990, beginning an evolution from pharmacists focus on a product-driven service to a focus on delivery of patient-centered care.
Since then, pharmacists have provided disease and medication management for patients with diabetes, hypertension, and heart failure, for example, with a positive impact on clinical and economic outcomes. Health care reform over the last 10 years sparked further opportunities for pharmacists to practice at the top of their license.
The Medicare Modernization Act of 2003 mandated the provision of medication therapy management (MTM) to high-risk beneficiaries and explicitly highlighted pharmacists as potential MTM providers.
In 2010, the Affordable Care Act (ACA) expanded opportunities for pharmacists to be engaged in team-based care models including patient-centered medical homes and accountable care organizations (ACOs) as well as prevention and wellness services.
The ACA expanded access to insurance for uninsured or underinsured Americans, which has placed pressures on the primary care workforce to keep up with demand. There has also been an increasing emphasis on team-based care and incentive-based pay-for-performance to improve quality and efficiency of care.
Given that pharmacists are one of the few health professions expected to be in adequate supply in the future and medications are used in 80% of treatments,6 pharmacists are primed to be integral members of health care teams.
Although pharmacists roles on health care teams have expanded and opportunities abound, the sustainability of pharmacist services has been limited and the integration of pharmacists on health care teams is not mainstream. One reason for this is the exclusion of pharmacists as Medicare providers, which limits independent billing for services in the outpatient setting.
Pharmacists can bill incident-to a physician in the outpatient setting, however, at this time most payers only recognize Medicare designated providers for high service levels, 99212 ($42.88) – 99215 ($142.05), leaving the lowest service level, 99211 ($19.72), for billing pharmacist services.
This approach alone would not provide enough revenue to support a full-time pharmacist in the outpatient setting.7 Incident-to billing can also be used for pharmacists involved in chronic care and transitional care management. Medicare Annual Wellness Visits (AWVs), a benefit included in the ACA legislation, provide another opportunity for clinics to be reimbursed for pharmacist services.
In 2014, the Medicare payment was $167.70 for an initial visit, which consists of a health risk assessment and medication review, and $112.14 for subsequent visits. While other health care professionals can perform AWVs, there has been an increase in reports from across the country highlighting pharmacists success in billing for AWVs. Factors such as practice size and the number of Medicare beneficiaries in a service area impact the potential revenue from AWVs, with one report indicating 1,070 AWVs per year would support a full-time pharmacist.
Fairview Health System in Minnesota is one exemplar of how pharmacist-provided comprehensive medication management has evolved over a 15-year period to be a viable service integrating 18 pharmacist FTEs across 30 clinics. Fairview has aligned outcomes with ACO quality metrics and used shared savings arrangements and direct fee-for service contracts to justify the cost of pharmacists.
The Asheville Project in North Carolina was a pioneer in creating an employer-based model to support pharmacist provision of medication and disease state management for diabetes, hypertension, and asthma, which has been sustained for more than 10 years.
What is needed to reach a tipping point of pharmacists being the norm rather than the exception on health care teams? Key elements of creating sustainable business models include having a visionary leader with progressive thinking about transforming practice. It is also important to understand organizational gaps in quality measures by conducting a needs assessment and then aligning pharmacist services to fill these gaps.
Being aware of billing opportunities is also critical and billing and compliance personnel may need to be educated about billing codes for pharmacist services. To maximize billing opportunities, awareness about patient and payer mix is also necessary. A plan to generate revenue for services is the foundation for sustainability. Several resources exist that provide guidance for developing business models for pharmacist services.
As health care continues to be transformed, we must proactively think about financial implications of our services and propose business models for sustainability. Doing so is key to tipping us into the future as valued members of health care teams.
Leticia R. Moczygemba, PharmD, PhD