Align reimbursement to expanded role of pharmacists

For years, pharmacists have been evolving their role beyond dispensing medications. When the COVID-19 pandemic hit, pharmacists demonstrated the immense value they bring to patients and the entire healthcare system. Now, it is clearer than ever that community pharmacies are essential to protecting the health of our communities.  

Community pharmacists have the unique ability to provide personalized care in their communities because they know the patient, know their medications and actively keep tabs on their changing needs.

At a national level, the current pharmacy payment model is based on dispensing without accounting for clinical services that optimize patient care. Pharmacists routinely counsel patients on medication and health issues, but new payment structures are needed to support pharmacists’ role as providers, allowing them to receive consistent reimbursement for disease management, medication optimization and other preventive services.

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The Equitable Community Access to Pharmacist Services Act (H.R. 7213). H.R. 7213 would create a direct Medicare reimbursement mechanism to pay for certain pharmacists’ services relating to testing for COVID–19, influenza, respiratory syncytial virus, or strep throat;  drug regimens for COVID–19, influenza, or strep throat; and the administration of vaccines for COVID–19 or influenza.  H.R. 7213 will also ensure pharmacists can safeguard our communities in the future, by establishing Medicare payment for pharmacist-provided services in the case of Public Health Emergencies. Pharmacists can send a letter in support of this legislation at www.pharmacycare.org.

In addition to aligning payment for clinical services delivered by pharmacy providers, we must also address the lack of transparency in prescription reimbursement. Reform is needed to help increase transparency and support the growth of alternative payment model. That’s where Pharmacy Services Administrative Organizations (PSAOs) can help community pharmacies get access to payer contracts and support reimbursement for prescriptions as well as emerging clinical services. 

While the Pharmacy Quality Alliance (PQA) has created and validated pharmacy-level measures, we still don’t see adoption of a standard measure set for pharmacy accountability and there continues to be variability among payers in their approach.

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These pharmacy-specific quality measures represent a tremendous opportunity to fully leverage the potential impact of pharmacists as a driver of value and outcomes. It is up to pharmacists to prepare for these sustainable models to be able to demonstrate the value that community pharmacists bring to patient care.

In support of this, Health Mart Atlas is a participant in six quality-based performance programs that have positive payments tied to outcomes. The programs, which span Medicare, Medicaid and Commercial plans, tend to be regional or state specific and focus on a variety of chronic disease adherence measures, as well as incorporation of med sync, and medication therapy management. Adherence measures alone don’t capture the true impact of pharmacist provided care which is why we need to shift toward more programs tied to outcomes.

In one of the diabetes control programs tied to outcomes, pharmacists engaged with patients to encourage them to complete an A1c test and counseled patients to lower their A1c. Results showed a 4% improvement in A1c test completion and 20.6% improvement in patients with A1c at goal. Similar programs around blood pressure control are under discussion.

Fortunately, the industry is moving to more value-based reimbursement with community pharmacy playing an increasingly important role. We need to focus on demonstrating the impact pharmacies have on patient outcomes and reducing total cost of care. Not only is it the right thing for our patients, it is also critical to future of community pharmacy.