Counter Talk: Hope for community pharmacy

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Counter Talk: Hope for community pharmacy

By Ed Vess, QS/1 - 08/31/2018
When I attend meetings and visit pharmacies, our conversations typically involve some frustration with decreasing reimbursement rates coupled with increasing direct and indirect remuneration, or DIR, fees and a proliferation of preferred networks that exclude us. It seems unlikely federal provider status for pharmacists will pass this year, though many of us feel provider status will improve patient care and the fiscal health of our pharmacies by giving us the ability to bill Medicare and Medicaid for patient-care services we can provide in the pharmacy. While it is disappointing that the legislation has not passed, there is hope.

In 2017, more than 20 states passed pharmacist provider status legislation, according to data collected by the National Alliance of State Pharmacy Associations. In the states, the American Pharmacists Association reports that “provider status activities — to increase patient access to pharmacists’ services — generally comprise provider designation, scope of practice and/or payment for services.” While this does not open the door to Medicare or Medicaid billing, it positions us for billing services to forward-thinking payers.

Community-based enhanced pharmacy services focused on improving patient outcomes have the potential to benefit the patient and the overall healthcare system. Better patient health costs the system less and creates a better quality of life for the patient. Most insurers historically have been slow to compensate pharmacists specifically for services that are separate and apart from prescription fulfillment, and patients may not be financially able to pay out of pocket due to rising healthcare costs that are increasingly being shifted in the patient’s direction.

Community Care of North Carolina is a statewide primary care and care management program that has provided support for the North Carolina Medicaid population using the patient-centered medical home model for 20 years. While pharmacists have participated in this interdisciplinary care team model for some time, a more recent innovation added a network of high-performing, community-based pharmacies to the care team. Enhanced services provided by pharmacies in the Community Pharmacy Enhanced Services Network, or CPESN, were a welcome new care-team resource, and a large-scale CMMI award was secured to test a value-based payment model.

These CPESNs aim to provide opportunity for high-performing local community pharmacies to coordinate patient care with the broader care team, and provide medication-optimization activities and enhanced services for high-risk patients.

All CPESN-member pharmacies offer core services that include medication reconciliation, clinical medication synchronization, immunizations, comprehensive medication reviews and patient personal medication records. While these services should be within the scope of almost all pharmacies, they are often not offered due to workload and time constraints. These services are particularly helpful for high-risk, chronically ill patients, providing high opportunity to demonstrate value.

Local CPESNs may choose to offer additional enhanced services to further meet the needs of patients and care team members. These services may include transitions of care, chronic care management, pharmacogenomics, point-of-care testing and more.

With pharmacists being the most accessible member of the healthcare team, it is encouraging to see an organized movement to leverage the services we can provide to improve patient care and reduce overall healthcare costs. While these services can be provided to individual patients, likely at their expense, the ability to lump multiple services to a group of patients and track the improved outcomes shows the value of pharmacists and delivers hope to those struggling with declining profit margins. Better patient care, lower overall healthcare costs and more opportunities to compensate pharmacists and pharmacies for the value they provide the healthcare system are a great combination.




Ed Vess is the senior manager of pharmacy professional services at QS/1.