Appropriate reimbursement for pharmacists—especially community pharmacists—is a third major challenge.
Tyrrell and DiGregorio agree that pharmacists are not being compensated for services beyond dispensing drugs even though they are providing cognitive services, such as medication management, patient education, and counseling; reducing polypharmacy; promoting adherence; and giving wellness and prevention screenings.
Enhanced medication therapy management is one of the few mechanisms enabling reimbursement for community pharmacists. Tyrrell says legislation is needed to turn the situation around.
Pharmacists practicing in outpatient hospital or physician office settings have more opportunity to bill for special services. According to the Academy of Managed Care Pharmacy, these pharmacists have three options for reimbursement in a fee-for-service setting:
- They can work as part of a physicians' group practice and file for payment under a physician's provider number;
- They can be recognized as a provider and bill a managed care organization directly; or
- Patients can pay cash for their services.
Pharmacists are not currently recognized as a provider under Medicare and, therefore, cannot bill Medicare directly for services under the Part B benefit.
“Too often pharmacists and PBMs are at odds with each other with reimbursement formulas and policies that have made it hard for pharmacists to survive on a system that has historically been driven by the mark ups of prescription drug products,” DiGregorio says. “Pharmacists do not wish to be compensated in this model, and the need to drive the cost down for PBMs is creating demand for a new model to provide for the cost of professional cognitive services.” He would like to see outcomes tied to reimbursement rates.
“Until pharmacists receive provider status,” Barnes adds, “plans will not compensate them even though their functions have grown.”
Mari Edlin, a frequent contributor to Managed Healthcare Executive, is based in Sonoma, California.