Background/Intro: Studies have continually shown that community pharmacists can impact and improve patient outcomes if they utilize clinical skills during the dispensing process. The question that arises is: How can we change current reimbursement models to reward pharmacies for the clinical and cognitive services we provide in the dispensing role?
Traditionally, as highlighted in previous article, pharmacy reimbursement has always been product-based. Reimbursement is based off ingredient costs (AAC, AWP, etc) and dispensing fees. Depending on the PBM contracts accepted, the type of cost used to calculate reimbursement and dispensing fees vary drastically. Due to non-transparent costs and minimal dispensing fees, pharmacies lose money on prescriptions. Community practices have therefore adapted to this by become volume-driven because no one pays for the value/costs associated with problems identified and addressed by dispensing pharmacists.
The most common way that pharmacy gets paid for clinical services are for select Medicare Part D patients through Mirixa and Outcomes MTM platforms. These interventions and medication reviews take 30-60 minutes and are usually performed by a pharmacist outside of the dispensing role. But the question still stands: How can we be reimbursed for interventions we perform on a daily basis during dispensing and performing a thorough prospective DUR?
Towncrest Pharmacy has collaborated with a local payer to initiate a pilot project that pays the pharmacy a professional fee in addition to a dispensing fee for each prescription dispensed for patient’s enrolled in this specific health plan. The objective of my project was to evaluate the different types of interventions that were performed and documented for the pilot project patients.
Methods: Data from April 1, 2014 to October 31, 2014 was extracted from PharmClin. Descriptive variables were collected for patient’s age, gender, and number of medications; Frequencies and descriptive statistics were tabulated for each intervention and drug therapy problem (DTP) documented.
Results/Discussion:
Patient Population: Interestingly, this cohort of patients compromises only 7-8% of Towncrest Pharmacy’s total patient population and only represent 3% of Towncrest’s total prescription volume. A majority (77%) of these patients were 18-64 years age category with an average age of 49 years, and only on an average number of 4 medications. Despite not being a high-risk population, 75% of the patients had a pharmacist documented intervention with the total number of interventions being n = 483. The interventions were further categorized, based on the options available in PharmClin. See Below:
Discussion: Of the documented interventions, half involved prescription counseling (n = 241; 49.9%) and nearly 30% (n=144) of interventions identified various drug therapy problems. As counseling is required for any new prescription in the State of Iowa, this figure was not surprising. However, the most common DTP assessed by pharmacists was medication adherence (n = 119; 82.6%). This number has significance as 3 of the 5 current criteria for CMS Stars Ratings relates to adherence (statins, diabetes medications, and ACE-I/ARB/DRI). This makes it vital that pharmacists in the dispensing role are taking advantage of every encounter with the patient to address issues; forcing the dispensing pharmacist to change their mentality from “right person, right drug.” Instead, pharmacists are assessing the medication profile as a whole to evaluate the safety, efficacy, and appropriateness of therapy during the prospective DUR process. We have continually made improvements to PharmClin to assist in this process and flag for potential problems.
Conclusions: Pharmacists can make critical clinical interventions during the dispensing process. Better clinical documentation of interventions and reform of current reimbursement models can help shift community practice to focus on delivering quality health care.