Pharmacists in Ohio managing care as providers—and getting paid for it too

“We tend to have better results in getting people care when we’re working with them within their communities,” said Michael Roaldi, who leads UnitedHealthcare’s Medicaid business in the state. “It occurred to us that pharmacies—community pharmacies and chain pharmacies—are literally thousands of examples of medical professionals in people’s communities that they regularly interact with that can be a conduit for receiving care.”

A number of other insurers in the state, including Centene-owned Buckeye Health Plan, CareSource, and Molina Healthcare, are rolling out similar pilots focused on Medicaid members in anticipation of new rules from the Ohio Department of Medicaid that would formally recognize pharmacists as healthcare providers and reimburse them for services that go beyond counting pills.

[..] “We’re at the beginning of a care revolution here,” said Antonio Ciaccia, former director of government and public affairs at the Ohio Pharmacists Association who was recently named a senior adviser to the American Pharmacists Association. “Once the diagnosis is made and the patient is on established therapy, having the pharmacist act as a touchpoint to make sure the patient is adequately calibrated on the therapy plan and on progress to meet their goal—that is right in their wheelhouse.”

[..] While there are a few mechanisms through which pharmacists can be paid for services beyond dispensing drugs and administering vaccinations, payment opportunities are limited, and that’s especially true for community pharmacists, said Anne Burns, vice president of professional affairs at the American Pharmacists Association.

A major reason is that Medicare Part B does not recognize pharmacists as healthcare providers, so pharmacists can’t bill the program for their services. Because other payers look to Medicare for guidance, CMS’ refusal to recognize pharmacists has dampened uptake of their services elsewhere, Burns said.

[..] Pharmacists have long argued their extensive training, medication expertise and accessibility could be tapped to manage patients with chronic diseases, who drive the bulk of healthcare spending. Their inclusion on the care team could alleviate the effects of the physician shortage on patients, they say. According to the National Association of Chain Drug Stores, 9 in 10 Americans live within 5 miles of a pharmacy.

[..] A wealth of evidence shows pharmacists have helped improve clinical outcomes for people with diabetes, hypertension, cardiovascular and respiratory diseases and other chronic illnesses. Some studies have also found that pharmacist interventions save healthcare costs. One review estimated that every $1 invested in clinical pharmacy services produced savings and other economic benefits of nearly $5.

Meanwhile, payment for dispensing has become tighter and tighter. Pharmacists are forced to fill prescriptions faster to stay afloat, leaving little time or incentive to counsel patients.

[..] pharmacy transformation is underway in Ohio. A law that took effect in April 2019 not only recognized pharmacists as healthcare providers but gave insurers the option to pay for higher-level pharmacist-provided services under the medical benefit. Pharmacists are usually reimbursed not by the insurer, but by the pharmacy benefit manager through the separate drug benefit, where incentives and goals differ.

Several other states, including Tennessee and Washington, have passed stricter laws that fostered payment for pharmacist services. [The other four states identified by the National Alliance of State Pharmacy Associations were New Mexico, Texas, West Virginia and Virginia.]

Many pharmacists, particularly those working in clinics, are now billing insurers as healthcare providers in Washington. Getting community pharmacists set up to bill health plans has been a heavier lift, said Jeff Rochon, CEO of the Washington State Pharmacy Association. Tennessee has also made strides, but both states have been more successful at getting local commercial plans on board. National insurers like UnitedHealthcare have been slower to adjust, Rochon said.

[..] “Don’t you want to incentivize the pharmacist to actually get them on the right medicine, make sure the dosing is correct and monitor those medications to see if the patient’s getting better? That’s the incentive I’m going for, and those are the same incentives and the same metrics these payers and primary-care offices are currently being held to, and they’re not meeting them,” said Stuart Beatty, associate professor of clinical pharmacy at Ohio State University who directs strategy and practice transformation at the pharmacists association.

[..] One by one, Ohio health insurers began to bite. Most of the five Medicaid managed-care companies in the state have rolled out their own programs to experiment with how they can best use pharmacists’ expertise to care for Medicaid patients, each taking a different approach to ensure care doesn’t become duplicative or fragmented.

[..] UnitedHealthcare’s program gave pharmacists flexibility in who they see and what they can do within their scope of practice. It encourages pharmacists to keep the primary-care physician in the loop by paying them for time spent coordinating care with the doctor.

A six-month pilot launched in August by CareSource, the largest Medicaid managed-care insurer in the state, is more prescriptive and requires pharmacists to enter upfront agreements with primary-care doctors who will sign off on which basic services they are comfortable delegating to pharmacists. A physician may allow the pharmacist to adjust or prescribe new medications, for instance.

[..] For now, insurers are paying pharmacists for extra services out of their own pockets. CareSource said it’s paying pharmacists $25 for 15 minutes spent with the patient, and will move to medical code billing as soon it can. UnitedHealth said it is paying pharmacists based off the physician fee schedule but at a reduced rate.

Under draft rules, the Ohio Department of Medicaid would foot the bill for high-level services provided to the state’s 3 million Medicaid enrollees. Most members receive benefits through private insurers that contract with the state to manage their care.

[..] [Ohio Medicaid director Maureen] Corcoran said pharmacists would be able to bill evaluation and management codes for clinical consultations on asthma, diabetes, cancer or any condition that involves medication. The draft rules, which could change during the rulemaking process, specify payment for managing medication therapy and administering immunizations and certain medications.

Like in CareSource’s program, the department would require a pharmacist to have an agreement with a patient’s primary-care doctor, rather than acting independently. Some groups, including the National Community Pharmacists Association, have said the draft rules are too narrow and would unnecessarily limit what a pharmacist can do.

Insurers will adapt their programs to meet the Medicaid department’s rules when finalized early next year. They could still choose to pay for pharmacist services beyond what the state pays for, but the companies would be footing the bill. Each pharmacist who wants to bill Medicaid for these higher-level services would have to enroll in the safety net program.

[..] The billing process has been especially difficult to nail down because it hasn’t been defined, she [Meera Patel-Zook, vice president of pharmacy operations at Buckeye Health Plan] said. Buckeye’s pilot that launched in June started with two federally qualified health centers and a hospital system because they already had pharmacists embedded in their facilities and were used to collaborating. The pilot will soon include two independent community pharmacies, and the variety of settings helps the insurer test how processes will differ between them.

[..] Other challenges include getting patients and physicians to embrace the changes. Todd Baker, CEO of the Ohio State Medical Association, said the group opposes giving pharmacists independent authority to prescribe medications and order or interpret tests.”