SummaryPharmacists are increasingly providing direct patient care based on each state's scope of practice regulations in a variety of settings spanning inpatient, outpatient, and community pharmacies. Examples of these direct patient care services include immunizations, wellness and prevention screening, medication management, chronic condition management, and patient education and counseling. While opportunities for pharmacists to provide direct patient care services emerge, options for obtaining reimbursement for these services continue to be limited. Avalere Health assessed the current healthcare delivery and payment landscape to identify factors that can facilitate broader reimbursement of pharmacist services.
Outside of traditional Medicare Part D medication therapy management (MTM), the mechanisms through which pharmacists in the community setting may obtain reimbursement for services allowed under each state’s scope of practice regulations are limited and vary by payer. The lack of reimbursement has been identified as a key challenge in delivering pharmacist-provided direct patient care services on a widespread basis.1
Factors that would facilitate broader reimbursement of pharmacist services include
- Establishment of federal statutory recognition of pharmacists as healthcare providers under Medicare Part B;
Standardization of billing methods from a federal and state perspective for specific services outlined in scope of practice regulations that pharmacists provide through direct patient care; and
Improved coordination between the pharmacy and medical benefit, enhanced through health information exchange that delivers clinical and administrative information to and from the pharmacy to other healthcare providers within the patient care team.
Moving forward, the development of new care delivery models will create opportunities to test new mechanisms for pharmacist reimbursement in the context of alternative payment models’ (APMs) transition to value-based care. Pharmacists are trained medical professionals who have been shown to improve the clinical and cost outcomes of patients and are likely to play a critical role in determining the continued growth and success of APMs given their unique access to, and relationship with, the patient community.2
With a greater focus on improving the value of care, the opportunities for pharmacists to provide a variety of direct patient care services will continue to evolve as incentives for reimbursement of these services are established.
Funding for this research was provided by the National Association of Chain Drug Stores (NACDS).
For more information on how opportunities through payment and delivery reforms can help shape provider strategies within evolving alternative payment models, please contact Josh Seidman at JSeidman@avalere.com.