If we want to be universally recognized and paid by the system that pays for patient care, then it is a good idea to understand the rules of that system. If the rules are understood, then everyone can decide if they want to play by those rules or not – it should be emphasized here that these rules are non-negotiable.

The rules of compensation for patient care services in health care have been defined and are clear for all patient care providers who wear white coats and who care for patients.  Patient care providers are paid for one primary function, to find, fix and prevent a unique set of patient care problems.  For the physician, he or she diagnoses and resolves medical problems, the nurse works with nursing care problems and for the pharmacist providing medication management services it is drug therapy problems.  Documentation is required so both the patient and the payer have evidence of the problems addressed in order to justify the claim made for payment, and the payment structure is based on the number of problems identified and resolved.

Identifying and resolving drug therapy problems are the unique contribution to the care of a patient and are the cornerstone of reimbursement for medication management services – it is the “currency” for the pharmacist providing these services.   We are able to identify them, count them, document them, fix them and monetize them.   This is straight forward; the more problems we identify and resolve the more compensation we can earn.  

I have yet to meet a payer who has been interested in how long it takes to conduct a “CMR”.  And why should they be?  It takes inefficient practitioners longer than it does expert ones.  Many payers I have spoken with are interested in knowing which problems are identified; for which medical conditions; for which medications and what is being done to fix the problems after they are identified? CMS is moving in this direction, as have other payers. 

Fortunately, the heavy lifting has been done and there are rules (standards) that are used to define the service and practice I am describing here.  There is also a state Medicaid payer who has put these rules in place and can serve as a model of how to do this for other payers.   The standards are simple and already exist so the pharmacist providing medication management services can be recognized and paid for the unique contribution made to the care of a patient.   With these rules, patients, prescribers and payers know exactly what it is that we will do, how we will do it and what they can expect to receive from the service.   The rules and structure provide a framework for the provision of the service, so the same service can be duplicated by others and then recognized by patients, prescribers and payers, whether the service is delivered in Minneapolis, Indianapolis or Kannapolis (that is in North Carolina).  

Some have argued that the terminology and processes of this practice are too esoteric or too academic.  There is no need to expose patients, prescribers or a payer to the terminology that we may argue about, this is not the point.  For me the path to success starts with exposing patients, prescribers and payers, to a service that is delivered by professionals using recognized standards.  Pharmaceutical care defines the professional practice, the rules and standards, that we can own, and that allow us to demonstrate our contribution to the patients served when medication management services are provided.  

The Center for Medicare and Medicaid Services (CMS) proposed regulation change which would mandate the separation of consultant pharmacy services from the companies that provide pharmaceutical products to long-term care residents is a game changer for pharmacists.  If the rule, as proposed today, is adopted by CMS, the services provided by pharmacists could no longer be bundled and bartered with the distribution and dispensing of medications.  The services offered and provided by long-term care (LTC) pharmacists would stand alone, independent of the distribution of drug products.  

This proposed rule change has far reaching implications for all pharmacists, not just those practicing in the long-term care arena.   The conflict of interest that was exposed in the long-term care space clearly is the impetus for the proposed rules change but, as was pointed out by many in the overflow crowd attending the Town Hall Forum held on this topic during the ASCP Annual Meeting in Phoenix earlier this month, why stop at LTC?  If this conflict exists in LTC, doesn’t it exist in community pharmacy, specialty pharmacy and other settings?  It clearly does but that is material for a future discussion.

The point to be made now with this proposed ruling is that if CMS is going to make this change, then pharmacists need to be recognized as care providers and compensated at a rate that will support the delivery of comprehensive medication management services  to patients.   This should be done for all pharmacists providing the service, regardless of where the service is delivered, and should not be limited to those practicing in LTC or any other setting.  Imagine how the practice of pharmacy could change when the practice of pharmaceutical care is recognized as a reimbursable service and compensated on the merits of the value it adds to the care of patients, without conflict or without having drug product sales financially supporting the service providers.   These changes are necessary to care for all those patients who could benefit from medication management services.  #      

“For pharmacists, I believe that you have come to one of the rare crossroads that will define the future of your profession. You will either take your place as providers of care, or your numbers will dwindle as most dispensing activities are replaced by robotics and pharmacy technicians. I am a physician, and I say our profession and the patients that we serve need you “on the team” as clinical pharmacist practitioners. But, will you truly join us?”

This quote comes from an article written by Dr. Terry McInnis. The article provides a very interesting assessment of the state of pharmacy and offers a challenge for our profession.  

Read the complete article >

It is exciting that more and more employers and payers are stepping up and paying for, or offering  MTM services as part of their employee or member benefit package. The list includes many recognizable names, including Fortune 500 companies like General Mills, the Federal Employee Program, Fairview-University Health System, government sponsored programs like Medicare and 15 state Medicaid programs are just some examples of payers who cover comprehensive medication management services.

I find it ironic, however, that many organizations which employ or support pharmacists providing MTM services have not yet stepped up to the plate to pay for this service for their own employees.   Imagine how the landscape of payers would change if Walgreens, Wal-Mart, CVS/Caremark, Rite-Aid, or United Health Group covered medication therapy management services for their own employees. These organizations employ thousands of people and tens-of-thousands of pharmacists. It only makes sense that if these organizations promote the delivery of MTM services to others, then they should offer MTM services as a benefit to their own employees.  

All patients deserve the right to appropriate, effective, safe and convenient drug therapy. And, unless this is assured, then the dollars spent on all the other medical services and benefits are potentially being wasted. This should be obvious to those organizations offering medication management services – so it is time for them to step up, don’t you agree?  

The news and information wires were buzzing again today with the news from Consumer Reports’ Health Rating Center that more people are cutting corners with health care resources in an effort to reduce costs.   As the bloggers and healthcare journalists (Bloomberg News (9/28, Wechsler) Los Angeles Times (9/28, Stein), New York Times (9/28, Carrns),   WebMD (9/28, Mann) )dissect and comment on the survey results, it strikes me that this is yet another situation where comprehensive medication management services could have a significant impact on patient care.  A pharmacist trained with the knowledge of how to properly assess the needs of the patient and interact with others providing care for the patient can solve this “problem”.    The comments made by the blog authors lead one to believe that this behavior is primarily driven by economics.  Economics contribute to this behavior but this problem is not caused solely by economics nor will an improvement in one’s economic status eliminate this problem.

The behavior of splitting tablets, skipping doses, taking expired medications, not filling prescriptions, “borrowing” medications from friends is not new behavior and it has been reported many times before. This behavior is also not going to end anytime soon.  As the Consumer Report survey clearly points out, the rate at which the behavior of cutting corners with health resources is playing out every day is not going down.  In fact, when compared to last year, this behavior is up 23%. 

Is there a potential for this type of behavior to have a negative impact on a patient’s health status or wallet?  Certainly, but I contend that the behavior displayed by patients is rational, expected, and in some cases has been encouraged by providers and payers. Consider pill splitting for example.  It is not an uncommon practice for health plans to provide a pill splitting devise to patients as a means to trim high medication costs, unfortunately this practice cannot be safely applied to all medications.  Who knew the extended-release narcotic would deliver a toxic level in the blood when split? We should not be surprised when patients apply these learned cost saving strategies, and how would patients know when they can and cannot be used safely.

If we believe the problems identified in the Consumer Reports’ survey need to be solved, and I believe they do, then I suggest that one step to solving this set of  problems  is to cover and pay for the service that can best address this issue; namely comprehensive medication management services.    This service, when delivered properly, can help patients and their care providers understand which medications may be skipped, split, not filled or even borrowed from a friend.  This patient behavior may very well be appropriate, effective and safe for the patient.   Maybe the behavior that needs to change is not that of the patient, but that of the health care providers and payers.  #

As the Assurance System™ training program director at Medication Management Systems, I have the unique opportunity to follow new practitioners as they develop into extremely capable pharmaceutical care providers.  We’ve seen this not in just one practice setting, but in several –the classroom, clinics, telephonically, even virtually.  As we continue to provide care to more and more patients, it is important to reflect upon what we’ve learned.  We believe reflection is vital for growth and improvement; in fact, we teach all of our new practitioners the importance of reflection in practice.   Over the next few months, I will be reflecting upon some of the lessons we’ve learned along the way:  understanding the rational taxonomy of drug therapy problems, the importance of documentation in practice, the benefits of collaborative practice agreements, and the unique contribution pharmacists provide in patient care.

The first thing that became obvious in practice is that “common things are common,” which I had heard for years from Dr. Bob Cipolle.  When I first heard this phrase, I thought how obvious it seemed.  When I reflected on what it meant, I realized that this could be very helpful as I was learning to practice.  Our practitioners - across the globe, in all different types of service venues - are seeing patients with the same conditions, over and over again.   Diabetes, hypertension, hyperlipidemia, depression, pain; these were consistently the medical conditions (with their accompanying medications) that needed to be managed.  As a result, common drug therapy problems were occurring over and over again.  In fact, over half of our patients’ conditions are represented by the same ten conditions.  This is great news for practitioners learning to practice.  Learn as much as you can about these medications and conditions.  In doing so, you will be prepared to identify, resolve, and prevent the majority of drug therapy problems encountered each day.  Every practitioner will encounter these common situations because, well, they’re common.  So prepare yourself, and you’ll be more confident to manage these conditions as well as having time to learn to manage those conditions which are less common.