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.