Until a few months ago, pharmacists at Franklin Pharmacy in Warren, Ohio, would rattle off a familiar script when a customer arrived at the counter to pick up a prescription: here’s how to take your medicine; these are the side effects; do you have any questions? Most times, the answer was no.
Since June they have begun sitting down with patients who have chronic illnesses or have just been discharged from the hospital. They go over medications and make sure the patient is taking them as prescribed. They ask about stress, exercise routines, smoking and other health concerns—topics usually reserved for the primary-care doctor.
Danielle Hubbard, a pharmacist who has been with the 50-year-old pharmacy for two decades, said she’s helped patients quit smoking and put one on the right track after a hospital stay by consolidating his medications and throwing out old dosages he was mistakenly taking. George Graham, another pharmacist, said he’s caught medication errors and has recommended blood pressure machines and pulse oximeters for some patients.
Franklin Pharmacy is part of a UnitedHealthcare experiment in Ohio to put community pharmacists on the team of clinicians who care for a patient in hope of controlling chronic conditions and reducing hospital readmissions. The insurer is paying pharmacists to have these conversations, uncover any health and medication issues, and then do something about them.
“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.
It’s a stark departure from the usual role of the pharmacist and positions Ohio as one of a few progressive states that will pay pharmacists as providers, in part to extend healthcare access to rural and underserved communities.
“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.”
Pharmacists traditionally have been paid to dispense medications. Their services have evolved over the past two decades to include administering vaccines and immunizations, such as flu shots, and addressing other public health needs, like providing the opioid overdose reversal drug naloxone to high-risk patients. Pharmacists today are also commonly embedded in hospitals and physician offices, where they tailor drug therapy and address medication problems alongside other practitioners.
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.
“You have this assembly line mentality,” Ciaccia said. “If you can start inserting new incentives into the pharmacy that press (pharmacists) to offer a higher standard of care, integrate new services into their system, and ultimately start grading them on how well the patients are doing … now all of a sudden you’ve stuck a wrench in the gears of this machine and are forcing the pharmacy to slow down and have skin in the game on how well the patient is.”
That 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.
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.
“It’s a long-term systemic change issue we’re all fighting for, but with those bigger companies it’s more difficult” Rochon said. “All the other successes in other states help to push that forward and certainly Ohio is helping in a big way right now.”
Ohio insurers have been unusually swift in adopting the change. “There are other states that have those laws on the books, but there’s never been the exigency,” Ciaccia said.
That may have to do with the scrutiny that befell insurers after a state-sponsored study and reporting by the Columbus Dispatch revealed that pharmacy benefit managers in 2017 bilked $224 million from the Medicaid program and drove hundreds of independent pharmacies out of business.
Lawmakers criticized Medicaid managed-care companies for failing to ensure their contracts with PBMs got the best deal for taxpayers. Some sources said insurers are now scrambling to prove their worth ahead of a Medicaid contract rebid.
The Ohio Pharmacists Association has also labored to convince insurers and lawmakers of the value pharmacists could bring to the table, which the group argues goes beyond improving medication adherence.
“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.
Insurers sign up
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.
“For somebody who is needing care, (the pharmacy) is the No. 1 point of contact that is severely underutilized in society. … How do we leverage that point of contact to become that valued asset, that trusted partner to be able to go beyond just filling a script?” said Steve Ringel, president of CareSource’s Ohio operations.
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.
Participating pharmacists could also assess health and social needs, take blood pressure readings, and recommend treatment in collaboration with a patient’s primary-care doctor, Ringel said. The program, which so far includes two community pharmacies and a hospital system, focuses on four clinical areas, including smoking cessation, asthma, diabetes, and naloxone therapy and opioid management. Pharmacists follow care plans designed by CareSource to help guide and document visits and send those care plans to the primary-care doctor to be filed in the electronic health record.
Some critics argue that tying payment to collaborative agreements can be limiting.
Nnodum Iheme, owner of Dayton-based Ziks Family Pharmacy, which is part of the CareSource program, said he’s had no trouble entering practice agreements with local primary-care practices. “We can walk into the doctor’s office, look for the charts, look at the labs, or we can go into the information management system the doctor is using.
Then when we are talking to the patient we are more knowledgeable,” Iheme said.
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.
“We have some very remote areas of Ohio, very rural, not a lot of provider access, and so pharmacies—individual pharmacies, small chain pharmacies as well as larger stores—provide another hands-on access point for people in our program,” said Maureen Corcoran, the state’s Medicaid director.
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.
More adjustments ahead
The work doesn’t stop there. While the pilots are helping lay the groundwork, it will take time for insurers to credential pharmacists, learn which pharmacist-provided services deliver the most value to payers and their members, and work out the billing processes. “We don’t want to just pay to pay, and I don’t think the provider wants to just bill to bill,” said Meera Patel-Zook, vice president of pharmacy operations at Buckeye Health Plan.
The billing process has been especially difficult to nail down because it hasn’t been defined, she 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.
Buckeye is monitoring claims data to pinpoint patients who may not be taking their medications or are not controlling their blood sugar levels and is then feeding that information to the pharmacists so they can work with those patients to manage their conditions, Patel-Zook said. Buckeye declined to say what it’s paying the pharmacists.
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.
Because the pilots are new, none of the insurers had results to share beyond positive anecdotal accounts. Still, they anticipate expanding the pilots to commercial and other businesses, and they hope to eventually tie reimbursement for pharmacists’ services to outcome measures.
“Don’t underestimate this at all. This is a change to the healthcare system,” Ringel said.
The hope, Ringel said, “as we look to the future, is that we expanded access by thousands of points of contact, meaning every pharmacy store that’s out there, and that people are getting services in a more synergistic fashion with how they live their lives.”