Thursday, September 23, 2010
Tuesday, September 21, 2010
Today I want to discuss reimbursement for the professional services that are provided by pharmacists. As the system exists now, pharmacists are not even recognized as providers by health insurers. I checked the websites of several insurers in my state (Ohio) and did not see a single instance of a pharmacist being recognized as a health care provider.
This is where the organizations that represent pharmacy need to get on the ball. For years we've been hearing about how pharmacists are able to decrease expenses and improve patient outcomes.
Well good for us. But that's not good enough. We need recognition as individual health care providers so that we can bill for the interventions and services that we provide. The organizations that I mentioned in my last post need to forget about showing the value of pharmacist services and get us recognized as providers. If pharmacists are able to bill insurers directly for services, you'll see a lot more pharmacists get on board. Money is a motivator.
A few years ago, the company I worked for wanted each pharmacist to get their own NPI. At the time I didn't think much of it. Now I can see the importance of your own NPI. If pharmacists are able to bill for the professional services that pharmacists provide, I want the reimbursement to come to the pharmacists, not the pharmacy. The pharmacy is just a building.
Right now pharmacists are able to bill for three CPT codes....three. All tied to medication therapy management services. The organizations that represent pharmacy need to get us more recognized services and codes so we can show all of the services that we provide.
The way the system works now, when I show a newly diagnosed asthmatic patient how to use their nebulizer, peak flow meter, inhalers, etc... I'm doing so basically out of the goodness of my heart. The $1.75 dispensing fee on the prescriptions doesn't cover the 15 minutes that I'm going to take to educate the patient. The same goes for diabetic patients and their glucose monitors and education on how to use their insulin delivery system. We need billable codes (that are unique to pharmacist services) so we can be reimbursed for the specific educational services that we provide.
And just like physicians are able to have patients come back in for follow-up visits to check BPs after starting a patient on a new medication, we should be able to bill for follow-up services to make sure that the patient is using their medical devices correctly. Or following our prescribed therapy. Or whatever service we have provided.
For the dispensing pharmacist, there should be reimbursement for the professional services provided on each and every prescription. We should be able to bill for all of the DURs we do. Of course we would need to document a little bit more, but it would reinforce the fact that we are providing a professional service on each and every prescription. The documentation process would use our individual NPIs to direct where the reimbursements would go.
The take home message today is this....pharmacy organizations, you need to stop worrying about showing the value of our services and get us recognized as individual health care providers. Pharmacists, you need to recognize that you provide unique professional services and should be compensated accordingly for these professional services.
More to come on reimbursements in my next post.
Thursday, September 16, 2010
When I look at the profession of pharmacy, I don't see a whole lot of organization among pharmacists. Sure, there are a lot of pharmacist organizations out there. Organizations like:
- American Pharmacists Association
- American Society of Consultant Pharmacists
- American Society of Health System Pharmacists
- Board of Pharmaceutical Specialties
- National Community Pharmacists Association
- American Association of Pharmaceutical Scientists
- The Pharmacy Alliance
- American College of Clinical Pharmacy
- Academy of Managed Care Pharmacy
- Christian Pharmacists Fellowship International
- National Association of Chain Drug Stores
- Society of Infectious Disease Pharmacists
- Hematology/Oncology Pharmacy Association
- College of Psychiatric and Neurologic Pharmacists
We've all heard the saying too many cooks spoil the broth. Well, too many organizations destroy the profession. One voice that is speaking gets heard, many voices speaking at once sounds like chatter and gets dismissed as background noise. I think that's where we are now. We have too many organizations trying to advance the profession and the messages are lost in all of the noise.
I look at the American Medical Association as the example of a strong voice for a profession. When the physicians group speaks, the legislators and media pay attention. We don't get multiple messages from the radiologists, pediatricians, internists, intensivists, pulmonologists, and oncologists. We get one statement from the AMA. That's where pharmacy needs to be.
Am I saying that the APhA should be the voice for all of pharmacy, since they have a name that is similar to the AMA? I don't know.
If they start to address issues that affect all pharmacists, then they could be the voice. I'll be honest with you, I'm an APhA member. I joined in August 2009 and just renewed my membership for another year. I hope to see progress from them. If not, I won't renew.
That being said about the national organizations, we need to look at the local levels of organization. Several months ago I put up a poll to see how many pharmacists were active in local pharmacist associations. I was not surprised when the results showed that a majority of respondents were not active.
How can we expect to have any organization and a voice if we are unwilling to meet as a group outside of work? I know that it's not convenient to meet and you just want to go home after work to relax. That's what is keeping us from having a voice in our profession. If we meet together, even if it's just once every other month, we are able to share our experiences and find out what is happening in other practice settings. Who knows, maybe the consultant pharmacist at the long-term care facility may be able to help solve an issue faced by a community pharmacist who is trying to start up a medication therapy management business practice.
We will never know if we don't get together to share our thoughts and ideas.
Once we have been able to discuss the issues that we face, we can forward them to the larger organizations and hopefully have an impact on the profession.
My concern is that if pharmacists don't get off of their butts to organize and advance the profession of pharmacy, there won't be a profession left in twenty years.
Tuesday, September 14, 2010
The medical fields are changing quickly. We, as pharmacists, need to know where we are and where we are going. If we don't adapt to the changes that are occurring, we may find ourselves to be extinct.
Over the next few weeks, leading up to American Pharmacists Month, I'm going to run a series of posts on issues that I perceive to be important as we move forward. Be forewarned, my experience has been in the retail environment for the past 15 years so my writing will be biased towards those who practice in the retail setting. I don't have the numbers, but I believe that most pharmacists work in a retail setting so I believe that we should address issues facing those in retail first.
That being said, the first topic in my state of the profession series is...
When you describe your occupation to somebody that you just met, what do you say you are?
- Retail pharmacist?
- Clinical pharmacist?
- Consultant pharmacist?
- Hospital pharmacist?
- Nuclear pharmacist?
All of these are valid answers to the question. But the answers are part of one of the problems we face as professionals.
We fragment ourselves.
By identifying with the particular practice setting we are involved with, we break ourselves down into, for lack or a better term, special interest groups. Me, I work in a community retail setting. If I view myself as a retail pharmacist only, I'm not going to concern myself with issues that affect other practice settings. By self-segregating ourselves into these groups, we lose the ability to speak as a whole profession.
I still have my dictionary from college. One of the definitions of unity in my dictionary is the quality or state of not being multiple : ONENESS.
Do you feel that the profession of pharmacy is unified? If not, what can you do to bring the profession into a state of unity?
I'm going to offer a simple solution that will hopefully start to bring unity to the profession. The solution lies in the answer to the question that I posed earlier.
When somebody asks you what your profession is, there is one and only one answer:
I am a Registered Pharmacist.
Monday, September 13, 2010
Thursday, September 9, 2010
I read the first few comments on the thread and decided that I had to share my two cents. Since that section of the pharmacist.com site is members-only, I thought that I would share the comments that I left. I believe that my comments should be considered for every new venture that pharmacists pursue.
My comments were the following:
We, as pharmacists, have grown accustomed to being contracted with insurance companies as a result of the dispensing function. We are comfortable having that contract with the insurers. It gives us security.
Over the years, the insurers have chipped away at the reimbursements to pharmacies. So pharmacists have looked for alternative methods to generate income. MTM is one method where we can utilize our professional expertise and see the impact that it has while getting reimbursed at a decent rate.
So why are we in a rush to get contracted with an insurer?
The insurance companies have people whose sole job responsibility is to reduce costs for the insurer. Don't you think that they will reduce payments to MTM providers? They are doing it to physicians. Do you think pharmacists will get treated any better?
Maybe we need to take a step back and talk to physicians about how the insurance companies have treated them over the past 10 years. Maybe we don't want to jump into bed with the insurance companies right away. Just looking at the EOBs that I receive from my medical insurance company shows me how much the providers discount their professional services. I'm not sure that I want to do the same. I'm not willing to bill an insurer my U&C only to see them discount it 40 percent.
Maybe we should take a look at how dentists have set up their contracts. They seem to be sitting pretty on the reimbursements.
I just think that if we are going to pioneer a new practice in the field of pharmacy, we need to be careful to not give away the farm in order to say that we are a provider for XYZ Insurance Company. I like what Don has said that he does...bill the patient directly and take payment, then provide the patient the form to submit to their insurer. We protect our fees this way. As insurers see more people seeking reimbursement for our services, they may approach us about being providers. We can control the reimbursements better this way. I don't like the idea of submitting claims and hoping to be reimbursed. Collect from the patient and let them worry.
The sad thing about this lack of change is that most pharmacists that I talk to really don't care to see the profession evolve. They are there to collect a paycheck and go home. Get up tomorrow and repeat. They are literally trapped inside the box.
Pharmacists need to get out of the box. One of the other comments on the thread was the following: Many times our biggest obstacles are other resistant pharmacists who can only think of why we shouldn't expand our cognitive services and recognition for those services or colleagues who cannot visualize us as anything other than what we have traditionally been in the past professionally (i.e. the "in-the-box" thinkers).
As a pharmacist (or student), you need to step back and do a little self-evaluation. Are you an in-the-box pharmacist? Are you okay with allowing your professional practice to be dictated to you by others, many times non-pharmacists?
Or are you going to step out of your comfort zone and start to think outside of the box? There are limitless opportunities to expand your practice if you take a look outside of the box. Are you going to be the pioneer to lead pharmacists into a whole new world of pharmacy?
I fear that 99 percent of the people who read this will think it sure would be nice to see the profession evolve, but then do absolutely nothing about. I encourage the other one percent to voice their thoughts and ideas, preferably as a comment (so everybody can benefit) rather than as an email to me.
We, as pharmacists, need to set the agenda for the pharmacist organizations. Rather than follow along with (or gripe about) whatever the organizations are proposing, we need to get our own ideas out and discussed. If we get enough chatter going, it might, just might, get heard by the organizations and get acted on.
Even if the organizations don't listen, that doesn't mean that we can't share our ideas about the profession of pharmacy and how we can expand the roles of pharmacists.
Personally, I'm aiming big. I want to build a self-sustaining medication therapy management business that is not affiliated with a dispensing pharmacy. I want to be recognized for the medical services that I provide, not the product that I put in a bottle. It's going to take some time, but I believe that the effort is going to pay off.
I hope to see other pharmacists join me in taking the profession to another level. I'm tired of dealing with third-parties and junkies and ungrateful people. That's the stuff I've seen from inside the box for the past sixteen years.
Come join me outside of the box, it's going to be fun.
Tuesday, September 7, 2010
The volume is starting to pick up as kids are getting each other sick.
There's hardly any eye candy running in and out of the store as classes at the local university have started back up and the students are dressed more conservatively. Plus the weather has been a little cooler than normal for this time of year.
It's only been a week or so and I already miss seeing the chicks show off their belly buttons.
Thursday, September 2, 2010
It's part of the Affordable Care Act, which is supposed to eliminate the doughnut hole for Medicare D beneficiaries by 2020.
Here's how the system is supposed to work. It is my analysis of the information presented in the link above.
Manufacturers must agree to discount the price of medications for selected beneficiaries once they reach the gap (or doughnut hole) in their Medicare D coverage. If you don't discount the price of the medication, it will not be covered by the third-party administrator.
The bulk of the responsibility for the program falls into the hands of the third-party administrators. By the design of the Medicare Coverage Gap Discount Program, the third-party administrator will:
- Determine which beneficiaries are eligible for the discount
- Determine if the drugs are discountable (should be all drugs since CMS says only drugs that will be discounted will be covered under Medicare D)
- Calculate the amount of the discount, depending on doughnut hole status
- Send the discount information to the dispensing pharmacy as part of the on-line adjudication process
- Reimburse the pharmacy for the discount within 14 days of the online claim
Call me a cynic, but I see all kinds of potential problems with this. Maybe I'm just a tad jaded from working with third-parties for the past fifteen years. Maybe I've actually read a third-party contract and understand how the third-party will nickle and dime the retail pharmacy on this. Maybe I can see what is going to happen to drug prices as a result of this program.
Before renewing any contracts with Medicare D plans, a smart pharmacist should carefully read the contract. Look for changes in the reimbursement rates. I can foresee terms for brand name medications to read something like AWP-18% + 1.75 or the MCGDP* + 1.75, whichever is less.
* Medicare Coverage Gap Discount Price, I just made it up but I can see it as a new formula to join FUL, MAC, WAC, and GEAP.
Right there, the plans will attempt to reimburse at the lowest rate possible. And I can guarantee that many pharmacies will sign without even looking. There will also be some terms that allow the plan to delay payment for discounted prescriptions pending audits. Of course every claim will be flagged for an audit. Again, this is just the cynic in me speaking here.
But let's assume that the third-party administrators will be on the up-and-up. Let's think about what the manufacturers are going to do.
Over the last week or so on Twitter, I have seen several links to stories that talk about how the brand name medications have seen price increases of about 8 percent over the past year.
Now we have CMS requiring that the manufacturers discount prices for people who are in the doughnut hole. The manufacturers never discount prices, they pass the cost of the discounts on to others. That means that the non-Medicare D plans and self-paying patients will see prices skyrocket.
The $180 bottle of Nexium that we see on our shelves. Medicare D patients in the gap will see the discount. Let's be nice and say they will only have to pay $120. That sixty dollar discount isn't going to be written off. It's going to drive the price up to $250 per bottle for everybody else. Classic move. The manufacturers aren't going to see any change in profits. Heck, between now and January I wouldn't be surprised to see the big-name medications to see hefty price increases.
In an effort to help out the Medicare D patients, CMS has screwed everybody who is not on a government funded prescription drug plan. Like I said earlier, maybe I'm just cynical but I see multiple places where the system can be hijacked. And in just about every instance it will be the pharmacist who gets the short end of the stick.