Thursday, December 9, 2010

Pharmacist reimbursement for professional aspects of dispensing

By now I think that anybody who reads this blog knows that I believe that pharmacists should be getting reimbursed for all of the professional activities that we engage in. In the community practice setting, a dispensing fee just doesn't cut it any longer, especially when the drugs are being reimbursed thru WAC, MAC, and GEAP-minus formulas.

The effect of the $4 generic programs has reduced the profession to a product. People aren't valuing the professional expertise of the pharmacists, they are frequenting the pharmacies that sell the product cheaply. In my state, a regional chain has started offering $2 generic prescriptions. Couple that with the free diabetes medications at a certain Pittsburgh-based chain and free generic antibiotics offered by several pharmacies and I can see why the public doesn't value our services.

It's because we don't value our services.

I honestly don't see pharmacy rebounding to the point where a respectable dispensing fee will ever be offered to pharmacies. The chains and insurers have seen to it that we will accept horrible reimbursements, so why should we expect to ever see a decent dispensing fee again?

What I propose is to remove pharmacist services from the equation when it comes to setting reimbursements to the pharmacy for the product. CVS, Walgreens, Target, Walmart, whoever can accept whatever reimbursements they want for the product, because we (the pharmacists) would be getting reimbursed for the professional functions on each and every prescription.

The NPI number of the pharmacist is included on every claim that is submitted to the insurer. This is in addition to the pharmacy's NPI that is submitted for product reimbursement. Prior to submitting a claim, all of the pharmacist's professional functions are summarized and coded to be submitted with the claim (software determines the coding). Based on the level of pharmacist intervention, the pharmacist will be reimbursed personally for his/her intervention.

If the pharmacist doesn't want to be reimbursed for their professional services, they can opt to submit the facility's NPI instead of their own. But once pharmacists see other pharmacists raking in the money from their interventions, all pharmacists would be submitting their own NPIs on the claims.

For example, a mother drops off a prescription for cefdinir 250mg/5ml 2.6 ml qd x 10 days. The prescription is entered for a quantity of 60 ml (the smallest package available) for the 10 day supply.

The pharmacy dispensing system flags the order as being an overdose for the patient age. Pharmacist reviews the dose and documents that the dose is appropriate for the patient's age and weight and that the days supply is 10 days due to both the prescription order and the expiration dating of the reconstituted product.

When the claim is submitted, the pharmacy is reimbursed to the product at the contract price. The pharmacist receives payment for verifying the dose and day supply. There would have to be a means to edit the intervention info based on the OBRA-mandated counseling session (maybe professional service claims get submitted every Saturday night), but I think you get the drift of where I would like to see this going.

Anybody know if an idea like this has ever been explored?


Unknown said...

A blog post on this subject -

Honestly, the level of dispensing fees today were established/negotiated with the full understanding that the "ingredient cost" of claims is significantly inflated. The "benchmarks" used are barely reflective of true cost, and in the case of generics, I would argue completely useless.

Also, the Medicare Part D MTM programs are an opportunity for pharmacists to initiate, record, and get paid for patient interactions and interventions that improve patient care and ultimately lower overall health care costs (thus the only reasoning for the program to pay for them). Interestingly, pharmacists have, to date, still had a very low level of adoption of those MTM programs that are available to them (Outcomes, Mirixa, etc).

lovinmyjob said...

Great idea, Eric. I bet this kind of reimbursment would quickly reduce the number of senseless DUR rejects we deal with every day. By the way, I had no idea that my personal NPI number was being transmitted with each claim. Thanks for the insight.

Unknown said...

One more thing - I am pretty familiar with the NCPDP Standard Pharmacy Claim Transaction, and I am not aware of where a pharmacist's personal NPI would be included. Certainly pharmacy dispensing software will capture the identify of the pharmacist involved (and that could be by NPI, or a proprietary or internal identifier) but I don't believe it is transmitted on the claim to the payer.

Eric Durbin, RPh said...


Currently only the pharmacy NPI is submitted on claims. My proposal is to add the individual pharmacist NPI for the purpose of direct pharmacist reimbursement for professional services.