Wednesday, December 15, 2010

Reimbursement for OTC consults

One my last post, I proposed a means by which individual pharmacists can be reimbursed personally for the professional services that they provide on each and every prescription. By including our personal NPIs on claims, insurance companies would reimburse us for DUR review, interventions, etc...

But that only encompasses part of the professional aspects of our profession. Those are duties required to accurately process a prescription medication order. As pharmacists, we currently give away our professional knowledge without being compensated for it. I have a possible means by which we can be reimbursed for what we are currently giving away.

I'm talking about our OTC consults.

Think about a typical consult. We gather pertinent information about both the condition and the patient that we are being asked to help treat. Think of it as taking a history of the patient and condition. After gathering this information, we basically diagnose what we are being asked to treat. Most of the time we can select an OTC product, but other times we refer the patient (notice...patient, not customer) to be evaluated because the condition is more complex and beyond the scope of our practice.

And we do this for free.


If this patient went to the ER, urgent care, or their physician, the same triage process would be done. Most of it by a nurse. The prescriber would come in, take a look at the patient, make a diagnosis and move on. For this the physician would bill anywhere from $70 to $180, depending on the complexity of the visit. More if it was done in an ER.

Why can't we bill for our triage. Think of the hundreds and thousands of dollars we save the health care system every day by keeping people away from the ERs. We are individual health care providers, but we just haven't decided to bill for our services.

It's time.

* * * * *

In case you've missed it, this past March a little bill was passed and signed into law that basically provides health care to all Americans. Like it or not, it's now the law. Even with the Virginia ruling on the constitutionality of one of the provisions, the law is still in effect. One of the provisions of the bill is the implementation of electronic health records.

How these are going to work, I haven't a clue. But pharmacy/pharmacists have the opportunity to capitalize on this. This may seem a little bit Big Brotheresque, but it is what it is. If we are going to be required to maintain electronic health records, let's go all in with it.

I propose that all persons should have a card, similar to a credit card, that has their insurance information embedded on it. The information can only be modified by certain entities, such as insurance carriers and benefits administrators. If a person has coverage, it is recorded on the card. If coverage has been dropped, the administrator modifies the data. Get a new job, you take your card to your new benefits administrator to have the information added to your card.

The card is required for all transactions surrounding a person's health care. That way a person can't jump from provider to provider, using insurance at one place and claiming to be self-pay at another. The card would simply carry the patient's insurance information and record which providers they have seen. No medical information would be captured on the card. But in the event of an emergency, it would provide information about where the patient had been seen. Phone calls could then be made. No more calls to see if Mr Jones had his prescriptions filled at CVS, Walgreens, or Target. The ER would know simply by swiping the card.

* * * * *

So how does this apply to pharmacy and pharmacist reimbursement?

Glad you asked. Whenever we provide any professional services for anything other than that which is mandated by OBRA, we must be presented with the card. No card = no service.

Basically we swipe the card on a PDA-type device to gather the patient's information. Conduct our OTC consult as normal, but at the end we record the details of our consultation. Depending on the length of time and complexity of the consult, we bill the insurance appropriately for our services. The details we provide determines the reimbursements that we receive. At the end of the day, we upload our interactions for the day and submit the claims. All claims are tied to our individual NPIs, so reimbursements are sent directly to individual pharmacists.

(For people without insurance, the data is still recorded for the sake of electronic health records. Rather than bill for the intervention, pharmacists receive a tax break as "charity care")

This post only addresses the community pharmacy aspect, but it can be easily adapted to clinical and consultant services.

* * * * *

This idea may seem a little far-fetched, but we (as pharmacists) need to start looking out for the economic survival of our profession. The AMA just had the cuts in physician reimbursement delayed because they pay attention to the money. We need to do the same.

Your thoughts?


young rx said...

I agree with this idea. I don't know how exactly all of the issues regarding pharmacist reimbursement will be resolved, but I believe that it is up to us to try to find a way. Maybe your idea, maybe someone else's idea. Either way, we need to start making it happen.

pharmacy chick said...

I think its an excellent idea. I dont know how it will all work but this card will also keep the patient from hiding pertinent information from us as well. We give away so much of us that we might as well call ourselves a pharmacy charity.