Pharmacists in almost every setting are pushing for provider status. While provider status is the most direct and transparent way to get paid for clinical services, it’s not the only way. Pharmacists who learned how to navigate the reimbursement system have been getting paid for clinical services for years.
“We started our first pharmacist-managed ambulatory care clinic in 1996 and have been getting paid for our services from day one,” says Dean T. Parry, RPh, assistant vice president for clinical informatics at Geisinger Health System. “Today we have about 60 pharmacists working full time in ambulatory disease and medication management. Getting paid is a matter of figuring out where in your specific administrative and financial system you can fit in. Provider status would be nice, but it is not a prerequisite to getting reimbursed for clinical services,” says Parry.
Like many other integrated networks, Geisinger covers only about 40% of members through its own insurance program. The remaining 60% are covered by standard commercial payers. The key to convincing commercial payers to reimburse clinical pharmacy services is to provide a reasonable return on the payer’s investment, says Parry.
ROI: The Key to Reimbursment
Payers have seen all the data on the health and financial outcomes of clinical services. Parry says that they know just as well as pharmacists that the appropriate pharmacy interventions can improve health outcomes and reduce overall costs of care—over time.
“Payoff time is the obstacle for payers,” he explains. “They need to see a payoff in reduced total cost of care in less than one year. That might be possible in some disease states, but the return on investment for anticoagulation, asthma, COPD, cardiovascular disease, and most chronic diseases is too long term for most payers to work with.”
The current wave of consolidation among payers, PBMs, pharmacies, wholesalers, and providers may ease the ROI problem. With far fewer payers in the system, each payer is more likely to retain patients for a longer period of time, Parry suggests. The longer patients remain with a single payer organization, the longer that payer’s time horizon for a return on its clinical pharmacy investment.
Integrated networks like Geisinger seldom worry about whether their pharmacists can bill payers directly, Parry said. Clinical pharmacists are part of the overall patient care team working to control costs, reduce admissions, improve adherence and provide more effective care. When pharmacists are part of the patient care team, the health system looks to the total cost of care versus the total reimbursement for care. Whether services are reimbursed directly or through some other provider becomes an accounting exercise for the integrated health network. The key to convincing commercial payers to reimburse clinical pharmacy services is to provide a reasonable return.
For now, closed systems like Kaiser, where a network is exposed to patients’ entire cost of care over multiple years, have an easier time justifying the financial investment in clinical pharmacy services. Pharmacists in other settings must find an appropriate work-around. Closed system pharmacists don't get reimbursed individually because the system is responsible for everything: insurance coverage, cost of care, quality of care, patient and provider satisfaction. If a third party payer is involved—Medicare, Medicaid, or some other public system—the system gets reimbursed, not the provider.
Up next: Collaborative agreements and how to get started