Community Pharmacists as Experts on Complex Patient Encounters
Researchers identified factors contributing to Medicaid Managed Care complexities and collected evidence of pharmacists’ ability to address patients’ health needs.
Community pharmacists participating in a Medicaid Managed Care Organization payer program exhibited significant expertise in addressing the complex health needs of their patients, according to data published in the Journal of the American Pharmacists Association.1 Care coordination with other health care providers, behavioral health support, and addressing social determinants of health were all factors contributing to pharmacists’ expertise.
“Community pharmacists frequently care for patients with complex medical and social needs; however, evidence on how pharmacists can address these complex needs within the community pharmacy setting has not been clearly characterized,” wrote authors of the study. “Other health care providers, payers, or pharmacists who do not practice within community pharmacies may be unfamiliar with the complexity of care that community pharmacists provide.”
Researchers looked at pharmacists participating in a Medicaid Managed Care Organization (MCO) payer program to explore perspectives on complex patient encounters. | image credit: Drazen / stock.adobe.com
As patients’ most readily available provider, pharmacists are typically seen as the first line of defense in addressing immediate health needs, especially when regarding medications. Indeed, 60% of US patients have chronic health conditions and 80% require medication for their conditions. In the context of patients’ medication needs, research has shown that community pharmacists improve outcomes and save patients money.1
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Researchers looked at pharmacists participating in a Medicaid Managed Care Organization (MCO) payer program to explore pharmacists’ perspectives on its complexity and how the program allows them to care for patients.
“The objectives of this programmatic case study were to: elucidate factors that contributed to patient encounter complexity that were part of a Medicaid MCO comprehensive medication management payer program in community pharmacies and curate a series of patient case vignettes that provide evidence of pharmacists care for patients with complex medical and social needs within community pharmacies,” they continued.1
From October to December 2018, researchers conducted interviews with community pharmacists participating in the Pennsylvania Pharmacists Care Network (PCCN) and were asked to describe complex patient encounters. Researchers interviewed a total of 30 pharmacists at 48 pharmacies, reporting a total of 48 patient case vignettes. Of the 48 vignettes, 67% occurred at pharmacies in urban areas, 21% in large rural cities, and 6% in small rural towns as well as isolated rural towns. Regarding pharmacy type, 52% were at multiple-location pharmacies; 44% at independent, single-location pharmacies; and 4% at chain pharmacies.
“From these patient case vignettes, we identified that the following 3 factors—care coordination, behavioral health support, and social determinants of health—contributed to patient encounter complexity in this Medicaid population,” they wrote. “The patient case vignettes described in this report adds to the existing evidence that community pharmacists care for patients with these factors as part of comprehensive medication management services but may find this care more complex.”
Care coordination for community pharmacists often involved interprofessional communication with other providers and health care employees to manage medications. Behavioral health conditions were another prominent factor because of their ability to exacerbate chronic conditions and make health care management more complex. Finally, pharmacists noted that social determinants of health were often a complex barrier to providing valued care.
“In the past 5 years, we have witnessed an explosion of programs covering pharmacists’ services across the states,” wrote President of the American Pharmacists Association Michael D. Hogue, PharmD, FAPhA, FNAP, FFIP.2 “Many of these programs are being established through state Medicaid fee-for-service and managed care plans, or by commercial health plans operating in the states. Pharmacists are being enrolled as providers in much the same way that health plans enroll physicians, nurse practitioners, and physician assistants.”
With progress and realization of their capabilities are coming to fruition, experts agree pharmacists are crucial health care providers that deserve proper reimbursement and scope of practice to conduct their services. In the community pharmacy space, however, reimbursements have become a challenge. For example, 90% of independent pharmacies are considering dropping out of the Medicare Drug Price Negotiation Program because of its financial risk to pharmacy business.3
Evidence, like the data presented in the current study, highlighting pharmacists’ role within health care is crucial to ensuring the appropriate reimbursement of pharmacy services. And while experts believe administrative and financial challenges still need to be addressed, pharmacists are making their expertise known amongst other health care providers.
“Pharmacists, who participated in a community pharmacy Medicaid MCO payer program, provided care to patients with complex health needs. In addition to medication-related problems, specific factors that increased pharmacist perception of encounter complexity were care coordination with other health care providers, behavioral health support for patients, and addressing the patients' social determinants of health,” concluded authors of the study.1
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References
1. Carroll JC, Doong K, Mitra S, et al. Complexity of patient encounters within a clinically integrated community pharmacy network Medicaid payer program. JAPhA. 2024;65(1):102264. https://doi.org/10.1016/j.japh.2024.102264
2. Hogue MD. Payment for pharmacists’ services is spreading quickly across the states. News Release. APhA. April 26, 2024. Accessed February 21, 2025. https://www.pharmacist.com/CEO-Blog/payment-for-pharmacists-services-is-spreading-quickly-across-the-states
3. NCPA to CMS: A third of independent pharmacies won’t carry drugs in the negotiated price program, and 60 percent more are considering dropping out. News Release. NCPA. January 27, 2025. Accessed February 21, 2025. https://ncpa.org/newsroom/news-releases/2025/01/27/ncpa-cms-third-independent-pharmacies-wont-carry-drugs-negotiated
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