Medicaid managed care plans start paying Ohio pharmacists as providers

Abstract

Medicaid managed care companies are working with the Ohio Department of Medicaid to act on a 2019 law that recognizes pharmacists as providers in Ohio. Since getting wind of what pharmacists are capable of doing for patients, three Medicaid managed care plans in Ohio have launched programs of their own to pay pharmacists as medical providers. Additional plans are expected to make announcements in the coming months. In April 2020, UnitedHealthcare began working with two independent community pharmacies in Ohio to launch a program that uses the expertise of pharmacists to expand access to care for patients and drive better health outcomes for Medicaid beneficiaries. Pharmacists in the program are able to bill and receive reimbursement for providing patient care services using existing CPT codes for evaluation and management, virtual check-ins, and transitional care management. “We feel community pharmacies can do more if we create the right incentives,” said Mike Roaldi, CEO of UnitedHealthcare Community Plan of Ohio. So far, two community pharmacies are participating in the program. UnitedHealthcare selected them based on the high concentration of plan members who frequent the pharmacies. These members also have multiple prescriptions and chronic conditions. Results are being measured both qualitatively and quantitatively. “The first thing we want to do right now is prove the concept works and get outcomes—we want the data,” said Roaldi. They are keeping track of three specific quality metrics: hospital readmissions, unnecessary prescriptions, and the management of chronic conditions. “We also want stories in this early stage about how pharmacists provide better care and [prevent errors for] patients,” said Roaldi. Ohio’s Centene managed care organization, through Buckeye Health Plan, launched its program in June 2020 and during the initial phase, participating pharmacists at a health system and two federally qualified health centers are expected to work with physicians to provide care for patients who have chronic conditions. As this article went to press, another Ohio Medicaid plan, CareSource, announced a provider status program focused on two independent community pharmacies. All programs will reimburse pharmacists for clinical services. When former Ohio governor John Kasich signed SB 265 at the beginning of 2019—a law that formally recognizes pharmacists as providers in Ohio law—the work had only begun for any real change to happen for Ohio pharmacists. “Ohio’s momentum has been based on three factors,” said Stuart Beatty, PharmD, director of strategy and practice transformation at the Ohio Pharmacists Association (OPA) and associate professor of clinical pharmacy at Ohio State University College of Pharmacy. Passing legislation and the overarching changes due to health care transformation have been critical, said Beatty. But so was Ohio’s investigation of the PBM industry. Once the public became aware of the issues for pharmacies, legislators started putting pressure on payers, specifically managed care organizations (MCOs). Beatty said the timing is important to consider. During the spring of 2019, as the provider status law was still waiting to go into effect officially, legislators questioned the MCOs during an April 2019 Ohio Joint Medicaid Oversight Committee meeting that was focused on PBMs. With Ohio legislators aware of the provider status law, they also began asking how the plans were going to implement the new law. According to Beatty, the public questioning opened the door for OPA to have meaningful conversations with payers about how pharmacists are an underutilized resource. “As a result, the plans started to realize what pharmacists can do and a shift happened,” said Beatty. “This combined with a focus toward value-based care got the discussion quickly turned in Ohio about how pharmacists can help patients achieve better health outcomes with an incentive structure in place,” he continued. The Ohio Department of Medicaid announced they will create provider identification numbers for pharmacists in January 2021. Antonio Ciaccia, director of government and public affairs at OPA, said this will put “rocket fuel” in the existing Medicaid managed care plans that are already working collaboratively with pharmacists. The Ohio Department of Medicaid has begun compensating pharmacists to conduct COVID-19 testing as well. After the U.S. Department of Health and Human Services made it clear earlier this year that allowing pharmacists to order and administer FDA-authorized COVID-19 tests supersede state limits on scope of practice, Ohio governor Mike DeWine had to take action, instructing Ohio’s Medicaid program to create codes that allow pharmacies to bill for tests on program beneficiaries.