Part B provider status would guide payers today, in future

Abstract

“Tom” and “Ann” were not quite old enough for Medicare when they went to see Dan Buffington, PharmD, MBA, for medication therapy management (MTM). The couple’s monthly out-of-pocket prescription drug costs were about $900, and they were struggling to cover them. They went to Buffington for help. “We did an MTM consultation, and between a combination of patient-assistance programs and other strategies, we were able to reduce their costs from close to $1,000 to about $100 a month,” Buffington said. Buffington’s patients at Clinical Pharmacy Services in Tampa, FL, are typically on 10 to 15 medications and seeing about five physicians. “People are very happy to find someone who will be a bridge across all these doctors and monitor their therapy,” he said. They are not unlike many Americans. Nearly one-half of Americans older than 65 years have two or more of the nine most common chronic diseases, which makes treatment and management of those diseases particularly complicated. This may explain in part why one-third of hospital readmissions are medication-related and why a growing number of Americans seek MTM. In addition to managing multiple medications across numerous conditions and specialists, Buffington manages patients on chronic pain medications in order to help them avoid opiate tolerance or dependence. He tracks patient adherence, assesses regimens for possible drug interactions, educates patients, and refines regimens for patients who could take fewer drugs. Arguably, nearly one-half of U.S. seniors, and many younger patients as well, would benefit from this type of care. But Medicare, which is managed by CMS, does not recognize Buffington and other pharmacists as health care providers who are eligible for payment with CMS funds. As a result, neither do most other payers, such as commercial insurance and health plans. ■Dan Buffington relies on various ways to be paid for services for which other providers could simply bill.■Pharmacists are a pivotal part of future solutions in health care models. ■Dan Buffington relies on various ways to be paid for services for which other providers could simply bill.■Pharmacists are a pivotal part of future solutions in health care models. “Pharmacists are a pivotal part of future solutions in health care models, whether it’s controlling costs of readmissions, identification of drug-related problems, or controlling pharmaceutical spending. Pharmacists are integral to all those and just simply not able to be functionally paid,” he said. Medicare Part B covers care delivered by doctors, nurses, physical therapists, speech pathologists, and many other providers, but not pharmacists. So Buffington relies on a number of means, and some technicalities, in order to be paid for services for which other health care providers could simply bill. Some of his patients get care from Buffington by proxy through the physician on staff in his practice. Others get care because their Medicare Part D prescription drug plan requested it. Some carry one of the few health insurance policies that cover pharmacist-delivered MTM. And others pay out of pocket. Profiles in provider statusPharmacists explain how their patients would benefit from provider status in a new series of profiles appearing in Pharmacy Today and on pharmacist.com. Pharmacists explain how their patients would benefit from provider status in a new series of profiles appearing in Pharmacy Today and on pharmacist.com. “What Medicare does, secondary payers will do as well,” Buffington said. “There’s a laundry list of secondary impacts that achieving Medicare Part B- eligible provider status would resolve.” He is careful to point out, however, that achieving provider status isn’t just about ensuring MTM billing codes become included in standard fee schedules. “There are many other health care professionals who live in that elective service model every day and they do fine,” he said. More than fixing fees, Medicare Part B provider status would mean Medicare recognizes pharmacists as full members of the allied health professions, not simply providers of an elective service. “In fact, out of all the different health care professions, pharmacists’ services have some of the strongest and most impactful return on investment data,” Buffington added. While the Affordable Care Act may shift many health care providers out of the fee-for-service payment model and into bundled payment, that will not diminish the importance of provider status for pharmacists, according to Buffington. “Down the road, through health care reform, the new patient-centered medical homes and ACOs [accountable care organizations] could be confused and perceive that MTM is not a covered service under Medicare, simply because we are not included in the list of eligible providers for payment,” noted Buffing- ton. “We need to do something that is correct today and that simultaneously includes pharmacists in a position to be part of the solution in future health care delivery and payment models. And that, simply put, is correcting the Medicare Part B-eligible provider status issue.”