Affordable Care Act Regards Pharmacists as Health Care Providers, Not Just Prescription Dispensers

Nick Smock, PharmD, MBA, CEO of PBA Health

The Patient Protection and Affordable Care Act (ACA) recognizes the value of pharmacists to provide cognitive services as part of patients’ overall health care. Currently, the typical pharmacist earns income by selling a product—prescription medication—plus minimal profits on selling a variety of additional retail items. Interactive patient care is for the most part limited to at-the-counter drug counseling, which is provided free of charge. True cognitive care, also known as Medication Therapy Management (MTM) or Medication Therapy Services (MTS), tends not to be provided. Indeed, most patients don’t even know that pharmacists are equipped to provide this type of care.

As of January 1, 2013, the ACA began to require health systems and physician groups to form accountable care organizations (ACOs) that will work as teams to provide coordinated medical care for eligible Medicare Part D recipients, and several demonstration projects will be funded to carry this directive forward. Pharmacists will be an integral part of these teams, not just as dispensers of prescriptions, but as providers of MTM, including comprehensive medication reviews. This level of medication review is different from and in addition to basic medication counseling; it comprises big-picture management of a patient’s overall drug regimen, taking into account potential interactions among prescription and OTC medications, as well as factors including the patient’s age, gender, health history, and level of compliance.

MTM is time-intensive interpersonal interaction that cannot be performed at the counter while the cash register is ringing or through mail order. It requires dedicated time and one-on-one attention to a patient’s case. Pharmacists have always been qualified to provide this level of cognitive care and to charge for the service, since they have 5 to 6 years of higher education, but the norm has been to leave all patient management in the hands of the doctors. Today, pharmacists are more equipped and inclined to offer “high talk and touch” using their knowledge, skills, and technological tools to educate patients.

Increasingly, though, medical care of patients has become fragmented, with various specialists treating pieces and parts of a patient’s body and medical needs. There is no overall management, and that’s what the ACA seeks to remedy. A medical team approach, headed by a primary physician, will be required, and a clinical pharmacist will be part of the team in almost all cases.

This opens up huge opportunities for pharmacists. With their inclusion in patient care management, their practices will change. Dedicated consultations between pharmacists and patients and elevated care at the cognitive level will become part of the patient experience, which will lead over time to patients’ expectation that they should be provided with such care and that either they or their insurance coverage will pay for it.

Over time, the ACA will phase in a number of other demonstration projects involving dedicated pharmacist care as part of a team of providers for non-Medicare patients, and this will further strengthen the public’s perception of the pharmacist as an integral part of the medical care team.

What this means for pharmacists is that a new era of heightened professional practice is about to begin, and a new stream of income is about to open up. Those who can see what’s coming and prepare for it will fare best. At PBA Health, we are advising all of our members to prepare for private consultation appointments with patients and to lay the groundwork now for patient intake and management protocols, appointment scheduling, and the setting of fees.

This will benefit the patient without adding to overall costs. For example, a pharmacist may do an initial consult and charge, say, $60 to $100 for an hour visit. This consult may include talking with the prescribing physician, psychologist, dentist, nurse, and insurance company, in addition to the patient. After a comprehensive review, the pharmacist may deem a drug the patient is taking unnecessary and remove it from their regimen, which could save the patient hundreds of dollars each year. Or, the pharmacist may recognize a potential drug interaction and adjust the patient’s drugs or dosages to avoid the problem, protecting the patient against potential health problems and all of the costs that would result. And the patient isn’t the only one who stands to save money as a result; MTM and MTS will greatly reduce the chances of adverse reactions or side effects that lead to emergency hospital visits, helping to decrease overall health care costs.

The American Medical Association (AMA) provides 3 billing codes that pharmacists can use for face-to-face patient consultations. Whether an insurance company will reimburse a patient for pharmacist consultation fees is another matter, however. Under the ACA, Medicare will be required to pay for these very services for eligible patients, billed under any of these AMA codes. It is hoped that over time, the reimbursement models pioneered by the Medicare demonstration projects will be adopted by private insurers as well. Once patients see and understand how cognitive services can benefit them, they may even choose to pay for the services out of pocket just as they pay for legal or financial services.

The ACA gives independent pharmacists the opportunity to provide additional care to their patients and increase their profit margins. It’s time to plan ahead and be prepared for this positive new change in our country’s health care system. Pharmacists need to educate themselves about ACOs and formulate a strategy for being included in ACOs that are being formed in their area. A good overview of this process can be found in an article entitled “Pharmacists’ Role in Accountable Care Organizations” by Lisa Daigle of the American Society of Health-System Pharmacists.

Nick Smock is CEO of PBA Health, a purchasing and pharmacy services organization (PSO) that offers a menu of service options to help community pharmacies buy, operate, and sell more effectively. PBA Health serves more than 2400 independent pharmacies.