• April 17, 2021

Pharmacists in Ohio managing care as providers—and getting paid for it too

Sep 26, 2020

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One by one, Ohio health insurers began to bite. Most of the five Medicaid managed-care companies in the state have rolled out their own programs to experiment with how they can best use pharmacists’ expertise to care for Medicaid patients, each taking a different approach to ensure care doesn’t become duplicative or fragmented.
“For somebody who is needing care, (the pharmacy) is the No. 1 point of contact that is severely underutilized in society. … How do we leverage that point of contact to become that valued asset, that trusted partner to be able to go beyond just filling a script?” said Steve Ringel, president of CareSource’s Ohio operations.

UnitedHealthcare’s program gave pharmacists flexibility in who they see and what they can do within their scope of practice. It encourages pharmacists to keep the primary-care physician in the loop by paying them for time spent coordinating care with the doctor.

A six-month pilot launched in August by CareSource, the largest Medicaid managed-care insurer in the state, is more prescriptive and requires pharmacists to enter upfront agreements with primary-care doctors who will sign off on which basic services they are comfortable delegating to pharmacists. A physician may allow the pharmacist to adjust or prescribe new medications, for instance.

Participating pharmacists could also assess health and social needs, take blood pressure readings, and recommend treatment in collaboration with a patient’s primary-care doctor, Ringel said. The program, which so far includes two community pharmacies and a hospital system, focuses on four clinical areas, including smoking cessation, asthma, diabetes, and naloxone therapy and opioid management. Pharmacists follow care plans designed by CareSource to help guide and document visits and send those care plans to the primary-care doctor to be filed in the electronic health record.

Some critics argue that tying payment to collaborative agreements can be limiting.

Nnodum Iheme, owner of Dayton-based Ziks Family Pharmacy, which is part of the CareSource program, said he’s had no trouble entering practice agreements with local primary-care practices. “We can walk into the doctor’s office, look for the charts, look at the labs, or we can go into the information management system the doctor is using.

Then when we are talking to the patient we are more knowledgeable,” Iheme said.

For now, insurers are paying pharmacists for extra services out of their own pockets. CareSource said it’s paying pharmacists $25 for 15 minutes spent with the patient, and will move to medical code billing as soon it can. UnitedHealth said it is paying pharmacists based off the physician fee schedule but at a reduced rate.

Under draft rules, the Ohio Department of Medicaid would foot the bill for high-level services provided to the state’s 3 million Medicaid enrollees. Most members receive benefits through private insurers that contract with the state to manage their care. 

“We have some very remote areas of Ohio, very rural, not a lot of provider access, and so pharmacies—individual pharmacies, small chain pharmacies as well as larger stores—provide another hands-on access point for people in our program,” said Maureen Corcoran, the state’s Medicaid director.

Corcoran said pharmacists would be able to bill evaluation and management codes for clinical consultations on asthma, diabetes, cancer or any condition that involves medication. The draft rules, which could change during the rulemaking process, specify payment for managing medication therapy and administering immunizations and certain medications. 

Like in CareSource’s program, the department would require a pharmacist to have an agreement with a patient’s primary-care doctor, rather than acting independently. Some groups, including the National Community Pharmacists Association, have said the draft rules are too narrow and would unnecessarily limit what a pharmacist can do.

Insurers will adapt their programs to meet the Medicaid department’s rules when finalized early next year. They could still choose to pay for pharmacist services beyond what the state pays for, but the companies would be footing the bill. Each pharmacist who wants to bill Medicaid for these higher-level services would have to enroll in the safety net program. 

More adjustments ahead 
The work doesn’t stop there. While the pilots are helping lay the groundwork, it will take time for insurers to credential pharmacists, learn which pharmacist-provided services deliver the most value to payers and their members, and work out the billing processes. “We don’t want to just pay to pay, and I don’t think the provider wants to just bill to bill,” said Meera Patel-Zook, vice president of pharmacy operations at Buckeye Health Plan.

The billing process has been especially difficult to nail down because it hasn’t been defined, she said. Buckeye’s pilot that launched in June started with two federally qualified health centers and a hospital system because they already had pharmacists embedded in their facilities and were used to collaborating. The pilot will soon include two independent community pharmacies, and the variety of settings helps the insurer test how processes will differ between them.

Buckeye is monitoring claims data to pinpoint patients who may not be taking their medications or are not controlling their blood sugar levels and is then feeding that information to the pharmacists so they can work with those patients to manage their conditions, Patel-Zook said. Buckeye declined to say what it’s paying the pharmacists.

Other challenges include getting patients and physicians to embrace the changes. Todd Baker, CEO of the Ohio State Medical Association, said the group opposes giving pharmacists independent authority to prescribe medications and order or interpret tests.

Because the pilots are new, none of the insurers had results to share beyond positive anecdotal accounts. Still, they anticipate expanding the pilots to commercial and other businesses, and they hope to eventually tie reimbursement for pharmacists’ services to outcome measures.

“Don’t underestimate this at all. This is a change to the healthcare system,” Ringel said.

The hope, Ringel said, “as we look to the future, is that we expanded access by thousands of points of contact, meaning every pharmacy store that’s out there, and that people are getting services in a more synergistic fashion with how they live their lives.”

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