Acceleration of the Center for Medicare and Medicaid Innovation’s Mission

The National Association of Chain Drug Stores (NACDS) recently published a report aimed at policymakers. The report seeks to explain the benefit of expanding pharmacist services and begins by stating how the pandemic has highlighted both the value of pharmacists in patient care and reduction of healthcare costs. As the current administration works towards their goal of a sustainable and meaningful path for the future, it is important to recognize the valuable services pharmacies and pharmacists provide. These include preventative services such as screenings, vaccinations, and chronic disease management. Pharmacies and pharmacists also provide medication optimization services including medication adherence interventions. Additional services offered by pharmacists include point of care testing, patient education, risk assessments, identification and resolution of medication gaps, and screening of patients for social determinants of health. These services are often overshadowed by the stereotype that pharmacists in community pharmacies simply count pills. As a result, many are unaware of the value that pharmacies and pharmacists can provide to a population, not only during a pandemic, but also afterwards.

The Center for Medicare and Medicaid Innovation’s (CMMI) utilization of pharmacists is imperative to creating value for its beneficiaries. Pharmacy care is not systematically included in existing Medicare fee-for-service, value-based programs, or alternative payment models. There are five key recommendations outlined in the NACDS report, which is aimed towards increasing patient access to clinical pharmacy services and broadly improving healthcare quality, equity, and value through a new pharmacy care model. These five recommendations, are:

Include pharmacies and pharmacists as eligible providers and/or suppliers in existing and future value-based programs and alternative payment models.

  1. Allow pharmacies to be directly paid and/or incentivized for providing care to beneficiaries.
  2. Develop and implement meaningful measures, including standardized pharmacy-level quality metrics, across all value-based programs and alternative payment models.
  3. Support advancements in health information technology, interoperability, and other tools that support coordination across providers.
  4. Test a pharmacy value-based program to increase access to evidence-based community pharmacy care for Medicare beneficiaries.

The passage of the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act of 2015 (MACRA) created new incentives for providers to participate in alternative payment models that meet certain eligibility criteria (known as advanced alternative payment models). These include a five percent bonus for participation in the alternative payment models. The Merit-Based Incentive Payment System (MIPS) was born out of this MACRA. MIPS-eligible, Medicare Part B providers may receive a positive or negative payment adjustment based on their performance across four categories – quality, cost, promoting interoperability, and improvement activities. It should be noted that pharmacists are not MIPS-eligible providers. However, 25 percent of improvement activities and 20 percent of promoting interoperability measures were related to medications, suggesting that community pharmacies are leveraged to positively impact the performance of the MIPS program.

The NACDS report identifies six essential categories that are crucial in designing, implementing, and evaluating alternative payment models:

Patient and Provider Participation

  1. Payment
  2. Care Delivery and Management
  3. Quality and Performance Measurement
  4. CMS Operational Issues
  5. Evaluation

These categories should be consulted whenever designing, implementing, and/or evaluating alternative payment models. The categories have given way to five recommendations for the integration of pharmacy care into value-based programs and alternative payment models.

The first recommendation is to include pharmacies and pharmacists as eligible suppliers and/or providers in existing and future value-based programs and alternative payment models. This would allow pharmacies and pharmacists to serve on care teams that improve access to community-based care through the delivery of patient-centered services. The Centers for Medicare and Medicaid Services (CMS) would have to expand direct payment to pharmacies as suppliers of healthcare services, as pharmacies and pharmacists would be providers for preventative services, chronic disease management, medication optimization services, and beneficiary education and health coaching.

The second recommendation is to allow pharmacies to be directly paid and/or incentivized for providing services that enhance quality of care, improve health outcomes, and reduce the total cost of care to beneficiaries. One issue is that the current models, lack the infrastructure to support sustainable delivery of pharmacy services; these models allow alternative payment model plans to partner with pharmacies, yet do not allow direct participation with pharmacies.  CMS and payers designing value-based programs and alternative payment models should provide direct payments to pharmacies. The following are solutions to direct payment and incentive pharmacies and pharmacists:

  1. Permit pharmacists to be eligible for performance-based or bonus payments linked to outcomes for measures related to preventative care
  2. Test models that allow pharmacist to be paid under Part B for preventative care
  3. Incorporate a one-time or monthly, risk-adjusted care management fee into existing or new model design
  4. Expand incident-to billing opportunities and remove the requirement that incident-to services be provided at the physician’s site of practice

The third recommendation is to develop and implement meaningful measures, including standardized pharmacy-level quality metrics, across value-based programs and alternative payment models, payers, and programs. This would allow for more accurate and consistent evaluation of a pharmacy’s impact in the models and programs.

The fourth recommendation is to increase the support to advance health information technology and software, particularly in interoperability. This would allow pharmacists and other stakeholders involved in a patient’s care to communicate more easily and have a more complete picture of the care given. Currently, the Pharmacist eCare Plan allows for clinical information exchange between pharmacies and others, such as physicians and payers.

The fifth and final recommendation is to test a pharmacy value-based program to increase access to evidence-based community pharmacy care for Medicare beneficiaries.  CMS and payers should design and implement a model focused on pharmacy care to test the impact on quality and beneficiary outcomes and costs.  This model would support the CMS goal of moving more patients and providers into value-based care. It would also aid in advancing the CMMI goal of achieving better care, healthier people, greater equity, and smarter spending.

One challenge related to payment for pharmacy services is that pharmacists are not recognized as Part B providers. For a pharmacist who practices in hospital outpatient setting or a physician’s office and can bill for incident-to billing, the payment is made to the provider or the physician overseeing the pharmacist. The creation of a new system that allows pharmacies to bill as providers for their services also poses a challenge, as they are currently not set up to do so. However, there are opportunities for payment of pharmacy services. One example of this is the per-member-per-month (PMPM) fees being utilized in Iowa and South Dakota. Participating pharmacies are paid a prospective PMPM fee with an opportunity to receive further payment based on shared savings. Minnesota reimburses pharmacies or other providers based on a continuum of patient need.

Overall, the utilization and recognition of pharmacies and pharmacists as providers will be a giant step forward for healthcare on all fronts. Further legislation will need to be passed, but it is clear that pharmacists have a lot to offer in support of CMMI’s Mission.  The savings and increased quality of care are exactly what is needed during and after this pandemic. What are your thoughts on the expansion of the role of pharmacists?


Posted: March 2022

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