On November 21, 2012, the ACCP Board of Regents authorized the launch of a comprehensive initiative that will pursue legislative and regulatory changes to the Medicare program and relevant sections of the Social Security Act (42 USC and relevant sections, primarily Section 1861) to recognize the direct patient care services of qualified clinical pharmacists as a covered benefit under the Medicare program, regardless of the settings in which they practice.
Background and Rationale
As the movement toward more patient-centered, team-based, and quality-focused care accelerates in the Medicare program, as well as in private sector delivery systems, the critical importance of “getting the medications right” as a fundamental priority in health system reform in all settings of care has been increasingly recognized by health care stakeholders. Although current payment policy and traditional practice focus on the prescribing and distribution of medications, they fail to provide for a coordinated process of care that ensures effective and safe medication use. Consequently, medications are not being used optimally to help achieve overall patient care goals. The involvement of qualified clinical pharmacists, as part of interprofessional health care collaborations within community/ambulatory practices, institutional settings, or in managed care settings can address this fundamental health care delivery need.
ACCP will pursue this specific and targeted effort in 2013 by employing a comprehensive, focused, and consistent approach. The formation of a coalition of organizations representing other stakeholders (from within and outside the pharmacy profession) to work collaboratively toward this objective is planned. However, the membership of this coalition will be determined solely by the ability and commitment of each potential partner to fully support the initiative’s policy and legislative framework and to contribute meaningfully to achieving its stated goals.
This initiative will be the primary legislative objective and policy priority for ACCP going forward and the College is committed to long-term engagement in this effort. Indeed, in an increasingly challenging fiscal environment for the Medicare program, it is vital that a specific and demonstrably successful approach to the objective of “getting the medications right” for Medicare beneficiaries be employed. ACCP believes that such an approach offers the greatest potential to achieve this objective.
Policy and Legislative Components
Direct Patient Care Services — The “What” of the Proposed Coverage Initiative
The scope of the “direct patient care services” being proposed for coverage is based on the definition of direct patient care originally developed by ACCP and subsequently referenced in the glossary of terms within the Scope of Practice paper published in 2009 by the Council on Credentialing in Pharmacy (see http://www.pharmacycredentialing.org/Contemporary_Pharmacy_Practice.pdf).
These services are provided through a comprehensive and consistent process of care, in a collaborative/team-based environment, that is based on guidelines supported by the Patient-centered Primary Care Collaborative and several of its member organizations (see http://www.pcpcc.net/guide/medication-management). The services rely on direct observation of and interaction with the patient and include the (1) evaluation, (2) initiation, modification, or discontinuation, and (3) ongoing monitoring of patient-specific pharmacotherapy that contribute to the overall clinical goals of care for the patient. The pharmacotherapy plan is developed and implemented in full collaboration with the patient and his/her physician and health care team.
Direct patient care services are delivered in accordance with the clinical pharmacist’s general authority under state law to perform these activities together with either (1) the provisions of an established collaborative drug therapy management (CDTM) agreement with a physician or physician group (or other recognized provider) and/or (2) privileges to perform those services that have been granted to the clinical pharmacist by the medical staff of the institution or health care system within which the clinical pharmacist practices. These services may be provided in any health care setting that is licensed, accredited, or otherwise authorized to provide such services, so long as the preceding and following provisions are in place.
Qualified Clinical Pharmacists — The “Who” of the Proposed Coverage Initiative
“Qualified clinical pharmacists” will possess credential(s) beyond entry level that are commensurate with the scope of services being proposed for coverage and that assure the clinical pharmacist’s ability to contribute to team-based, patient-centered care. ACCP will advocate that clinical pharmacists possess the following in order to be recognized as providers within the Medicare program.
- A Pharm.D. degree (or B.S. in Pharmacy with evidence of equivalent pharmacotherapeutic knowledge and clinical experience) from an ACPE-accredited degree program of a US college or school of pharmacy;
- A valid CDTM agreement with a physician or physician group, and/or clinical privileges formally granted to the clinical pharmacist by the medical staff or credentialing system within the health care facility in which the clinical pharmacist practices;
- Evidence of completion of an accredited post-graduate residency program or an equivalent level of experience in the provision of direct patient care;
- Board certification or eligibility for certification as may be deemed appropriate and relevant to the practice in which the pharmacist is engaged and as may be required or expected in a CDTM agreement and/or by the privileging mechanisms under which the clinical pharmacist practices. Examples of such certification include those offered by the Board of Pharmacy Specialties, the Commission for Certification in Geriatric Pharmacy, and/or multi-disciplinary certifications within a specialized area of practice.
ACCP Government and Professional Affairs staff members have initiated targeted outreach to a range of professional and policy organizations, both within and outside the profession, with which relationships were previously developed during the passage and implementation of the Affordable Care Act. Enhanced outreach to these stakeholders will include discussion of the details of the “what” and the “who” outlined above.
The ACCP Board of Regents has committed multi-year financial support of this initiative and will retain the professional services of a consultant lobbying firm to support and facilitate the work of ACCP staff in pursuing this effort.