American College of Clinical Pharmacy
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ACCP Report - January 2013

ACCP Moves Forward with Medicare Benefit Initiative to Recognize Clinical Pharmacists’ Direct Patient Care Services

College Addresses FAQs About The Initiative


As announced in the December 2012 issue of the ACCP Report (see http://www.accp.com/report/?iss=1212&art=1), the College has begun implementing a long-term initiative to pursue recognition of the direct patient care (DPC) services of qualified clinical pharmacists as a covered benefit under the Medicare program. ACCP has retained the Federal Group, a Capitol Hill consulting firm with experience lobbying for provider recognition under Medicare, to provide strategic government relations and advocacy services to assist the College in advancing this initiative.

“Clinical pharmacists are recognized experts in pharmacotherapy and patient care,” said Paul T. Kelly, Vice President at the Federal Group. “As the nation moves toward a more accountable, team-oriented health care system, policy-makers would be wise to ensure that these highly trained professionals are fully utilized to help patients achieve optimal outcomes with their medications—and we are delighted to represent ACCP in this very important legislative initiative,” Kelly concluded.

ACCP’s initiative is concrete and specific. First, it focuses on “direct patient care services”—the clinical pharmacist’s direct involvement in the (1) evaluation of the patient and his or her pharmacotherapeutic needs; (2) initiation, modification, or discontinuation of patient-specific pharmacotherapy; and (3) ongoing pharmacotherapeutic monitoring and follow-up. These services rely on the clinical pharmacist’s professional relationship with the patient and close collaboration with the patient’s other health care providers. In addition, because these services extend well beyond the core elements of medication therapy management (MTM) commonly referenced in regard to the Part D drug benefit, they represent a different and comprehensive scope of clinical care not currently provided as a covered Medicare benefit. ACCP’s initiative points out that precisely this quality of service, provided in a collaborative and coordinated care environment, has been shown to produce improved patient outcomes and reduced health care costs.

The second component of the College’s Medicare benefit initiative focuses on the credentials and experience necessary to ensure that a clinical pharmacist can competently provide DPC services in a collaborative practice structure. Therefore, ACCP is advocating that clinical pharmacists engaged in the provision of this benefit (1) be board certified (or board eligible if a Board of Pharmacy Specialties [BPS] certification does not yet exist in their area of practice) and (2) have established a valid collaborative drug therapy management (CDTM) agreement or have been formally granted clinical privileges by the medical staff or credentialing system within the health care environment in which they practice.

Answers to Some FAQs

Recognizing that questions exist among both ACCP members and other stakeholders regarding this effort, answers to a preliminary set of frequently asked questions (FAQs) pertaining to the initiative have been prepared:

  1. The “what” of ACCP’s Medicare benefit initiative—the service to be provided by qualified clinical pharmacists—is DPC (direct patient care). How does DPC differ from Medicare Part D MTM programs, which are already covered under the drug product benefit (Part D) of the Medicare program?

Through the delivery of DPC, qualified clinical pharmacists provide the service of comprehensive medication management based on a specific relationship with and knowledge of the patient and his or her medication-related needs. DPC also involves maintaining a formal professional relationship with other health care professionals responsible for the patient’s care. This is the essence of providing DPC as defined by ACCP. Conversely, MTM programs commonly provided under the Part D benefit are often administrative or financial in nature, do not require a formal professional relationship with the patient’s other health care providers (or even the patient in some instances), and often do not address the totality of the patient’s medication-related needs and issues.

  1. Are there enough “qualified clinical pharmacists” (the “who” described by ACCP) to make a meaningful impact on the outcomes of America’s patients?

The short answer to this question is, “we don’t know.” However, the College believes strongly that the current workforce of qualified clinical pharmacists should be positioned to fully contribute to improved patient outcomes, even if the clinical pharmacy ranks are not yet adequate to address every American’s medication-related needs and issues. Challenges to meet the needs of the population exist throughout the health care workforce, particularly as health care reform proceeds to expand care for the millions of Americans who will gain insurance coverage as a result of health care reform implementation. Regardless of their number today, more efficient and “top-of-the-license” use of qualified clinical pharmacists as part of the patient’s care team can make the work of all providers more efficient in fulfilling those unmet needs. This high-impact contribution to achieving improved patient outcomes is likely to increase the demand for qualified clinical pharmacists, which ACCP believes will in turn drive an increased supply of these clinicians in the long run.

  1. Why isn’t ACCP seeking recognition for all pharmacists as part of its Medicare benefit initiative, instead of just “qualified clinical pharmacists”?

ACCP’s initiative focuses foremost on the “what” of DPC and comprehensive medication management as a new, distinct, and needed benefit within the Medicare program (see also the answer to question 1 earlier). Based on the policies, position statements, and core values of the College, ACCP believes these services should be provided by clinical pharmacists with the education and training needed to competently provide DPC. In addition, to attest to these qualifications, they must possess the certification credentials outlined in the initiative.

  1. Why allow the option of being “board eligible” to serve as an acceptable criterion for “qualified clinical pharmacists” instead of establishing board certification as the sole criterion with respect to documented knowledge and experience?

Although most practices that will seek to use clinical pharmacists can have their patients’ needs met by clinical pharmacists certified in the existing specialties of ambulatory care pharmacy (BCACP), nutrition support pharmacy (BCNSP), pharmacotherapy (BCPS), oncology pharmacy (BCOP), or psychiatric pharmacy (BCPP), some specialty areas (e.g., pediatrics) are not yet formally recognized by BPS. Therefore, including clinical pharmacists who are eligible for certification is reasonable for the practice areas not yet recognized (e.g., a pediatric clinical pharmacist who has practiced for 5 years but who has not taken the board examination because it’s not yet been offered). Board eligibility, as defined by BPS, varies depending on the specialty considered. In general, the criteria for specialist board eligibility consist of (1) graduation from a pharmacy program accredited by the Accreditation Council for Pharmacy Education; (2) current, active licensure to practice pharmacy in the United States; and (3) completion of residency training in the designated practice area (and, in some specialties, completion of additional time in that practice after residency training) or 3–4 years of practice experience, with at least 50% of that time spent in the activities of the specialty practice. ACCP’s expectation is that qualified clinical pharmacists will be board certified in the desired specialty if that specialty is recognized by BPS. If not, documentation of the expected eligibility criteria for that specialty can be applied temporarily until the specialty is formally recognized and a specialty examination made available.

  1. Why do the “who” criteria include a CDTM agreement or the formal granting of clinical privileges?

ACCP’s view is that formal documentation of the patient care privileges and responsibilities of the clinical pharmacist, in collaboration with other health professionals caring for a patient, is critically important to ensure (1) increased coordination and efficiency of patient care, (2) clarity of expectations by other members of the care team regarding the clinical pharmacist’s roles and responsibilities, and (3) greater flexibility and breadth of responsible decision-making by the clinical pharmacist.

  1. Does this initiative apply only to ambulatory care practitioners? Is it relevant to clinical pharmacists who practice in the inpatient setting?

The ACCP initiative is intended to apply to any setting in which this new Medicare benefit is applicable. It’s fair to anticipate that it will have its most beneficial and immediate impact in the evolving and reforming primary care delivery arena. This will include clinics of inpatient institutions, integrated and merging care delivery systems, physician practices, community health centers, and components of the federal health care system (e.g., care provided by the Veterans Administration, U.S. Public Health Service). New models of health care payment and delivery in the inpatient environment that are now emerging could well make this initiative of equal or greater importance to inpatient practitioners in the future.

  1. This appears to be an initiative that will require years of work. Does the College have the resources (human and financial) to bring this effort to fruition?

The ACCP Board of Regents and senior/executive staff weighed this question carefully (and foremost) before moving forward with this effort. Much planning and preparation has gone into embarking on this initiative. Although demands from the external and political environment will likely present new challenges, ACCP is well positioned to pursue the initiative’s desired outcomes. For the past 3 years, the Board of Regents has focused on developing, advancing, and positioning the clinical pharmacist in the midst of a reformed health care environment; methodically addressed each of these strategic directions in plotting the College’s course for the future; and consistently applied this approach in identifying future initiatives and securing the resources to support them, when necessary. This is one such initiative—perhaps the College’s most important initiative ever. Therefore, every effort has been made to ensure that ACCP will have the financial and human resources necessary to launch and sustain this effort.

  1. Because this initiative is focused on the Medicare benefit, will ACCP’s advocacy activities occur only at the federal level?

Of course, it’s true that Medicare is a federal program; hence, Washington, DC, legislators and regulators will be the primary focus of this initiative. However, if successful, these efforts will affect state and private sector health care programs, given Medicare’s role as a leader in health care payment policy. Therefore, while implementing this initiative, ACCP will engage stakeholders outside the Beltway in advancing its case for the ways in which the DPC services of clinical pharmacists can contribute meaningfully to “the triple aim” of heath care reform: achieving better population health, improving individual health, and reducing health care costs.

  1. Is ACCP advancing this effort so that clinical pharmacists can establish independent practices (i.e., “hang out their shingles”)?

The initiative promotes and advocates a team-based practice structure, which most health policy experts now strongly advocate to help achieve the efficiencies, quality, and outcomes needed in an effective health care system. Although the “independent practice” opportunity for a qualified clinical pharmacist would not be inhibited by the initiative itself, evolving evidence of the importance of team-based health care delivery and the business realities of developing and maintaining an independent clinical practice should be recognized and appreciated. ACCP doesn’t envision a future in which the vast majority of clinical pharmacists will truly practice independently.

  1. How is the College working with entities outside the pharmacy profession to enhance their understanding of, and support for, this effort?

Although perhaps not recognized by the ACCP membership at-large, organizations and health professionals external to the pharmacy profession have been a major focus of the College’s professional and government affairs staff work for the past 2–3 years. In this respect, ACCP has increased its involvement with health care provider groups, interprofessional collaboratives, payers, professional medical organizations, and consumer groups. This work is expected to increase further as the Medicare benefit initiative is implemented.