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ACCP Report

President’s Column

Seeking a Change in the Medicare Benefit—What it Means to ACCP

Written by Curtis E. Haas, Pharm.D., FCCP, BCPS

Curtis E. Haas, Pharm.D., FCCP, BCPS

In the December ACCP Report, the College publicly announced its major policy initiative for 2013 and beyond—pursuit of the inclusion of the direct patient care (DPC) services of qualified clinical pharmacists under Medicare Part B of the Social Security Act (“ACCP’s Medicare benefit initiative”). As most of you know, this is the beginning of a potentially long and challenging journey into a thorny legislative process that is not guaranteed to result in success. However, we believe the underlying principles that establish the framework of our initiative as defined in the recent announcement are those most likely to resonate with and establish a broad base of support across the many key stakeholders in health care delivery and finance necessary for success. The road map to success for this initiative starts with clearly defining what will be provided by clinical pharmacists that differentiates their contributions from those of other members of the health care team and what fills a need that is not otherwise capable of being met through the existing processes of care.

More importantly, we need to remember and actively articulate that this initiative is not about pharmacy or pharmacists; rather, it is about patients. We believe that through the development, advancement, and positioning of clinical pharmacists as members of the patient care team, the unique expertise of our practitioners will improve the quality, safety, and outcomes of patient care. This is the overarching focus of our organizational strategic plan. There is ample evidence that we are not getting the medications right in our current health care delivery system, and there is very little reason to believe this has improved much in the past 10–15 years, even though considerable attention has been focused on the issue by the Institute of Medicine and other quality and safety organizations. Recent estimates suggest that $290 billion per year is spent on managing drug-related morbidity and mortality in the United States, which is about 13% of health care spending, rivaling the amount spent on the drugs themselves!1 Patients receive suboptimal drug regimens, do not achieve attainable therapeutic goals, experience avoidable adverse drug events, are exposed to unnecessary drug therapy, and, in the process, expend a lot of resources to achieve these poor outcomes. For example, the recently launched Million Hearts initiative quoted that less than one-half of patients with ischemic heart disease take daily aspirin or other antiplatelet therapy; less than one-half of patients with hypertension have their blood pressure adequately controlled; only one-third of patients with hyperlipidemia receive adequate therapy; and less than one-fourth of smokers who attempt to quit receive counseling or medications. The initiative estimates that optimizing these goals could save more than 100,000 lives per year.2 These examples represent therapeutic interventions with decades of supportive evidence that have long been included in multiple clinical practice guidelines. We are clearly not getting the medications right. The primary purpose, to my mind, of achieving “provider status” for clinical pharmacists is to achieve a pathway for broader recognition and incorporation of clinical pharmacists as members of the patient care team with the intent of providing comprehensive medication management for patients who do not achieve therapeutic goals or who experience adverse events. In the current fee-for-service environment, recognition of the contributions of clinical pharmacists to improved patient outcomes will provide a potential revenue stream to practices and help justify the inclusion of clinical pharmacists on the team of health care professionals. In the longer term, overall health care payment model reform may make this consideration less important. However, formal recognition of qualified clinical pharmacists and the benefits they bring to patient care will more likely ensure a “seat at the table” for clinical pharmacists in whatever shape a reformed health care system may take.

In recent weeks, other national pharmacy organizations (ASHP and APhA) have announced their launch of initiatives to seek “provider recognition” for pharmacists. Regardless of what emerges as the legislative language to be considered in the pursuit of provider status for pharmacists, it clearly must be focused on what the pharmacist is going to provide for the patient that will bring value to his or her health care (that is, improved quality at an acceptable cost). The discussion and resulting “ask” cannot hinge on or be initiated with a focus on who will be providing clinical pharmacy care. A clearly articulated definition of what is needed by patients to help meet the goal of “getting the medications right” will dictate who is adequately trained and experienced to provide that care. The ACCP framework is based on the definition of DPC by pharmacists (endorsed by member organizations of the Council on Credentialing in Pharmacy) as members of the interprofessional team. Working from this definition, we believe this level of DPC requires board certification or board eligibility (for those practicing in a practice area lacking a current BPS certification option), which includes having completed postgraduate residency training (or engaging in equivalent direct care experience) and a CDTM agreement or similar formal granting of clinical privileges. Of note, this framework is not dependent on or aimed at achieving an expanded scope of practice for clinical pharmacists. It is intended to achieve recognition of clinical pharmacists as providers within a scope of practice that already exists or is capable of existing in most team-based patient care environments. Also of note, the ACCP initiative is applicable to all patient care settings: the neurosurgical ICU, primary care office, long-term care facility, community clinic, and other clinical venues.

It is estimated that 75%–80% of the cost of health care in the United States is for the management of chronic diseases and their complications. Given that medication therapy represents 80% of chronic disease management, the greatest opportunity to improve patient outcomes and control the costs of care will need to be focused on getting the medications right in the ambulatory care environment. With the anticipated rapid emergence of accountable care organizations in a reformed (and increasingly consolidated) health care delivery system and a greater focus on population-based health management, it is also reasonable to predict that many clinical pharmacy providers should and will be integrated into the overall team structure of the patient-centered medical home or other team-based model. Although the time line for this evolution to a new health care delivery and financial paradigm is currently uncertain, it will undoubtedly have an important impact on the recognition of qualified clinical pharmacists as health care professionals who contribute substantially to improved medication-related outcomes. “Hanging out one’s shingle” (see's_shingle) and independently billing payers for clinical pharmacy care is unlikely to evolve or be sustainable as a primary economic and care delivery structure, and we must plan and define the clinical pharmacist’s practice within the context of team-based care. The ACCP initiative is entirely consistent with this vision.

Although we should anticipate significant growth of clinical pharmacy in the ambulatory environment, the acute care setting will continue to be an important home for clinical pharmacy practice. Recognition of clinical pharmacists’ DPC services, as defined by the ACCP initiative, is very consistent with the team-based practice of many clinical pharmacists in hospitals. The ACCP initiative also has the potential to spur the growth of clinical pharmacy practice in the acute care setting; however, the potential financial models may be complex and different from the current, predominantly salaried employee model. Understanding these financial relationships and how they will be affected by a reformed health care system will be an important topic of discussion during the development of this initiative.

Finally, the DPC services described by the ACCP initiative are focused on comprehensive care, not discrete or episodic clinical pharmacy services. In this context, comprehensive care refers to a complete assessment of the patient, identification of medication-related problems, development and implementation of a therapeutic plan, and monitoring and follow-up as appropriate to the care environment. The goal is to link clinical outcomes to a therapeutic plan and take responsibility for maximizing the likelihood of achieving those outcomes as an active and integrated member of the patient care team. If unable to deliver a comprehensive process of care that is focused on patient outcomes, the clinical pharmacist will not and should not be recognized as an integrated member of the health care team.

In conclusion, the underlying principles of ACCP’s Medicare benefit initiative are well aligned with the current environment of health care reform. The framework is first and foremost focused on the care that will be provided (the “what”), acknowledging that health care delivery has become a “team sport” and that the clinical pharmacist must be a qualified and fully recognized member of that team. The principles are applicable to all practice settings, are consistent with the anticipated models of care delivery in a reformed system, and embrace a comprehensive role for the clinical pharmacist in the care of the patient. These are the elements that, I believe, will result not only in the successful pursuit of recognition of the value of the DPC services of qualified clinical pharmacists but, more importantly, will lead to our greatest chance to finally “get the medications right.”

  1. New England Healthcare Institute. Thinking Outside the Pillbox: A System-wide Approach to Improving Patient Medication Adherence for Chronic Disease. Appendix I. August 2009. Available here. Accessed January 11, 2013.
  2. Frieden TR, Berwick DM. The “Million Hearts” initiative—preventing heart attacks and strokes. N Engl J Med 2011;365:e27.