Catalyst Corner

A new report from Avalere Health, entitled “Developing Trends in Delivery and Reimbursement of Pharmacist Services,” outlines several factors that could help facilitate broader reimbursement for pharmacist services. The report was released in November and funded by the National Association of Chain Drug Stores (NACDS). A copy of the report can be downloaded at

Avalere Health assessed the current healthcare delivery and payment landscape to identify ways to broaden reimbursement for pharmacist services. They note that, “While opportunities for pharmacists to provide direct patient care services emerge, options for obtaining reimbursement for these services continue to be limited for community pharmacists.” They describe numerous examples of other practice site billing that exist, such as “incident to” the physician. They go on to say that “Outside of traditional Medicare Part D medication therapy management (MTM), the mechanisms through which pharmacists in the community setting may obtain reimbursement for services allowed under state scope of practice regulations are limited and vary by payer” and that this lack of reimbursement is a key challenge in delivering pharmacist-provided direct patient care services on a widespread basis.

Avalere identified three changes that could help improve reimbursements (see box).

Changes to Help Reimbursement

Establishing pharmacists as healthcare providers under Medicare Part B with federal statutory recognition.

Standardizing state and federal billing methods for specific services outlined in scope-of-practice regulations that pharmacists provide.

. Improved coordination through clinical and administrative health information exchanges between pharmacies and other healthcare providers on the patient care team.

In outlining the role of pharmacist services today, the report authors say that pharmacists are well positioned to provide more services to patients in need, as 93% of Americans live within five miles of a community pharmacy. Direct patient care services they highlight that are provided by pharmacies are immunizations, wellness and prevention screening, medication management, and chronic condition management.

The Value Factor

Looking forward, they say that development of new care delivery models based on value-based payment and performance will create new opportunities for pharmacist reimbursement. They note that, to succeed, pharmacists would need to be adequately compensated for their contributions and expanded role in the healthcare team, either through portions of shared savings or separate service-based fee contractual agreements within alternate payment models (APMs). These value-based care models are held accountable for population health against a global budget, which may include pharmacy spending over an extended period of time, emphasizing a need to foster a more comprehensive partnership with pharmacists.

The report does an excellent job of outlining current billing mechanisms for pharmacist services. These include use of current procedural terminology (CPT) codes, contracts with third-party payers, direct patient payment, “incident to” billing, outpatient setting billing, MTM service billing, and medication reconciliation in care transitions. They also outline the extent of pharmacist-provided services such as immunizations and point-of-care testing and the use of collaborative drug therapy management agreements.

With regard to existing system barriers that hamper broader service reimbursement, the report notes, the lack of “ability for different systems to communicate with each other to provide the most relevant clinical and administrative information at the time care is provided, and to ensure that services are coordinated across different practitioners” is problematic due to limited interoperability. This creates a constraint for the community pharmacist in accessing medical record information that can allow for interventions to be made and coordinated with the patient’s physicians. They point to the continuing development of the health information exchange (HIE) infrastructure over the next three to five years as a positive enabler to helping the interoperability barrier. “With a more robust data exchange infrastructure, pharmacists will be able to download a complete medical history when interacting with the patient, update their medical record to reflect the most recent visit, and then in turn send the updated record back to the patient’s traditional primary care provider,” they note.

Numerous case studies are sprinkled throughout the report, helping to illuminate many of its key findings that support expanded opportunities for direct payment for pharmacist services. As these opportunities unfold, so will the requirements for quality measure development and reporting to encourage efficient and optimal delivery of care. This is an area of focus, it seems, at every state or national meeting I attend.

Finally, the report says that pharmacist-provided care would help bridge the gap between the demand for primary care physicians and the supply. The demand for primary care physicians is projected to increase by 14% from 2010 to 2020, but the number of primary care physicians is only projected to increase by 8% during that time. They conclude that avenues for obtaining pharmacist reimbursement for patient care will improve with the new payment and delivery models.

I encourage ComputerTalk readers to download the report and incorporate its findings in their strategic planning processes. It is a very nice addition to the environmental scan landscape. CT

Marsha K. Millonig, R.Ph., M.B.A., is president of Catalyst Enterprises in Eagan, Minn. The firm provides consulting, research, and writing services to the healthcare industry. The author can be reached at mmillonig@