Sections of a recent letter entitled Not Crying Wolf This Time

by Douglas Hoey, CEO of NCPA offer information on preparing for pay for services.

Posted Feb. 3, 2015


For decades, pharmacy students and pharmacists have been assured that they will be paid for services. And, for decades that's been mostly like the boy who cried wolf. Despite dozens of studies plus good old common sense indicating that pharmacists save health care dollars and improve quality of life, the closest the vast majority of pharmacists have come to direct payment for non-dispensing services is from MTM in the Medicare Part D program. But there were some big developments this week that are finally going to make all of those past false alarms a reality—whether we like it or not.


The Department of Health and Human Services (HHS) has set a goal of in less than two years tying 30% of traditional fee-for-service Medicare payments to quality or value through alternative payment models such as accountable care organizations (ACOs) or bundled payment arrangements.

What's more, HHS set a goal of tying 50% to these models by 2018!


Basing payments on quality is going to have a dramatic effect on how community pharmacies do business, and it is going to require change that starts now.


CMS recently announced that comprehensive medication reviews (CMRs) will become part of the Part D Plan (PDP) star rating measures. Plans were found to have a dismal 11% completion rate of MTM cases! CMS is saying no more. CMS is demanding that PDPs significantly improve their MTM/CMR work. Starting in 2016, PDPs will be measured on their MTM/CMR completion. The ratings for 2016 will be based on what happened in 2014. That means pharmacies are already being measured on their MTM/CMR performance. PDPs need pharmacies that help them with their MTM/CMR performance or they will find other pharmacies or other methods for the CMRs to get done.


The House and Senate introduced pharmacist provider status legislation this week. (H.R. 592 and S. 314) Last year provider status legislation was introduced in the House, and it got support from 120 cosponsors in fairly short order. However, there was no companion bill introduced in the Senate. Virtually every pharmacy organization has rallied around this legislation. It will be historic when it eventually passes. But once it does, pharmacy will be expected to (gulp) deliver.


So what should you do? Understanding, you have the here and now issues on the front burner, there are two things you can do now that will position you for the fast coming future. First, do your medication therapy management (MTM) cases. In the past, many pharmacies have had so few opportunities that it hasn't made business sense to dedicate resources to working MTM cases. That is changing this year. There should be more MTM opportunities plus the benefit of taking advantage of the MTM/CMR opportunity will make your pharmacy more valuable in the future.


Second, implement an adherence program. Adherence improves your quality scores, helps the patient, and grows your business. If you are not initiating steps now to perform these types of services at a high level, you may very well find your pharmacy locked out of access to these patients in the future by plans that are being held accountable for the quality of their providers—that means you.


The payment for health care is changing. The HHS announcement confirmed that. This time the warning shouts are real.