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Creating an Anticoagulation Service in a Community Pharmacy

From left, Michah Hata, Pharm.D., and Roger S. Klotz, R.Ph., BCNSP, FASCP, FACA, FCPhA

THE MEDICAL LITERATURE is filled with examples of how anticoagulation services managed by pharmacists help reduce the number of anticoagulation-related emergency room visits and hospitalizations. This, in turn, results in significant cost savings¹.

Typically, these types of clinics only occur within health systems or medical group practices. But as pharmacy faculty members, I and my colleague, Micah Hata, wondered if this collaborative practice model could be implemented in a community pharmacy.

Overcoming Challenges

So, we worked with a community pharmacist owner in Arcadia, Calif., to add patient care services to his pharmacy. The pharmacy has a private area that can be used as a treatment room to provide patient confidentiality.

We faced a number of major challenges with this project, including:

• Physicians’ resistance to a community pharmacist managing their patients’ warfarin therapy,

• Patient concern about the pharmacists’ capability to manage a therapy that posed significant risk, and

• Payers’ lack of familiarity with community pharmacists’ billing under the major medical plans for services as well as pharmacist-managed medication therapy.

The first task in implementing such a service was to find a licensed physician to medically approve our warfarin management protocol. The second step was to obtain an FDA “Clinical Laboratory Improvement Amendments Waived” testing laboratory certificate so that the pharmacy could officially be recognized as a licensed laboratory. Both tasks were completed by the end of June 2009.

We then faxed a letter along with our physician referral form to the offices of four doctors in our community. The letter detailed the services we would be providing. Within two weeks, the four physicians began to refer patients to our clinic.

Two years later, we have 25 physicians who regularly refer their patients to us. The interesting thing is that we have never marketed to any physicians other than the original four. Therefore, the network of referring physicians has been developed by word-of-mouth among physicians and patients.

A Success Story

Patients have easily accepted pharmacists as providers of direct patient care services, including anticoagulation services. In fact, they have all commented on how much they prefer the pharmacy-based services. We currently have 71 active patients who utilize our services, many of whom have been with us since our debut.

Success in obtaining reimbursement from the patient’s insurance company has been the major challenge. Pharmacists were not listed as approved providers in the original Medicare Act. As a result, we cannot bill Medicare via Palmetto, Medicare’s intermediary claims processor. On the other hand, if the patient has a PPO as either a primary or secondary payer to Medicare, then we can bill the private payer.

One major payer in California initially refused to accept our claims because it had never seen pharmacists bill the major medical plan. Over time, we worked with this payer and responded to every question. We circumvented its refusal to acknowledge pharmacists as providers by starting a group practice, which the payer was willing to accept as a provider in its network.

We were finally informed that we are now listed as a provider in the payer’s network and now receive reimbursement. There are a number of other payers we are billing and from whom we receive reimbursement. Medicare Part B continues to be a problem, and we plan to inform our patients that reimbursement from Medicare is not available.

The best outcome of this new venture is that none of our patients have had problems with adverse events that necessitated a trip to the ER or admission to the hospital as a result of their anticoagulation therapy. In fact, we are now also receiving referrals for the collaborative management of diabetes Type II patients as part of our medication therapy management approach.

It’s clear from our experience that pharmacist-managed direct patient care services can be implemented in a community pharmacy.

By Roger S. Klotz, R.Ph., BCNSP, FASCP, FACA, FCPhA,  and Micah Hata, Pharm.D. Both authors are assistant professors at Western University of Health Sciences, Pomona, Cal.

1 Comparison of “Two Different Models of Anticoagulation Management Services with Usual Medical Care,” Rudd, KM, Dier,  JG; Pharmacotherapy, April 2010; 30(4): 330–338.