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Health Care Reform and the Health-System Pharmacist: A Primer

IMPROVED THERAPEUTIC OUTCOMES… reduced medication errors and adverse drug events… enhanced coordination of care… lowered health care costs… decreased rates of hospital re-admissions…

Portions of the new health care legislation being debated in Congress read like a pharmacists’ wish list of sorts. And, as details of the plans under consideration begin to come out, there appears to be real synergy between what Congress is considering and the ways in which pharmacists can improve patient care.

The bills recently passed by the House of Representatives and the Senate both offer “a great opportunity to demonstrate to patients and providers such as doctors, nurses, and dentists the value of pharmacists as a critical medical resource,” said Joseph M. Hill, director of ASHP federal legislative affairs.

“Although there are a lot of ‘moving parts’ in the bills, we’re excited to see that they generally address the issues of work force, quality, and access that directly concern ASHP and our members,” Hill added.

So, how might the different concepts being considered in Congress affect the lives of frontline pharmacists and pharmacy managers alike? And are there unexpected consequences to the legislation?

Improving Quality, Decreasing Costs

“The whole national health care debate has revolved around access and affordability, but we can’t take action on those without improving quality and decreasing costs at the same time,” said former ASHP President Kevin Colgan, M.A., FASHP, corporate director of pharmacy at Rush University Medical Center in Chicago. “So that means we should ask for what pharmacists need to help meet those goals.”

ASHP has done just that, tailoring its top advocacy agenda items to support the goals of improved quality and decreased costs. In written testimony, in visits to Capitol Hill and the White House, in collaboration with other stakeholders, and in assisting members in their own direct advocacy, ASHP has kept a steady drumbeat of pressure around the issues of provider status for pharmacists, support for PGY2 pharmacy residency funding, and a new federal loan-forgiveness program for pharmacy graduates.

Reimbursement for Pharmacists’ Services

As pharmacists increase their patient-care activities, the need for compensation for those services rises, said Thomas Johnson, Pharm.D., M.B.A., BCPS, FASHP, professor of pharmacy practice at South Dakota State University College of Pharmacy and clinical specialist in critical care at Avera McKennan Hospital in Sioux Falls.Achieving recognition for medication management services “would enable pharmacists to get paid for what we know and do rather than just for avoiding costs,” he said.

The bills would implement a new grant program to accomplish just that. Pharmacists in all practice settings and in new care delivery models, including so-called medical homes, could provide medication management services to chronically ill patients. “As this bill opens the door for innovative care delivery models and pilot programs, there should be additional opportunities for pharmacists to ???conduct medication management, which is very exciting,” Hill said.

Reimbursement for pharmacists’ services has long been a contentious issue. ASHP has strongly advocated for years that pharmacists be recognized as health care providers, to enable billing for services. Although some third-party payers have started paying for certain services, pharmacists remain frustrated by the slowness with which payers are embracing this model.

One idea being floated is the implementation of financial incentives such as pay-for-performance measures. These measures, in theory, would make hospitals and other care providers more accountable for ensuring that patients remain healthy.

A pay-for-performance system would demonstrate the value that pharmacists can bring to hospitals as part of a “closed-loop system,” said Roy Guharoy, Pharm.D., FASHP, chief pharmacy officer and professor of medicine at UMass Memorial Health Care, Worchester, Mass.

Hospitals could simultaneously increase the level of care and reduce costs by making pharmacists a more integrated component of a patient’s care.

Gerald Meyer of Pennsylvania was part of a large contingent of ASHP members who fanned out on Capitol Hill last fall.

Guharoy pointed to the example of a patient who had recently been discharged from the hospital and given prescriptions for two blood thinners. The patient failed to pick up the prescriptions at his local pharmacy and was later readmitted to the hospital. In this case, “closing the loop” by having a pharmacist consult the patient at home would have ensured continuity of care and avoided a hospital readmission.

Pharmacists and patients alike would seemingly welcome the extension of care beyond the hospital into a patient’s home. But the notion of extending coverage also brings up the question of how to pay for that coverage, said James G. Stevenson, Pharm.D., FASHP, director of pharmacy services and associate dean for clinical services at the University of Michigan Health System and College of Pharmacy, Ann Arbor.

“I’m concerned that reform will dramatically increase the financial pressure on hospital administrators in particular, which could make it more difficult to find the money to invest in the safety of our pharmacy medication systems,” he said.

Renewing PGY2 Funding

Back in 2004, when the Centers for Medicare & Medicaid Services (CMS) eliminated $10 million in annual funding for pharmacy residents in second-year (PGY2) programs, it inadvertently began a process that has contributed to a shortage of qualified pharmacy specialists across the nation. Although ASHP has pushed to restore the dollars since the funding was first revoked, CMS has been reluctant to do so.

If reform efforts are to boost care quality and improve patient outcomes, more well-trained pharmacists who are capable of providing that high level of care will be needed, according to Guharoy. “Without the training and facilities, this will be difficult,” he said. “We need to continue to educate Congress that the potential return-on- investment of funding this program is critical.”

Federal Student-Loan Forgiveness

Health care reform efforts have high- lighted the need to attract medical staff to underserved rural areas, and legislation just passed in the House would include pharmacists along with doctors, nurses, and dentists in the federal loan forgiveness program that eliminates student loan obligations in return for two years of service.

The House version of health-care reform includes provisions for pharmacist involvement in medication management as part of the new “medical home” model.

“The services these new pharmacists could provide underserved communities would be huge,” Colgan noted, pointing to medication reconciliation, anticoagulation services, cholesterol monitoring, diabetes management and education, and case management of high-risk patients.

What’s important to remember is that pharmacists can play a leading rolein improving quality while reducing the costs of providing exceptional health care services, said Guharoy.

“Medication therapy management will be the cornerstone of the success of any health care reform plan,” he said.

From Grassroots to Grasstops: Getting Involved in the Debate

So, how can you begin to shape the future of health care? Simple: Get involved. The national conversation that is happening around health care reform offers pharmacists a unique chance to play a larger and more integrated patient-care role within their own institutions, according to Joseph M. Hill, director of ASHP’s federal legislative affairs. “It’s important to work proactively on shaping the reform agenda rather than waiting to be impacted by it,” he said. A number of ASHP members have been working on their own grassroots campaigns to educate their representatives in Washington, D.C., about the critical role pharmacists already play in the health care system— and how that role should be expanded.

	JAMES G. STEVENSON, PHARM.D., FASHP, has been in constant touch on the phone and via e-mail with the senators and representatives from his state. He also participated in ASHP’s Legislative Day, meeting with congressional staff members to discuss the inclusion of medication therapy management by pharmacists in any health care reform legislation. While Stevenson said that he doesn’t know what will result from his diligent efforts, “it’s critically important that we keep our representatives and senators up-to-date on the impact pharmacists can have,” he said.
	ROY GUHAROY, PHARM.D., FASHP, met with Rep. James McGovern, (D-Mass.) during ASHP’s Legislative Day and discussed the urgent need for restoration of PGY2 residency funding.
	THOMAS JOHNSON, PHARM.D., M.B.A., BCPS, FASHP, stays in touch with the two senators and one representative from his state. “All three of them understand the points I’m trying to get across,” he said. He, too, has been pushing for the reinstatement of PGY2 funds. “But there’s always the ‘but’ of how do we pay for it,” he said. “That’s where I’m trying to show them we can pay for it by improving patient care.”
	KEVIN COLGAN, M.A., FASHP, has gone one step further by actually getting Rep. Judy Biggert, (R-Ill.), to visit a hospital where all patients receiving anticoagulation medications were managed by pharmacists. “I was able to show the congresswoman the lack of handoff that existed when those patients reentered the community,” he said