Influence Local Health Insurance Benefit Design

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Influence Local Health Insurance Benefit Design 

Opportunity for Faculty to Influence Local Health Insurance Benefit Design, University of Minnesota School of Pharmacy

In spite of some putative successes in advancing the acceptance of the pharmacists value in managing the use of medicines such as the “Medicare Prescription Drug, Improvement, and Modernization Act of 2003” wherein medication therapy management (MTM) is a covered benefit for Medicare enrollees, the use of pharmacists’ services has still to reach a level that supports a sustainable practice.  The hoped for benefits of the Part D programs was that pharmacists would be compensated to provide services to the Part D members in their practices.  Instead, according to the Centers for Medicare and Medicaid MTM Fact Sheet, only 20% of these Part D plans use community-based pharmacists to provide services.

Among several reasons for this is a principle fact that there remains a lack of understanding what the service really is. The healthcare and economic value of these pharmacist-provided services is not recognized by consumers or the employers and their agents in managed care. This puts us into a “dog chasing its tail” conundrum.  Lack of consumer understanding drives the lack of employer demand of the managed-care organizations, which drives the lack of inclusion in the benefit design, which cause the member to not understand the value, which …

For many years curricula have reflected the profession’s belief that pharmacists should provide patient-centered clinical services. The expectation being that pharmacists trained to provide these services would drive changes in practice.  Many in the profession’s leadership and in academe believed that if pharmacists provided the service the value would be recognized and compensation would soon follow, notwithstanding the economic fact that no other legal business provides the service before the price is agreed upon.

How does a faculty stop the dog from chasing its tail?  Regardless of whether a college of pharmacy is stand-alone or part of a university, there is a health benefit plan. As with most employer-based insurance plans, including university/college plans medication management services are rarely a part of the benefit design.  If a faculty is committed to patient-centered pharmacist services in the curriculum it must be based in the reality that the program’s graduates will be able to use their knowledge and skills in practice.  The college/university health plan is a plan that faculty can readily influence. 

In 2006, the faculty of the Department of Pharmaceutical Care and Health Systems (PCHS) at the Minnesota College of Pharmacy believed that it had sufficient evidence of cost savings and improved outcomes of pharmacist-provided MTM to approach the administration of UPlan, the university’s health plan. The plan agreed to put in place a pilot project for the Duluth campus of 1500 employees in 2007.  Based on the positive results of the pilot the benefit was extended to all 39,000 UPlan members in March 2009.

The many structural differences that exist in plans, notwithstanding, there are opportunities for faculty  to work with their institution’s central administration and human resources to include a medication management benefit in the university/college plan. The UPlan design recognized that any pharmacist graduated after 1996, regardless of practice site, would be qualified to provide services.  Those graduating prior to 1996 would be credentialed by existing programs. 

It can no longer be asserted that there is little documentation of the benefits of these services.  There are now ample articles that document the economic and health-care value of pharmacist provided MTM services. Faculty members Isetts, Schondelmeyer, et al, investigated and published several works on the benefit of pharmacists-provided medication management including a review of the Minnesota state Medicaid MTM benefit [14],[15].  Additional work was done by the Peters Institute at the College in developing documentations and reimbursement systems.

Sufficient evidence exists of both the economic and clinical benefit of pharmacists-provided medication management services to support the inclusion of these services in a plan design. A literature review published in the October 2010 American Journal of Health Systems Pharmacists provides a good overview [16]. There needs to be additional resolve among faculties to aggressively seek to incorporate the skills and knowledge of their graduates into their college/university health plans.

Evidence is sufficient for faculty to present an actionable case to their university/college benefits department and health plan administrators to incorporate an MTM benefit into their health plans.  This benefit should use the services of qualified pharmacists practicing in any location in the university/college plan market.  The medication management benefit should provide for appropriate electronic documentation and billing. It should also serve as a leadership example for the community of the benefit of the expansion of pharmacists’ roles in health-care delivery.

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