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Payment Policy 

Increasing healthcare quality: the need for alignment in both workforce and payment strategies

ISSUE: While the evidence is clear that integration of comprehensive pharmacist services into team-based care improves patient outcomes, public policy frequently fails to align workforce and payment strategies to increase and sustain this integration.

RECOMMENDATION: Strategies created to move our health system from volume-based to value-based, whether developed at the federal, state or local level, must support the integration of pharmacists into care teams for the delivery of services that improve health, improve healthcare and constrain costs.

CURRENT LAW: 42 USC 1395x et seq. PL 111-148 including Sections 2703, 2704, 3022, 3023, 3024. 4103, 4107, 5403.

BACKGROUND: National, state and local efforts to improve health outcomes and reduce costs are maximized when health care workforce and payment strategies support the implementation and sustainability of integrated care delivery approaches that are patient-centered, team-based and supported by informatics [1]. Policy and legislation have increased patient access to services that are provided by an accessible, competent and trusted health professional, the pharmacist. These policy and legislative developments are components of programs implemented by the Health Resources and Services Administration (HRSA) [2,3], Centers for Disease Control and Prevention (CDC) [4,5], the Centers for Medicare and Medicaid Services (CMS) [6,7]. The benefit to some of our nation’s most medically underserved individual patients and populations benefit from the integration of pharmacists serving in the United States Public Health Service [8]. States, including Connecticut, Iowa and Minnesota have also addressed the need to improve healthcare quality and constrain costs through programs authorizing pharmacists to provide, and be paid for, the delivery of services to Medicaid patients and state employees [9,10,11].

Medications rank as the number one intervention in healthcare[12]. Medication therapy problems occur regularly and cost the U.S. healthcare system nearly $300 billion annually [13]. Recently pharmacists within the US Public Health Service issued the report, “Improving Patient and Health System Outcomes Through Advanced Pharmacy Practice,” that supports health care reform initiatives that integrate pharmacists. The report, submitted to the U.S. Surgeon General, outlines  barriers, including the exclusion of pharmacists as Medicare providers, to increasing patient access to services that can improve outcomes and reduce overall healthcare costs [14]. 

As many as 30 million newly insured individuals will gain access to medical care, with implementation of the Patient Protection and Affordable Care Act of 2010 (ACA). This increased access will place an even greater demand on the current primary care workforce. An additional 17,722 primary care practitioners are currently needed in certain areas across the country and another 35,000-44,000 adult primary care practitioners may be needed by 2025 [15,16].

Approximately 37% of a primary care physician’s time is spent on activities related to chronic care management, which often includes managing complex medication regimens [17]. The integrated care delivery models in development, some supported by provisions in the ACA others as independent collaborations among providers and private payers, promote improvements in individual and population health through patient-centered, team-based care [18,19,20,21,22].

The ACA’s focus on preventative care services will only add to the above concern about provider capacity to meet current demand. Meeting the increased demand for wellness and health promotion care is possible by building upon the success of pharmacists as productive collaborators with patients and other members of the care team [23,24,25].

AACP supports efforts to align health professions workforce and payment strategies so that innovative national, state and local efforts to improve the quality of healthcare and reduce healthcare costs are not impeded. These efforts should include defining pharmacists and pharmacists services in the Medicare provisions of the Social Security Act.

For additional information contact:

William Lang, MPH
Vice President, Policy and Advocacy
American Association of Colleges of Pharmacy
wlang@aacp.org
703-739-2330 x1038

REFERENCES:
[1] National Research Council. Health Professions Education: A Bridge to Quality. Washington, DC: The National Academies Press, 2003.
[2] Patient Safety and Clinical Pharmacy Collaborative, Health Resources and Services Administration.
[3] National Health Service Corps, State Loan Repayment Program.
[4] Centers for Disease Control and Prevention, Million Hearts Initiative, Team Up Pressure Down.
[5] Centers for Disease Control and Prevention, Guide to Community Preventive Services. Cardiovascular disease prevention and control: team-based care to improve blood pressure control. 2012.
[6] Center for Medicare and Medicaid Services, Medication Therapy Management for Part D plans.
[7] Center for Medicare and Medicaid Innovation.
[8] Indian Health Service, Designation of Pharmacists as Primary Care Providers with Prescriptive Authority. 
[9] Smith M, Giuliano MR, Starkowski MP. In Connecticut: Improving Patient Medication Management in Primary Care. Health Affairs 30, no 4 (2011): 646-654.
[10] Iowa Medicaid Enterprise, Iowa Medicaid Pharmaceutical Care Management, available at
http://www.ime.state.ia.us/Providers/PharmaceuticalCare.html
[11] Minnesota General Statutes, 256B.0625 13h Medication therapy management, available at
https://www.revisor.mn.gov/statutes/?id=256B.0625.
[12] 16 IMS Institute for Healthcare Informatics, The Use of Medicines in the United States: Review of 2011.

[13] NEHI, Thinking Outside the Pillbox: A System-wide Approach to Improving Patient Medication Adherence for Chronic Disease.
[14] Giberson S, Yoder S, Lee MP. Improving Patient and Health System Outcomes through Advanced Pharmacy Practice.  A report to the U.S. Surgeon General. Office of the Chief Pharmacist. U.S. Public Health Service. December 2011.
[15]US Health Resources and Services Administration, US Department of Health and Human Services. The physician workforce: projections and research into current issues affecting supply and demand, Washington, DC (December 2008).
[16] American Association of Medical Colleges, Quick Facts.

[17] When the doctor is not needed.  The New York Times (December 15, 2012).
[18] Smith M.  Pharmacists and the Primary Care Workforce.  Annals of Pharmacotherapy, 46(11):1568-71 (November 2012).

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