Reimbursement for pharmacist-provided health care services: A multistate review

Objective(s)To better understand individual state approaches to reimbursement for pharmacist-provided health care services, we sought to (1) review existing statutes and regulations on pharmacist reimbursement from select states (Alaska, California, Idaho, New Mexico, Oregon, and Washington) and (2) suggest approaches to changing state statutes and regulations to allow for reimbursement.MethodsWe reviewed approaches taken by 4 states that currently allow for direct reimbursement of pharmacist-provided health services and 2 states that are in process. Washington requires commercial health plans to credential and privilege pharmacists as health care providers deeming reimbursement and coverage disparities among providers as compensation discrimination.ResultsOregon does not require insurers to provide payment but requires pharmacists to contract and credential with each individual insurer, without the mandate for payment. In California, pharmacists receive 85% of the established fee schedule that physicians receive for equivalent services, and payment is issued to the pharmacy, not the individual pharmacist. California and New Mexico both only allow specified pharmacies or pharmacists to bill (advanced credentials or a tiered licensing model).In Alaska, scope and payor regulations align to allow compensation for covered services; however, insurance credentialing portals are not configured to enroll pharmacists as billing providers. In May 2020, pharmacists were added as nonphysician ordering, referring, and prescribing providers in the Idaho Medicaid basic plan regulations, and licensed pharmacists with national provider identification numbers were auto-enrolled.ConclusionThe states we reviewed took different approaches on the basis of their established statutes and regulations (pharmacy, public and private insurance), resulting in variability in compensated services and reimbursement. An intentional alignment of statutes, regulations, and scope of practice is required to support reimbursement and sustainability of services.     

Interventions to reduce medication errors in adult intensive care: a systematic review

Critically ill patients need life saving treatments and are often exposed to medications requiring careful titration. The aim of this paper was to review systematically the research literature on the efficacy of interventions in reducing medication errors in intensive care. A search was conducted of PubMed, CINAHL EMBASE, Journals@Ovid, International Pharmaceutical Abstract Series via Ovid, ScienceDirect, Scopus, Web of Science, PsycInfo and The Cochrane Collaboration from inception to October 2011. Research studies involving delivery of an intervention in intensive care for adult patients with the aim of reducing medication errors were examined. Eight types of interventions were identified: computerized physician order entry (CPOE), changes in work schedules (CWS), intravenous systems (IS), modes of education (ME), medication reconciliation (MR), pharmacist involvement (PI), protocols and guidelines (PG) and support systems for clinical decision making (SSCD). Sixteen out of the 24 studies showed reduced medication error rates. Four intervention types demonstrated reduced medication errors post-intervention: CWS, ME, MR and PG. It is not possible to promote any interventions as positive models for reducing medication errors. Insufficient research was undertaken with any particular type of intervention, and there were concerns regarding the level of evidence and quality of research. Most studies involved single arm, before and after designs without a comparative control group. Future researchers should address gaps identified in single faceted interventions and gather data on multi-faceted interventions using high quality research designs. The findings demonstrate implications for policy makers and clinicians in adopting resource intensive processes and technologies, which offer little evidence to support their efficacy.     

Physician perceptions of pharmacist-provided medication therapy management: Qualitative analysis

ObjectiveTo identify physician perceptions of community pharmacist-provided medication therapy management (MTM).MethodsThree focus groups consisting of family and internal medicine physicians were conducted in Pittsburgh, York, and Philadelphia, PA, using a semistructured topic guide to facilitate discussions. Each participant completed an exit survey at session conclusion.Results23 physicians participated in one of three focus groups conducted in Pittsburgh (n = 9), York (n = 6), and Philadelphia (n = 8). Participants identified common medication issues in their practices: nonadherence, adverse effects, drug interactions, medication costs, and incomplete patient understanding of the medication regimen. Receipt of a complete patient medication list was reported as the greatest potential benefit of MTM. Participants believed that physicians would be better suited as MTM providers than pharmacists. Concerns identified were the mechanism of pharmacist payment, reimbursement of time spent by physicians to coordinate care, and the training/preparation of the pharmacist. The need for a trusting relationship between a patient's primary care physician and the pharmacists providing MTM was identified.ConclusionThis study provides information to assist pharmacists when approaching physicians to propose collaboration through MTM. Pharmacists should tell physicians that they will receive an updated patient medication list after each visit and emphasize that direct communication is essential to coordinate care.     

Comprehensive medication review: development of a collaborative procedure

This commentary describes the development and evidence-base of the Comprehensive Medication Review (CMR) procedure for community and hospital settings in Finland. The development was coordinated by a national steering group. The group collaborated with 26 experienced pharmacists who developed and tested CMR procedures during a 1.5 year accreditation training for CMR. The development consisted of: (1) a literature review and inventory of medication review procedures in different countries; (2) the creation of potential procedures and related documentation; (3) integration of potential procedures into a national standard procedure; and (4) piloting the standard procedure in practice settings. The resulting comprehensive medication review procedure requires access to a patient's clinical information, an in-home patient interview and a case conference with the collaborating physician. This procedure covers the four main dimensions critical for safe and appropriate geriatric pharmacotherapy: aging and safety; co-morbidities; polypharmacy; and adherence. The CMR measures and documentation build on these dimensions.     

Generating demand for pharmacist-provided medication therapy management: Identifying patient-preferred marketing strategies

ObjectiveTo identify effective strategies for marketing pharmacist-provided medication therapy management (MTM) services to patients in a self-insured employer setting.DesignQualitative study.SettingUniversity of Pittsburgh during March through May 2008.Participants26 university employees taking at least one chronic medication.InterventionThree focus group sessions were conducted using a semistructured topic guide to facilitate the discussion.Main outcome measuresEmployees’ perceived medication-related needs, perceived benefits of pharmacist-provided MTM, potential barriers for employee participation in MTM, and effective strategies for marketing MTM.ResultsParticipants reported concerns with timing of doses, medication costs, access, and ensuring adherence. Participants generally felt positively toward pharmacists; however, the level of reported patient contact with pharmacists varied among participants. Some participants questioned pharmacists’ education and qualifications for this enhanced role in patient care. Perceived benefits of MTM noted by participants included the opportunity to obtain personalized information about their medications and the potential for improved communication among their health providers. Barriers to patient participation were out-of-pocket costs and lack of time for MTM visits. Participants suggested use of alternative words to describe MTM and marketing approaches that involve personal contact.ConclusionPharmacists should emphasize parts of MTM that patients feel are most beneficial (i.e., provision of a personal medication record) and use patient-friendly language to describe MTM when marketing their practice. Patients will need greater exposure to the concept of MTM and the pharmacists’ role in order to correctly describe and assign value to this type of pharmacist patient care practice.     

Evaluation of pharmacist-provided medication therapy management services in an oncology ambulatory setting

ObjectivesTo determine the effect of formal medication therapy management (MTM) services on pharmacist workload, as well as to describe the population receiving MTM, describe the services provided, and determine the reimbursement rate for billed MTM services.Data sourcesMTM Current Procedural Terminology (CPT) code claims, electronic medical records, and pharmacist MTM logs.Data synthesisA retrospective review of all MTM charges from January 1, 2010, to March 31, 2010, was performed. Data collected included location of the MTM visit, age, gender, insurance, primary malignancy, comorbidities, home medications, time to complete and document the MTM visit, and rate of reimbursement.ResultsIn the 3-month period, 239 MTM visits were completed. It took pharmacists a median of 20 minutes (range 15–127) of face-to-face time and 18 minutes (5–90) for documentation per visit. To date, no claims for MTM have been rejected, and reimbursement rates range from 47% to 79% depending on the insurance provider.ConclusionsMTM in the ambulatory clinic is feasible despite the increase in pharmacist workload from documenting and billing. The increased visibility of clinical pharmacy services justifies the extra time required for formal MTM.     

Outcomes of medication therapy review in a family medicine clinic

ObjectiveTo evaluate the effects of pharmacist-conducted medication therapy review (MTR) and intervention on the quality of care of patients in a family medicine clinic.DesignProspective, observational, cohort study.SettingFamily medicine clinic in Minnesota during 2000–2001.PatientsPatients were enrolled in a statewide nonprofit managed care organization; selected patients were seen by a clinical pharmacist.InterventionFollowing MTR, medication-related problems (MRPs) were identified and resolved.Main outcome measuresMRPs identified and resolved, improvement in clinical status, achievement of therapeutic goals, important medication use, and reduction in number of medications.Results92 patients were included in the study, with a total of 203 patient encounters. MRPs were identified in 90% of patients, with a total of 250 identified. Overall status of medical conditions improved in 45% of patients, 46% stayed the same, and 9% declined (P < 0.001). Significant improvement in status was found for hypertension (P = 0.007), dyslipidemia (P = 0.002), and asthma (P = 0.011). Significant improvement was seen for aspirin use for myocardial infarction prevention (50% vs. 93%, P = 0.031) and inhaled steroids for asthma (36% vs. 64%, P = 0.031). The number of medications was reduced from an average of 3.92 to 3.04 (P < 0.001) per patient.ConclusionMTR and intervention by a pharmacist positively affected quality of care in this family medicine clinic.     

Identification of essential elements in the documentation of pharmacist-provided care

ODJECTIVES: To develop guidelines for the documentation elements that need to be included in any record of pharmacist-provided care to allow the quality of the care to be assessed and to describe the use of these guidelines to improve the quality of pharmacist documentation. DESIGN: An initial list of 85 potential documentation elements, developed through a review of the literature, was validated by a group of pharmacy practitioners. Then, through three rounds of a Delphi process and a group meeting, a panel of experts reached consensus on a refined list of 27 documentation data elements. RESULTS: The documentation elements were formatted into a one-page Tool for Evaluation of Documentation (TED). The TED is a checklist for assessing the completeness of the documentation of pharmacist-provided care. CONCLUSION: The TED and the consensus-building methodology used in the development of this tool can serve as cornerstones of a quality assessment process for documentation of pharmacist-provided care, enable further assessment of the quality of care, and, ultimately, be used to measure the impact of pharmacist-provided care on patient outcomes. Our results should provide guidance both to pharmacists providing care and to organizations that assess the quality of that care.     

Pharmacist-led collaborative medication management programs for oral antineoplastic therapies: A systematic literature review

ObjectivesThe aim of this systematic review is to summarize the structure, process, and outcomes of pharmacist-led collaborative medication management programs for oral antineoplastic therapies (OATs).MethodsIncluded studies were peer-reviewed journal articles published in English, between January 2000 to May 2020, and reporting on pharmacist-led collaborative medication management programs for patients on OATs. To be included, studies had to report on the pharmacy practice model, pharmacist interventions, and outcomes of the medication management program. The Donabedian model informed the data extraction and summary. Two independent researchers assessed the risk of bias (confounding) for all included studies (n = 12) using the NIH tool and Cochrane ROBINS-I for observational research.ResultsThere were 12 studies that met inclusion criteria. The structure of the programs included hiring oncology pharmacists to deliver interventions, standardized templates for electronic medical record documentation, and administrative workflow changes (e.g., automatic referrals). The most common pharmacist interventions (processes) were patient education and counseling, adverse event monitoring, and dose modifications. All studies reported one or more positive outcomes, including improved patient adherence, safety, cost savings, cost avoidance, and patient satisfaction. All included studies used an observational study designs, and the majority of studies had moderate to high risk of bias.ConclusionThe evidence suggests that pharmacist-led collaborative medication management programs may have beneficial clinical and economic outcomes. The implementation of these programs could be strengthened by using a conceptual framework to guide program development, implementation, and evaluation and effectiveness-hybrid study designs to assess clinical and implementation outcomes. The risk of bias should be addressed by using more robust study designs and rigorous data collection and analysis methods.     

High-risk medication in community care: a scoping review

To review the international literature related to high-risk medication (HRM) in community care, in order to (1) define a definition of HRM and (2) list the medication that is considered HRM in community care. Scoping review: Five databases were systematically searched (MEDLINE, Scopus, CINAHL, Web Of Science, and Cochrane) and extended with a hand search of cited references. Two researchers reviewed the papers independently. All extracted definitions and lists of HRM were subjected to a self-developed quality appraisal. Data were extracted, analysed and summarised in tables. Critical attributes were extracted in order to analyse the definitions. Of the 109 papers retrieved, 36 met the inclusion criteria and were included in this review. Definitions for HRM in community care were used inconsistently among the papers, and various recurrent attributes of the concept HRM were used. Taking the recurrent attributes and the quality score of the definitions into account, the following definition could be derived: “High-risk medication are medications with an increased risk of significant harm to the patient. The consequences of this harm can be more serious than those with other medications”. A total of 66 specific medications or categories were extracted from the papers. Opioids, insulin, warfarin, heparin, hypnotics and sedatives, chemotherapeutic agents (excluding hormonal agents), methotrexate and hypoglycaemic agents were the most common reported HRM in community care. The existing literature pertaining to HRM in community care was examined. The definitions and medicines reported as HRM in the literature are used inconsistently. We suggested a definition for more consistent use in future research and policy. Future research is needed to determine more precisely which definitions should be considered for HRM in community care.     

积极有效护理在血液透析患者中心静脉置管中的应用效果

目的：探讨积极有效护理在血液透析患者中心静脉置管中的应用效果。方法随机选取2011年1月~2013年1月在本院接受血液透析中心静脉置管的60例患者作为实验组,给予中心静脉置管护理、置管后处理等有效护理,同时随机选取2008年1月~2009年12月在本院行血液透析中心静脉置管的60例患者作为对照组,给予常规护理措施。比较两组的感染发生率。结果实验组的感染发生率为5.0%,显著低于对照组的26.7%,差异有统计学意义(P<0.05)。结论采取有效的护理措施能够控制血液透析患者中心静脉导管感染发生率。     

Multidisciplinary medication review: evaluation of a pharmaceutical care model for nursing homes

Objective The objective of this study was to assess implementation of a pharmaceutical care model for the multidisciplinary care of elderly patients in nursing homes. Setting Prospective study, medication review, from January 2007 to December 2009 in ten nursing homes affiliated to the Pharmacie interjurassienne (PIJ), Switzerland. Method Medication use data were collected and reviewed by a pharmacist, focusing on drug indication, dosing, side effects, renal/hepatic elimination and interactions. Drug-related problems (DRPs) were discussed face-to-face with the responsible physician and a nurse. The pharmaceutical care issues were formulated and medication interventions proposed during this meeting. DRPs and interventions were documented using the Pharmaceutical Care Network Europe scheme version 5.00 (PCNE V5.00). The economic impact of the service was estimated through a retrospective evaluation of annual drug costs. A satisfaction evaluation was conducted among practitioners and nurses. Main outcome measures DRPs, interventions, treatment changes implemented. Results Drug therapy of 329 patients was reviewed. The number of medicines per patient ranged from 2 to 27 (mean 12.8). A total of 1,225 DRPs were detected and discussed with the physician and the nurse. Medication review led to 343 medical evaluations secondary to drug-drug interactions and 803 treatment adaptations: 373 drugs were stopped, 197 dosages changed, 95 instructions for use amended, 86 drug choices were altered, 35 drug formulations changed and 17 new drugs started. According to the Anatomical Classification System, the main classes involved in interventions were related to Alimentary tract and metabolism (n = 285), Nervous system (n = 189) and Cardiovascular system (n = 115). Since the outset of the PIJ, the annual drug costs decreased in nursing homes with medication review including a pharmacist, whereas it was stable in the other nursing homes. The satisfaction evaluation showed a very positive appreciation by practitioners and nurses. Conclusion The study showed an efficient pharmaceutical care model, well accepted by physicians and nurses. It also indicated that for elderly patients, continuous drug review contributed to improved drug therapy, reduced unnecessary polypharmacy and reduced pharmaceutical costs.     

经腹腔镜胆囊切除术患者预防应激性溃疡的用药分析

目的:对腹腔镜下胆囊切除术患者预防应激性溃疡的用药情况进行合理性分析,促进临床合理用药。方法:利用某院合理用药监管系统,采用回顾性调查方法,收集某院2012-2013年行腹腔镜下胆囊切除术的患者病历,对预防应激性溃疡的药物应用情况进行统计、分析。结果:2012-2013年行腹腔镜下胆囊切除术的患者共1 935例,最终纳入研究的1 600例患者中,有682例(42.63%)应用抑酸药进行应激性溃疡预防,其中质子泵抑制剂(PPIs)的使用率高达99.27%;466例(68.33%)患者为无指征预防性应用抑酸药;所有预防用药患者均采用静脉注射给药,其中有1例患者同时使用了PPIs和H₂受体拮抗剂(H₂RAs)。结论:该院应激性溃疡预防用抑酸药PPIs存在过度使用及药物品种、剂型选择不规范等现象。建议临床使用抑酸药PPIs预防应激性溃疡时应严格掌握用药指征,规范用药行为,促进临床合理用药。     

临床药师开展药物重整的药学服务实践

目的:为临床药师开展药物重整的药学实践提供参考。方法:探讨临床药师在实践工作中如何通过掌握用药史,及引入诺氏评估量表进行不良反应分析为切入点实现药物重整的药学服务实践。结果和结论:临床药师在药物重整工作中扮演着重要的角色。在临床实践中,临床药师获取精确的用药清单,加强专业知识地学习,借助一些适当的工具,才能实现药物重整。