Reimbursing pharmacists for the provision of pharmaceutical care services or disease state management programs is not a recent development. In fact, programs have existed since the 1970s. However, with the recent approval of an amendment to the Mississippi Medicaid waiver by the Health Care Financing Administration (HCFA), issues related to reimbursement structure and format have resurfaced. Mississippi will become the first state to reimburse pharmaceutical care services under Medicaid. Pharmacists willing to provide such services will have attained a Pharm.D. or will have completed a disease-specific certification program overseen by the Mississippi Board of Pharmacy.

Credentialed pharmacists will receive reimbursement for protocol-based asthma, diabetes, hyperlipidemia, and anticoagulation therapy programs. The pharmacist will be required to maintain a patient-specific record including physician referrals, treatment protocols, pharmacy progress notes, and laboratory data. But where is the focus on outcomes assessment?

This is an incredible opportunity for the pharmacy profession to participate in a state-sanctioned, patient-centered program integrating the pharmacist into the health care team with shared responsibility for disease state management and therapeutic outcomes. William L. "Buck" Stevens, executive director of the Mississippi Board of Pharmacy, believes that the Mississippi "…DSM credentialing program could be a prototype for the nation’s pharmacists." What can we learn from preexisting programs?

Prior approaches to reimbursement have predominantly been institution-based agreements with specific third-party payors. Providers of identified services have usually been preapproved. Early reports of such programs include a group of papers published in the late 1970s out of the Ohio State University Hospitals. The articles discuss reimbursement from Blue Cross of Central Ohio to pharmacists who provided patient education to home care-based patients for the self-administration of medications such as antihemophilic factor and cytarabine. One year, estimated cost savings related to avoided hospitalizations provided evidence that benefits to the health care system outweighed the cost of providing the education.

A program developed by Creighton University in 1993 incorporated the use of current procedural terminology (CPT) codes to obtain reimbursement for pharmacy services in an ambulatory oncology clinic in Nebraska. In this clinic, pharmacists bill using a physician billing code and identified CPT codes (for patient visit, team conference, and phone call). After this system was in place for one month, pharmacists had achieved an 80% reimbursement rate for claims submitted to third-party payors.

Currently, South Carolina pharmacists with Health Management Consultants are working with registered dietitians to provide diabetes management education for Medicaid patients. Reimbursement approval is anticipated sometime in 1998.

These programs have generated interesting, yet limited, outcomes information and did not involve credentialing of pharmacists to provide services and outcomes assessment, such as improvements in disease-specific parameters or indicators of overall patient health.

Credentialing is a step in the right direction. It will ensure quality of service and provide pharmacists with the training necessary to improve their disease management skills as well as enhance outcomes documentation. Such documentation is essential to the proliferation of these programs. Therefore, a comprehensive program must include outcomes-based training from which consistent and valuable information can be generated. Otherwise, we again will have a sound program with little to share. Credentialing is only as good as the training that is being credentialed.

The level of excitement surrounding this latest of developments in the area of pharmacy reimbursement is certainly encouraging. However, prudent and effective development of credentialing programs is paramount. Programs without effective outcomes research considerations on the front end make it difficult to achieve consistent and reliable data—data from which the value and impact of provided services are determined and which are used as the basis for continued and expanding services. If it is worth doing, it is worth doing well…then proven.

Paul A. Miner, Pharm.D.
Managed Care Pharmacy Resident
WHP Health Initiatives, Inc.
Deerfield, IL

Jennifer White, Pharm.D.
Primary Care Pharmacy Resident
University of Illinois at Chicago
Chicago, IL