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Pharmacy is a diverse profession. We have practitioners in many different environments, each seemingly a world unto itself. Pharmacists practicing in hospitals, community pharmacies, mail-order outlets, long-term care facilities, and managed care organizations (including HMOs and PBMs) often exhibit a "silo" mentality, not always considering the impact of their activities on the systems in which they practice or that are affected by their practice. For pharmacy to increase its value to the health care system, it must integrate into that system. We as pharmacists must have the energy to invest in infrastructure, training and education, legislative initiatives, and aligned incentives. Budgetary constraints will continue to provide downward pressure on reimbursement levels for traditional dispensing practice. Only those functions that add value will provide the opportunity for pharmacists to gain professional satisfaction and adequate remuneration for services rendered. Pharmacy will either find itself in a position of integrating and adding value, or will lose ground as a fundamental part of the health care system. Pharmacy is far ahead of the rest of the health care system in having a solid infrastructure for claims adjudication. However, there are significant deficiencies in the documentation of important clinical activities that have a huge potential for adding value to the system. The clinical and economic impact of pharmacist interventions, including therapeutic interchange, patient counseling, and disease management, are not well studied nor well described in the literature, are infrequently included in patients’ medical records, and are poorly documented in the claims adjudication process. In addition, they are not well marketed to the medical community, the health care system, or the public. Since the individual pharmacist is not identified in point-of-sale adjudication systems, the managed care organizations have no in-centive to pay for and monitor the quality of cognitive services. Pharmacists may need to be credentialed for providing services that add value to the system but that also require focused education and training. Pharmacy education provided by schools of pharmacy and other entities must recognize the potential value that pharmacists can (and do) add to the health care system. Studies that measure the value of pharmacist interventions in economic and quality improvement terms should be conducted. There are numerous anecdotal examples of pharmacists practicing in varied settings who have made a difference by improving the quality or reducing the cost of care. These cases need to be studied, and those examples that truly add value should be emulated by other pharmacists, incorporated into the health care system, and taught in various curricula. Integrating pharmacy services that add value to the health care system must be a high priority for the pharmacy community. All states must enact legislation that allows collaborative drug therapy management (CDTM) by pharmacists. Man-aged care organizations, hospitals, long-term care facilities, physician groups, and professional organizations, as well as the pharmacy community, must recognize the potential value that CDTM can bring to the system. Incorporating protocols that pharmacists and physicians have designed and implemented in a collaborative environment will improve the quality of care and reduce unnecessary costs. There is tremendous potential for CDTM in a managed care environment. Through CDTM, managed care organizations and their community pharmacy providers may find themselves in a true partnership, rather than the traditional adversarial relationship. The structure of economic incentives is important in aligning partnering organizations toward the same goals. Fee-for-service reimbursement includes incentives that tend to reward overutilization, while capitation incentives tend to promote underutilization. Pharmacy payment mechanisms must be developed that provide incentives for high-quality and cost-effective outcomes. The cost of drugs continues to outpace medical care inflation. Are they worth the money? To find out, the value of pharmaceuticals in improving outcomes and reducing overall health care costs must be determined through scientific study. Otherwise, actuarial analyses always will propose that increasing barriers to receiving care will reduce the cost of care. The design of economic incentives in pharmacy based on the promotion of high-quality and cost-effective outcomes must be linked to those findings to be truly accepted by the health care system. The future of pharmacy as an integrated component of the health care system is bright, especially within managed care. To realize the full potential, we must develop the infrastructure; promulgate legislation, rules, and regulations to enable CDTM; educate pharmacists, other health care professionals, and administrators regarding the potential benefits; and align economic incentives toward high-quality, cost-effective outcomes. Bruce B. Fallik, R.Ph., M.S.
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