Pharmacists' role in hospitals might be enhanced under health care reform

New bill creates openings for PharmDs

The key to the new health care reform bill is understanding how it attempts to reform the way health care is delivered, pharmacist experts say.

The 906-page Patient Protection and Affordable Care Act, signed by President Barack Obama in March 2010 will move the nation toward greater health care transition continuity. And this will create more opportunities for pharmacists.

"Throughout the discussion of health care reform, you would hear the president talk about having a coordinated effort in providing care," says Joseph Hill, director of federal legislative affairs for the American Society of Health-System Pharmacists in Bethesda, MD.

"We saw several delivery models in the bill where pharmacists could play a role as a member of a care team in providing medication therapy services," Hill says.

The reform bill recognizes that medication use is an important issue to address, says Kristina E. Lunner, vice president of government affairs for the American Pharmacists Association of Washington, DC.

"The bill recognizes that pharmacist services are a way to address this issue, so, in general, the profession was well recognized in the bill," Lunner says.

The subtitle C provisions section, which discusses Medicare Advantage payments, focuses on medication therapy management services in the treatment of chronic disease. At page H.R. 3590-398, the medication management services section states that a new Patient Safety Research Center will establish a grants program for the purpose implementing medication therapy management (MTM) services provided by licensed pharmacists.

These MTM services will be designed as a collaborative, multidisciplinary approach to treating chronic diseases for targeted individuals, the bill states.

"The bill uses the definition of MTM that pharmacy organizations developed in 2005 when it became part of Medicare Part D," Hill adds. "We were happy to see that was included in the bill."

Patient safety is a big focus of the new bill. There are incentives that will result in hospitals focusing more intently on patient safety and care coordination, potentially with more clinical pharmacists, says Caroline Steinberg, vice president for trends analysis at the American Hospital Association in Washington, DC.

The legislation's emphasis on information technology solutions to quality and safety issues could spur hospitals to more quickly adopt electronic health records, Steinberg notes.

"A lot of the benefits of electronic health records accrue to patients and insurers, but there are some cost advantages to hospitals, including fewer duplicated tests, less cost for transcriptions, and quality improvement," Steinberg explains. "In the private sectors there are provisions that promote administrative simplification between providers, and that, hopefully, will result in lower costs for hospitals."

The new bill also provides funding for medical home model pilot programs, he notes.

"This is an attempt to coordinate care among all caregivers with the primary care provider as the point person," he explains. "We see that as a model in which pharmacists could play a role."

Pharmacists could play an important part in this model because of their skill at medication reconciliation and providing MTM services, he adds.

"One recurring theme throughout the health care bill is how it's a big problem and cost-driver to have people who are discharged in the hospital return within 30 days," Hill says.

The bill looks to reduce preventable hospital readmissions through a focus on transitions of care, Lunner says.

"One of the elements they suggest is that they conduct a comprehensive medication review and management and provide appropriate counseling in self-management support," Lunner adds. "We read that as providing access to medication management services."

It's important to the hospital pharmacy profession that this provision was included.

"We're happy that provision is in there because data show people often are readmitted for medication misuse," Lunner explains. "So it makes a lot of sense to include medication-related services, and we're working to make sure of that."

The next step would be for the government to provide compensation for pharmacist services in this area, she notes.

"This is something the profession will need to continue to advocate for," Lunner says. "We're happy the need for the services is recognized, but, obviously, in order to better ensure pharmacists can play a part in providing those services, you need some kind of compensation for them, and the bill is silent on this."

MTM also makes an appearance in the bill's Centers for Medicare & Medicaid Services (CMS) innovation center provision.

"There's a recognition by members of Congress that a new delivery model probably is worth testing," Lunner says. "And they've established this new center in CMS to test those various new models of care with the goal of reducing overall costs and including quality outcomes."

MTM is one of the models the center may test.

"There's wonderful recognition that there already are data showing there is value, and they want to test it a little bit further to see what's the best way to deliver it," Lunner says. "Similarly, and sort of a star program from our perspective, is a grant program that is a stand-alone medication management therapy grant program that is specific to pharmacists."

This MTM grant program is unrelated to Medicare Part D, and it would allow pharmacists to provide a robust set of services to a broad population of people suffering from chronic disease, Lunner explains.

"It's intended to provide some funding to develop an infrastructure, and so it's an attempt to study and evaluate the best way to deliver MTM," she says. "This is specific to licensed pharmacists and looks at what sort of infrastructure pharmacists need, what the patient population will look like, and what are the best practices for delivering MTM."

There also is funding for hospitals to provide transitional care plans, Hill says.

"We think medication reconciliation should be an essential component of this," he adds. "We've seen things like bundling payments to hospitals to include these plans."

Hospitals will receive financial incentives if they meet certain performance thresholds, including having lower hospital readmissions in a year, he says.

"We want our [ASHP] members to know that in a lot of these care delivery models, the other thing they'll test is looking at different ways to reimburse health care professionals," Hill says.

For example, there are different models for reimbursement. One is a national pilot program on payment bundling. This is for integrated care during an episode of care that includes hospitalization.

Another model is the accountable care organization (ACO), which is set up as a coordinated care approach where providers coordinate services, Hill says.

The bill refers to shared savings programs in which groups of providers and suppliers manage and coordinate care for Medicare fee-for-service beneficiaries through ACOs.

"Any savings would be shared among members of the group," he explains. "We'll have to look at these and see how pharmacists could be paid for their clinical services under these models and look to make it meaningful as a care model."

The bill's focus on these different payment models suggests that a goal is to move more health providers into an integrated delivery system with the goal of finding the highest quality and more cost-effective care, says Jason A. Scull, program officer for clinical affairs at the Infectious Diseases Society of America in Arlington, VA.

Overall, the health care reform bill would appear to be a positive force for hospital pharmacists, Hill says.

"We were very pleased to see we were mentioned in some of these sections, and we think a corner has been turned in recognition that medication use is a problem, and pharmacists can be part of that solution," Hill says.

The chief concern involves the continued lack of funding for second-year pharmacy residency programs, he adds.

"That's something we think is a great value to patient care," Hill says. "But that, unfortunately, wasn't included in the bill, and so we'll still work on that."