PQS Quality Corner Show
Join Pharmacy Quality Solutions Associate Director of Pharmacy Accounts Nick Dorich, PharmD, for a podcast series "Quality Corner Show" that covers everything quality in the world of pharmacy and patient care. Look for future episodes to interview guests and experts in the healthcare profession.
PQS Quality Corner Show
The Value of Including Pharmacists in Primary Care Teams
Marie Smith, PharmD, FNAP, Henry A. Palmer Professor - Pharmacy Practice and Asst. Dean -- Practice and Public Policy Partnerships at UCONN School of Pharmacy, explains the value of including pharmacists into primary care teams for clinical services.
PQS Quality Corner Show Host Nick Dorich asks Smith to talk about her Health Affairs publication from a November 2024, "Building The Primary Care Workforce With Pharmacist Clinical Services." Smith elaborates on why pharmacists are necessary team members for Primary Care Teams, and how their services can help with the rising population demand. Pharmacists can also help decrease workload hours and increase in patient access and care.
Read the full article: Building the Primary Care Workforce with Pharmacist Clinical Services- Health Affairs Nov. 13, 2024
00:00:00:02 - 00:00:37:24
Marie Smith
It's gotten the attention of hospital administrators. You know, clinician leaders, medical directors to say, well, you know, we've been talking about the quadruple aim and the joy of practice. We didn't realize or didn't think about the fact that it's not just having a pharmacist there to work on workflows, but if we appropriately, you know, shift and refer patients who are mostly there for medication management, monitoring those kinds of things that we ship them to the pharmacist who's highly trained to do that, working under collaborative practice, we can open up thousands of appointments, which
00:00:37:24 - 00:00:41:06
Marie Smith
would, help with accessibility for patients.
00:00:43:03 - 00:00:47:01
Voice Over
Welcome to the Pharmacy Quality Solutions Quality Corner Show,
00:00:47:17 - 00:00:52:21
Voice Over
Buckle up and put your thinking cap on. The Quality Corner Show starts now.
00:00:53:09 - 00:01:16:15
Nick Dorich
Hello. Quality corner show listeners, welcome to the PQS podcast, where we focus on medication use, quality improvement and how we can utilize pharmacists to improve patient health outcomes. I'm your host, Nick Dortch. Now for today's episode of the show. I'm really excited to have on a special guest someone that's been involved with community pharmacy practice and someone that's been a great cheerleader for community pharmacy practice, and that is Marie Smith.
00:01:16:15 - 00:01:35:18
Nick Dorich
I'm going to introduce Marie here in just a second and give her a chance to say hello to everyone. But, Doctor Marie Smith is she is the Henry A Palmer Endowed Professor of Community Pharmacy Practice and Assistant Dean for Pharmacy Practice and Public Policy Partnerships at the University of Connecticut School of Pharmacy. So, Marie, welcome to the show.
00:01:35:18 - 00:01:37:08
Nick Dorich
And how are you doing today?
00:01:38:02 - 00:01:50:14
Marie Smith
Hi, Nick. Thanks for having me. Great opportunity to talk about the work that we've done, over the years that has culminated at a number of publications that we're going to talk about today, especially the Health Affairs article.
00:01:50:17 - 00:02:16:15
Nick Dorich
Yeah, absolutely. So, as we get started here for everybody, I'm going to give everybody a quick homework assignment. If you are listening, we're going to be referring to and really talking about an article that was published, November 13th, 2024, in Health Affairs. It's called Building the Primary Care Workforce with Pharmacist Clinical Services. Now, Marie and a couple other authors, were involved in this publication, and I had a great time reading reading it, as did some of my teammates here at PQS.
00:02:16:20 - 00:02:32:16
Nick Dorich
And we thought, hey, what a great opportunity to talk about what pharmacist and pharmacy can do moving forward. Let's have Marie on to talk about this. So, we're going to be doing that today. We're going to be talking about the article. So, I would recommend you either pause the podcast. Now if you're in a position where you can do so, look up that article.
00:02:32:16 - 00:02:49:24
Nick Dorich
We'll have it in the show notes, give it a read through, or make sure you listen to it after you listen to the episode. But, Marie, before we talk about this publication and talk about what you and your colleagues, described, can you tell us a little bit about yourself? What is your background in pharmacy and in health care?
00:02:50:16 - 00:03:39:04
Marie Smith
Yes, sure. Thanks, Nick. Actually, I started in, primary care and ambulatory care as a clinician educator at the University of Tennessee in Memphis. And in that that was this was in the 1980s, which seems like, so long ago. But, looking back, I this was my first job after, getting my PharmD degree, and, I was in a very unique situation, one that was so innovative at the time, I didn't even realize it, but, we had two doctor pharmacy practitioners, myself and another colleague, and two AP RNs who worked in what we call today a safety net clinic in, the bowels of a inner city hospital serving mostly underserved
00:03:39:04 - 00:04:04:02
Marie Smith
African American population and we did a lot of triage. It was a walk in clinic. It was meant for people who had just fall into the cracks, missed an appointment, lost their medications, didn't get refills, whatever. And we had at that time, what we would now call collaborative practice agreements. We didn't have it as formal then.
00:04:04:02 - 00:04:37:00
Marie Smith
We were working with an internal medicine physician group, and we would see patients and get them back on their meds, do a quick physical assessment, call in APRNs if we thought it was more of a diagnostic issue. But we really were doing, you know, very early on what we'd call medication management. We would see those patients until they got plugged back into a primary care setting so that was my first, and very innovative practice, working directly in a collaborative practice agreement with APRNs.
00:04:37:02 - 00:05:12:08
Marie Smith
Subsequent to that, I worked in other, academic positions in schools of pharmacy and medicine, worked with family medicine residency programs, to teach trainees and family medicine, primary care, more about medication management, have more of a consultation service with them. And then move more into the academic side of not doing, direct primary care, but working more on health services, research for the primary care workforce and payment reform.
00:05:12:19 - 00:05:45:08
Nick Dorich
Excellent. Marie, thanks for the background there. And I know you and I have, have met and worked previously, talking about primary care items, pharmacist involvement and engagement. I believe you've also done some work with the CMS Innovation Center as well. So if if folks, have heard or have seen some of your work before may be coming from that, but I'm excited to have you on the show today and talking about how pharmacists can be, and pharmacists, specifically pharmacists clinical services can be part of the, the primary care workforce, which is, much needed in our current US health care system and environment.
00:05:45:08 - 00:06:03:17
Nick Dorich
So, again, as we get started here, this is a health, we're going to be referring and speaking about, Marie and colleagues, their article from the November 13th, 2024, published in Health Affairs. It's called Building the Primary Care Workforce with Pharmacist Clinical Services. Marie, ready to jump into our questions for today?
00:06:03:23 - 00:06:04:10
Marie Smith
Yes.
00:06:04:19 - 00:06:29:01
Nick Dorich
Excellent. Well, starting off here and I always like to, start with why begins with why? Why are we why are we looking at this? And I think really the big question here is why pharmacists and why is there this opportunity for pharmacists. So in a specifically what I want to start off with here, you know, pharmacists engage in pharmacists involvement for care teams.
00:06:29:03 - 00:06:49:12
Nick Dorich
Why is this a topic that is being or that that has been discussed, and why is it continuing to be discussed? What is it about the current environment that is inviting this conversation? You know, is there are there aspects of it specifically to pharmacists training that are new, or is this more so just simply the environment that we are seeing from a primary care standpoint?
00:06:50:00 - 00:07:12:06
Marie Smith
So I think there are two main reasons why this is, top of mind discussion today, Nick. One is there is a for a long time now, we've known that there's a primary care physician shortage. And secondly, there are very long wait times for patients to get primary care appointments. So I'll I'll talk about them. The first one I'm the primary care physician shortage.
00:07:12:08 - 00:07:37:04
Marie Smith
Several reports have come out in the last few years trying to get a handle on estimating what is the kind of, scope of this shortage. And the latest report says that somewhere between 20,000 and 40,000 primary care physicians, are needed by 2036, more than we will have coming through the pipeline. And another report kind of gave it a different twist.
00:07:37:04 - 00:08:06:08
Marie Smith
And, this is the health of U.S Primary Care 2024 Scorecard Report that came out last year. And it talked about the primary care workforce, not growing fast enough to meet population needs. Where we are all getting older. We have people with multiple comorbidities and chronic diseases. Many of them are going to be dependent on medication therapy. So the number of primary care physicians per capita has declined over time.
00:08:06:10 - 00:08:34:18
Marie Smith
And the share of all primary care clinicians that includes physicians, nurse practitioners, PAs, who are working in primary care settings has really been stagnant. It's also been reported that, even for those, medical students who do pursue primary care residencies, only about 15% of them are still practicing primary care, 3 to 5 years after they complete their residency.
00:08:34:20 - 00:09:10:11
Marie Smith
So that kind of is, kind of a stark wake up to say, you know, the primary care workforce needs to be more creative and looking at who are the team members and how can we expand those team members. The second part of that is these long wait times. I don't know if you or any of your listeners or their family members have tried to get, primary care appointments, not with an established practitioner, but if you've had a move or you're trying to change, you know, the practice you go to or your insurance doesn’t, you know, doesn't cover who you went to, and you have to look for a new primary care
00:09:10:11 - 00:09:34:06
Marie Smith
practitioner. We have in our family, we've got, you know, situations where it took 6 to 12 months to get an appointment with the primary care provider. So those long wait times are real to people, and we actually did a little bit of research here as part of a CMMI grant that came to the Connecticut Office of Health Strategy.
00:09:34:06 - 00:10:05:22
Marie Smith
And we did that a couple years ago. And we looked at estimating the amount of PCP, primary care physician time saved by having a pharmacist integrated with the primary care team. And we did this in two places. We did it in a health system affiliated primary care group, which saw mostly working adults, people who had insurance. And we also, conducted it in a federally qualified health center where you're serving more underserved, you know, population.
00:10:06:08 - 00:10:41:01
Marie Smith
And what we came up with is, on an annual basis, one full time equivalent of an embedded pharmacists, embedded pharmacists, meaning, pharmacists that practices in the office is a visible daily team member of that primary care practice when they are embedded using a collaborative practice agreement, it can save up to 640 physician hours per year by shifting those responsibilities to the pharmacists for medication management, and it results in simplified workflows for that primary care physician.
00:10:41:03 - 00:10:56:18
Marie Smith
So that's time saved of the physician, which is great. But more importantly, we can translate that time by saying how many, appointments could the physician see. And if if those hours were freed up,
00:10:56:18 - 00:11:17:02
Marie Smith
and would that help us? You know, be able to get patients in sooner and especially for more urgent issues and new patients. And that equivalent is the one time, full time, equivalent of the embedded pharmacists can open up approximately 1900 primary care physician visit appointments per year.
00:11:17:04 - 00:11:24:04
Marie Smith
So that's amazing. And that that really is well, we've, reported here in meetings locally in Connecticut.
00:11:24:04 - 00:12:02:04
Marie Smith
It's gotten the attention of hospital administrators. You know, clinician leaders, medical directors to say, well, you know, we've been talking about the quadruple aim and the joy of practice. We didn't realize or didn't think about the fact that it's not just having a pharmacist there to work on workflows, but if we appropriately, you know, shift and refer patients who are mostly there for medication management, monitoring those kinds of things that we ship them to the pharmacist who's highly trained to do that, working under collaborative practice, we can open up thousands of appointments, which
00:12:02:04 - 00:12:05:11
Marie Smith
would, help with accessibility for patients.
00:12:05:11 - 00:12:15:03
Marie Smith
So I think those are the two big factors that I think are top of mind as to why this is a pertinent and, current discussion topic.
00:12:15:03 - 00:12:43:12
Nick Dorich
Yeah. Marie, it's great, and I appreciate you going through the situation in the current environment. I think he explained it well. I, you talked about being able to find doctors or get appointments and I can say my own personal example, and it's one anecdote, right? Not necessarily the case for everybody, but, you know, when switching insurance at eight months to get a primary care visit under my right, finding a doctor that's in network, that's going to be that's going to be paid or covered for the service eight months, you know, from that part.
00:12:43:12 - 00:13:09:18
Nick Dorich
So that's an example there where, someone looking or trying to seek out preventative care or just regular maintenance. Right. It shouldn't take that that long. So that's, you know, one such example of the situation, what we're covering in. But as you explained there, we're not asking when I say this. We as the pharmacy community, are not necessarily asking that we're wanting pharmacists to do more or saying something that's out of the scope of practice.
00:13:09:23 - 00:13:30:22
Nick Dorich
The we're talking about here, as you said, managing medications and doing activities that are within the pharmacists expertise, within the pharmacists scope of training. And often items that whether or not they can be billed directly by a pharmacist, they're often going to be items that could be covered under billing for, you know, location or, through collaborative practice agreements or other avenues.
00:13:30:22 - 00:13:49:09
Nick Dorich
So this is a part here where it is somewhat of a change in practice and to some degree, a change in expectation for providers or other providers or other parts of the health care system, and maybe to some extent for the patients themselves. But this is something where it really should be an easy kind of layup, if you will, to get pharmacists involved. With that,
00:13:49:09 - 00:14:08:11
Nick Dorich
Marie, I want to dive into this next item and say, okay, we kind of talk broadly about this, what pharmacists can do and what pharmacist are trained for, but what are some of the, you know, the service opportunities, the patient care services, that can be or should be delivered by pharmacists as part of this primary care team.
00:14:08:16 - 00:14:20:21
Nick Dorich
If you have any particular examples where you know your work and research has, has, referred to specific examples that have shown to really produce, you know, good ROI or improving outcomes, those would be great. But where would you point people to?
00:14:20:21 - 00:14:21:24
Nick Dorich
What are some of these services
00:14:21:24 - 00:14:27:06
Nick Dorich
that pharmacies, you know should be taking over and managing as part of the primary care workforce?
00:14:27:22 - 00:15:02:20
Marie Smith
Sure. So I think, the most of your listeners are going to be able to, understand that and know that a little bit about the pharmacist training. But when we think about it, the pharmacists are highly trained yet grossly underutilized part of the health care workforce in the community. And they really can, as I mentioned, fill the gap in this physician shortage, especially when it comes to medication management and monitoring for chronic diseases that, you know, that, are dependent mostly on their therapy plans around medical treatment.
00:15:02:22 - 00:15:24:10
Marie Smith
Couple of our, our, coauthors on some of our work have, Tom Bodenheimer and and Kevin Grumbach in San Francisco, have done a lot of work on primary care teams and talked about, you know, what is this ideal primary care team? And it really should incorporate health care practitioners who have complementary skills to those of physicians.
00:15:24:10 - 00:16:04:22
Marie Smith
So including us as pharmacists, where we can help achieve high quality patient outcomes and improve, physician productivity that we talked about, it's estimated that about 37% of the time of a primary care physician is spent on activities related to chronic care management and a lot of these, this time both in the office visit, looking at refill request, interpreting lab values to make changes in a patient's medication therapy plan will include things that are well within the wheelhouse and training of a pharmacist.
00:16:04:24 - 00:16:30:13
Marie Smith
So the types of primary care services could be something starting out as simple as, you know, some of our work and work of others has shown how many medications discrepancies there are between what the patient is using at home and actually doing at home, what the patient's intended therapy was, as ordered in, in the electronic health record or, you know, documented in an electronic health record.
00:16:30:19 - 00:16:57:05
Marie Smith
When you're have an embedded pharmacist in the primary care office, they can spend the time to go over and do a very comprehensive, you know, medication reconciliation, looking at what's the best actual, list of medications that are being taken at home and can, you know, provide anything that comes up with the discrepancy, can correct that. So that would be just the simplest thing to do.
00:16:57:07 - 00:17:21:09
Marie Smith
But once a pharmacist is actually in the office, can work with the patient directly., doesn't need to involve the physician time if it's a collaborative practice arrangement. There are various types of services that can be provided by the pharmacist as long as they are, within the scope of practice. And so that's going to, really vary by state.
00:17:21:09 - 00:17:43:21
Marie Smith
Each state's going to regulate what they consider the scope of practice for pharmacists. And just to give you some idea of this was, kind of dovetails with what we talked about in the article. There are states that allow what we'll call full or broad scope of practice, meaning it allows the pharmacist to perform any service as covered under that state’s
00:17:43:21 - 00:18:12:11
Marie Smith
Scope of practice. And then there are other states that, would really have a more limited scope of practice. And that would be usually what we think of as state protocols. So let's talk about the first one. When the state does allow broad scope of practice, this includes any, any topic, any service that would be considered within that scope of practice to be, performed in that as a member of that primary care team.
00:18:12:12 - 00:18:36:09
Marie Smith
And just to give you the listeners a little bit of a reference point, there are ten states where both Medicaid and commercial health plans allow broad scope of services, seven states where only Medicaid allows the broad scope of services, and seven states, different states where you have only commercial health plans allowing broad scope of services.
00:18:36:09 - 00:19:01:17
Marie Smith
So there are a number of states that do allow a very broad scope of service. Most of the time, if you have a embedded pharmacist in a primary care practice, they're going to be, involving, collaborative practice agreement between the pharmacist and primary care physicians. Some states will allow that collaborative practice with, APRNs, nurse practitioners as well.
00:19:01:19 - 00:19:26:10
Marie Smith
And these collaborative practice agreements will define specifically the responsibilities of what’s delegated to the pharmacist. So some examples could be developing a medication treatment plan based on the physician's diagnosis. It could start with selecting and initiating a new medication, or adjusting a medication of a dosage where the patient's been on a medication, but the therapeutic outcome hasn't really been achieved.
00:19:26:10 - 00:19:55:01
Marie Smith
And it needs the someone to spend a little bit more time and attention and looking at how to titrate, and adjust those medication dosages and monitor that. Or could be ordering and interpreting a lab value, test result to monitor chronic disease medication. So those are some examples, services under full broad scope of practice for those states are about 19 states that have more of what we call limited scope of practice.
00:19:55:06 - 00:20:27:01
Marie Smith
Usually those states operate, on what we call statewide protocols. So the state, regulatory agency has put out a service, a specific service type of service that allows the pharmacist to be involved, for very specific things, like some examples of, hormonal contraceptive prescribing or certainly we all went through the Covid test and treat, naloxone prescribing.
00:20:27:01 - 00:20:53:16
Marie Smith
It could be HIV, PrEP and PEP, smoking cessation. So they are very discreet services, certain kinds of populations that you have the authority to work with, in a limited scope of practice. So I think that will, give you a good overview of how it varies state by state and for your listeners. It'd be good to check in with your state board of pharmacy and find out kind of what they do allow.
00:20:53:16 - 00:21:09:12
Marie Smith
Do they allow full, broad scope of practice? For a number of services or it could be and they may also have limited scope of practice that are targeted for certain kinds of Pharmacist services.
00:21:09:18 - 00:21:17:03
Nick Dorich
Yeah. State Board of Pharmacy, a good place to check. Maria also recommend for any of the listeners as well. NASPA has great resources, information.
00:21:17:03 - 00:21:17:21
Nick Dorich
Yes.
00:21:17:21 - 00:21:26:15
Nick Dorich
What what's happening in the States. And this is often a rapidly and especially you mentioned since Covid there's between test and treat and some of the other services that can be provided.
00:21:26:15 - 00:21:49:22
Nick Dorich
It's also been a rapidly evolving and changing landscape. So, even if you were familiar with what you could do last year in your state based upon your pharmacist, license and working that that could be subject to change. And I know NASPA and some other, other groups have resources or templates or other things like that that can help to, you know, create some of these legislative changes in the state that you're working with.
00:21:49:24 - 00:22:08:13
Nick Dorich
Maria, appreciate the rundown and covering what we're talking about, what you talked about as far as services, just as you were speaking, I'm just kind of taking some notes on the side of my desk here looking through it. And I graduated pharmacy school in 2011, and just about everything that you covered as part of the curriculum, even now, almost 15 years ago, that I went through in school.
00:22:08:13 - 00:22:28:11
Nick Dorich
Now I'm not necessarily the pharmacist qualified being a bit out of practice myself, but at least coming from that perspective on hey, is the pharmacist workforce ready and able? I certainly there's going to be and some institutions or some collaborative practice. Other groups may have some other training requirements, certificates, it's other things like that that may be involved.
00:22:28:11 - 00:22:48:07
Nick Dorich
So that could be subject to some variation. But this is an area where pharmacists are ready and able generally to be able to provide these services. Now, Marie, the last thing that we kind of want to talk about, and it's an important one because this work and this, this work that can be done by pharmacists, it does come down to pharmacists’ time.
00:22:48:07 - 00:23:10:00
Nick Dorich
It does come down to how this can be implemented with a with a health system. And ultimately it needs to be ensuring that, not just that this work is being done, but that that work is being and that, that time that is being paid for. So are there models or methods in place, that are being tested or perhaps that are already implemented that cover, you know, for a pharmacist
00:23:10:00 - 00:23:17:09
Nick Dorich
time and involvement with these types of, operations and with their engagement as part of that primary care, workforce?
00:23:18:08 - 00:23:39:03
Marie Smith
Yeah, that's a great question. And, you know, even today in my teaching, role, there is a kind of myth in many ways on the part of students and practitioners that, we really are limited because we don't have any kind of reimbursement for our services.
00:23:39:03 - 00:23:39:23
Marie Smith
And
00:23:39:23 - 00:23:54:13
Marie Smith
that's a little bit of what sort of, you know, we're sort of in the back of my mind when we started to write the Health Affairs article, is to say, okay, you know, we hear, you know, we go to national meetings and we'll hear a speaker talk about, you know, what they're doing in their state.
00:23:54:13 - 00:24:22:08
Marie Smith
And yet we didn't really think there was a great amount of information out there for pharmacists alone, never mind health care policymakers and other health care professionals about what really is happening on a broader scope. Across the country, we have little pockets, we know. But so that kind of, you know, made us kind of look at this idea of, what is the payment landscape look like for pharmacists?
00:24:22:10 - 00:24:52:22
Marie Smith
And we were, pleasantly surprised that there are 41 states that do allow some degree of payment for pharmacy services. So, it might be just one payer. It might be just for a limited service, like just for Covid test and treat or just for hormonal contraception. But 41 states have recognized that pharmacies services are, able to be allowed within scope of services
00:24:52:22 - 00:25:18:20
Marie Smith
and there's some payment mechanism for that. The caveat so that's exciting news, 41 out of 50 or 51, if you count District of Columbia. The sad part of that is, is it's not pervasive. You know, it's just, for one service or a limited number of services, or it could be that the, you know, it's just one payer or something like that.
00:25:18:20 - 00:25:44:14
Marie Smith
And most importantly, as is our listeners, I'm sure no, we still we've been talking here about states that cover for Medicaid and commercial health payers, but the largest health payer is Medicare. And we're all struggling professionally, to try to get over the finish line there for Medicare, to recognize the talents and the services and, positive patient outcomes,
00:25:44:14 - 00:26:09:10
Marie Smith
and I believe cost savings that pharmacies can provide so that the Medicare will provide and allow us to have some provider status for payment as well. So good news is, there are a lot of states that do allow some degree, opportunity is that we've got to get it more pervasive across, beyond Medicaid or commercial and beyond just for certain services, but have it for broad coverage for all services.,
00:26:09:12 - 00:26:37:16
Marie Smith
and we need to really still work on the Medicare piece. So, you mentioned, you know, you asked, other examples today and I'll offer a few. So let's take Medicaid as the health care payer. Hormonal contraceptive prescribing is now allowed in about I want to say it's probably upwards of 25 to 30 states have pharmacist services for hormonal contraceptive prescribing.
00:26:37:18 - 00:26:58:18
Marie Smith
Many states allow it. However, the downside is that they allow it professionally, but they haven't put in a payment mechanism, you know, so that's going to hinder what ability we have. And we in Connecticut face that. We have had for the last couple of years. We had a bill passed. We now have authorization and regulations in place.
00:26:58:18 - 00:27:24:14
Marie Smith
We have a training program in place. We have no payment mechanism. So it's going to really hinder the, anticipated, effect and public health benefit, I believe, for what we can do. But in some states, California, Maryland, Oregon, Nevada come to mind. They have active Medicaid programs to not only allow for hormonal contraceptive prescribing, but to pay for it.
00:27:24:16 - 00:27:50:09
Marie Smith
And the payment is structured, very similar, and you follow most of the mechanisms of payment requirements for physicians or other health care practitioners who are paid by, you know, a health payer. So you have to go through a credentialing process and, you need to sign up for, you know, making sure you're on the provider registry.
00:27:50:09 - 00:28:26:22
Marie Smith
And, and you, you have to go through all those things. But they have negotiated, payments for hormonal contraceptive in those four states, and they vary by state, as you would imagine. They're all negotiated. But the payment for an initial encounter when a patient first comes in to a pharmacy for hormonal contraceptive prescribing, that's going to take, a little bit of time to do an, a patient assessment, go over kind of a history, find out what's, you know, the patient's been been using in the past, so it's going to take time, do blood pressure checks, those sort of things.
00:28:26:24 - 00:28:56:02
Marie Smith
That initial encounters could take anywhere from 30 to 45 minutes, and in those four states, California, Maryland, Oregon and Nevada, those initial patient encounter payments range from $39 to $74. And then they also have a second, payment structure for any kind of follow up, meaning existing patient encounters, and those won't take as much time. So the payment ranges there from about $18 to $41.
00:28:56:02 - 00:29:36:03
Marie Smith
So that's an example for hormonal contraceptives. One state that really has had a long history of payment by Medicaid is Minnesota Medicaid, and, they have had medication therapy management payment. Gosh, I think since probably 2006, 2007, it's been quite a while. They use they have used specifically the MTM codes, the 99605 to 99607, which are time based codes and that Medicaid program has payments again, based on whether you're a new patient or an existing patient.
00:29:36:05 - 00:30:04:10
Marie Smith
But the new patient ranges from $52 to $148 for that initial patient encounter with a pharmacist. Depending on the number and complexity of drug therapy problems that the pharmacist is going to address, and then for payments for any follow up or existing, you know, existing patients for follow up appointments, they would usually be working on something that has already been identified and monitoring.
00:30:04:12 - 00:30:35:11
Marie Smith
So those are a little bit less. They range from $34 to $130 again depending on the number and complexity of the drug therapy problems to follow up. So that's an example of things that have been going on, you know, and are happening today and been going on, in Medicaid in some states, commercial payers, most commercial payers use a billing code similar to that of primary care physicians and will pay the pharmacist the similar rates to primary care physicians.
00:30:35:13 - 00:31:01:20
Marie Smith
There are some states that have or some plans which try to negotiate that we should be paid, not at the physician rate, but more at the mid-level provider, the APRN, or the PA rate. And I'm not a big fan of that. And I know, about a year ago, Michael Hogue, who's the CEO of APhA, came to visit us at UConn and we had a great discussion about this.
00:31:01:20 - 00:31:33:07
Marie Smith
And he said that he had he was advocating that as a profession, we should go. We should be, stand fast on getting reimbursed the same level of the physician and he talked, I forget which state he had been in, but he talked about how in one state, a physician said, you know, when I referred a patient to a, specialist or to, a pharmacist, I'm doing that because they have a skill set that is able to be used as different from mine.
00:31:33:07 - 00:31:57:08
Marie Smith
I spent most of my time on diagnostics when I refer a patient or a patient sees somebody who's a mid-level practitioners, mostly to do things that are an extension of my skills. And so, yes, there might have been a negotiation of wanting to, you know, do something along the lines of 85% of payment or something like that, just for competitive purposes or whatever.
00:31:57:14 - 00:32:28:05
Marie Smith
But when I, when I, send a patient and refer a patient to another practitioner outside of an APRN or a PA who's doing similar work, scope of work to what I do, I expect them to be paid 100% of whatever that going rate is. If I had to do it. So that's I think a caveat we should keep in mind is, there may be, you know, these situations, but try to see if you can get parity with what physicians are paid.
00:32:28:11 - 00:32:55:19
Marie Smith
The most common billing codes that are used would be for patients who are existing patients. So you're not seeing them new. They've been to the physician. They've got a diagnosis. You are now seeing them to develop or to manage a treatment plan. And those codes, similar to what primary care physician would use the CPT codes of 99211 to 99215, again based on complexity of medication, medical decision making.
00:32:55:21 - 00:33:17:18
Marie Smith
So those payments are negotiated. We don't have a way to go in and find out, you know, what those are like we do in a public domain like Medicaid. So they can be negotiated in proprietary, but usually commercial payment would be a little bit higher than, than Medicaid as well. So that might be just a relative scale to use.
00:33:17:20 - 00:33:22:22
Marie Smith
So those are some examples of existing programs that, are going on now.
00:33:23:04 - 00:33:43:21
Nick Dorich
And I agree. Maria, when you let off your comments talking about how there's the idea that you often hear or see when you're teaching that, well, pharmacies can't do these things because we don't have the payment that's there. They're there are enough models or enough examples where this has been done, as you pointed out, would be great if Medicare was paying pharmacists like it does other providers to be able to do these sort of items.
00:33:43:21 - 00:34:03:13
Nick Dorich
But, addressing that, it's it's one item and that would certainly open up the floodgates, but that also comes with its own challenges, and own unique, you know, scenarios around, billing and management. But there's enough examples that we see in different states, and different programs. Right. And it's an item that I know I've said and that I've shared with others.
00:34:03:13 - 00:34:23:01
Nick Dorich
You know, previously is, you know, if you're a pharmacy, pharmacist or a pharmacy team looking to engage with some of these programs, either with a health system or with a payer specifically, or even an employer group. You know, there's ways that if you're providing a valuable service that, you know, you can set up some form of direct billing or direct payment, do you have able to account for these?
00:34:23:01 - 00:34:52:04
Nick Dorich
And I think we do see enough examples of that occurring. It's a part that where I think pharmacy, we need to step a little bit outside of our comfort zone and somewhat selling ourselves and selling the value in the worth in the ROI that's there. But there's certainly enough examples to show that adding or including a pharmacist for these tasks that are very much part of the education, the training and the experience are worthwhile, not just for the hospital, the health system and the providers, but most importantly and ultimately for the patients receiving the care.
00:34:52:06 - 00:35:12:02
Nick Dorich
So, Mary, with this, I'm going to kind of wrap us up as far as, you know, this conversation, discussion on pharmacists involvement in the primary care workforce. But, you're still working in this area. So are you able to give us any kind of sneak peek or an idea on, you know, hey, what? You know what you and you know, you're I know you worked with a couple other authors on this.
00:35:12:04 - 00:35:27:09
Nick Dorich
That was published and Health Affairs. But is there any kind of, you know, next step or next phase that you're looking to address? Both for, you know, for pharmacy, but more broadly, for those that are involved with public health and, being engaged with innovative practice models.
00:35:28:03 - 00:36:11:10
Marie Smith
So, yeah, I think, first of all, it was surprising to us, as I mentioned, to see when we really had the landscape of what was going on in the States across the country to see that there are some very, very great models that we can build on. So I think what we are focusing on now is to get that word out, like the Health Affairs article being one, we have some other work that we've done here, in Connecticut where we surveyed, primary care, practitioners, physicians and aprons, mostly, to just see, you know, how comfortable would they be with these scenarios of pharmacists working either in a community setting where
00:36:11:10 - 00:36:38:02
Marie Smith
they could monitor the patient? You know, we know that the community pharmacists sees a patient probably between five to maybe as many as ten times more than the patient will see their primary care, practitioner. So they have a lot of access in the community pharmacy setting, and what would they be willing to, incorporate into like a more community based practice model?
00:36:38:04 - 00:37:14:14
Marie Smith
And we were glad to see that, as long as they had the correct training and it was within scope of service, most clinicians who are in primary care, we would welcome, pharmacists and community being part of their team. Logistically, I think the things that we noticed that still need to be worked on is, trying to get access in the community pharmacy to the electronic health records, whether that's directly through, like being part of a network in your community, or perhaps your state has a health information exchange,
00:37:14:14 - 00:37:45:18
Marie Smith
so you could at least see some of that, medical information about the patient. So that's one thing I think that that can be worked on. I think the other thing would be, that as practitioners ourselves, we need to not only educate, you know, we think of policymakers and things like that, but, just getting out and maybe speaking in our local communities, going to monthly state medical meetings, medical society meetings, and being kind of advocates to let them know.
00:37:45:18 - 00:38:10:06
Marie Smith
Many of them don't know. Still, it's amazing, but they don't know what our training is. They know what you know, what it was when they practiced, or when they were training. They saw pharmacists in hospitals, and they have no concept of what we can do and what is going on in the, in the community, setting out in the ambulatory setting, outside of a hospital environment.
00:38:10:08 - 00:38:33:05
Marie Smith
And then I think, thirdly, we need to think about, you know, we can be great advocates with our state pharmacy associations and our schools of pharmacy, our boards of pharmacy at our state levels to make sure that we, make them aware of what other states are doing and not only just allowing it in scope of practice, but having a payment mechanism.
00:38:33:05 - 00:38:54:22
Marie Smith
I think without having the payment mechanism built in, we're going to see very, very underutilization of what, you know, authority we have as licensed health care, practitioners. There's just not going to be the uptake if we don't have a payment model, built with it. So those are some thoughts that I can end with.
00:38:55:06 - 00:39:16:03
Nick Dorich
Yeah, we've certainly, we've covered the payment part and, we've had some different folks, I think back a couple episodes more than a couple episodes. Julie Acres from State of Washington spoke about that we're Washington is considered one of those more progressive states in allowing farmers to a whole lot. But if the payment mechanisms aren't set up there, it makes it a lot more to get the ball rolling on these.
00:39:16:07 - 00:39:31:07
Nick Dorich
Yeah. Yeah. So Mary, with that, and I appreciate having you here on the episode today. And as we wrap up, folks may have questions, or may I follow ups, and they want to learn more about some of the examples or some of the states that you kind of talked about here. Yeah. Is there a good way to reach out to you?
00:39:31:09 - 00:39:41:23
Nick Dorich
You know, can they find you on LinkedIn? Or else you can share and, and, and, or are there any other conferences or events where you're going to be covering this topic and more, you know, coming up in the not so distant future?
00:39:42:13 - 00:40:13:06
Marie Smith
Yeah. Thanks. So, yes, if there are questions I can be reached. Certainly. I first at the University of Connecticut School of Pharmacy. Very simple. Email Marie, Marie.Smith@UCONN.edu. So that's one way. Also, I'm pretty active on LinkedIn, so that's another way. And yes, actually, the Virginia Commonwealth University School of Pharmacy and UConn School of Pharmacy are doing an invitational conference.
00:40:13:06 - 00:40:25:05
Marie Smith
So it's not open to the general public, but we are doing an invitational conference in the beginning of March that is specifically on state Medicaid programs and to share the
00:40:25:06 - 00:40:46:16
Marie Smith
kind of trials and tribulations and strategies and examples of value added services and value propositions of having pharmacists. And it'll include, states that, have had Medicaid programs, both full scope of practice and some limited ones, talking to other state leaders.
00:40:46:16 - 00:41:21:01
Marie Smith
So this will be mostly for, policymakers, you know, state Medicaid administrators, pharmacy leaders, maybe medical directors. As well as some of our, you know, health plan colleagues to, share a little bit more. So I think that, those are all ways and I would encourage those of you in your own state, if you've got programs in place, try to get out and educate, your physician colleagues as well about what you're doing, because many times they just aren't aware of what is happening.
00:41:21:01 - 00:41:31:12
Marie Smith
And if you still need to get payment in place, then, look for them to advocate for you. It's always better when we have other professions advocating for our services.
00:41:31:14 - 00:41:51:23
Nick Dorich
Other professions are, of course, patients. Being the best patient. Patient advocates are are huge in that regard as well. Marie, thank you very much for the time today. And again, very we referenced it a couple times, but it's Health Affairs article, building the primary care workforce with Pharmacist Clinical Services. We've got, author Marie Smith.
00:41:52:00 - 00:42:09:11
Nick Dorich
Marie, I'll shout out your other colleagues on the article as well. Thomas, Boden Heimer and Kyle Rob. So this is really, you know, a great article and a great opportunity to highlight the opportunity that pharmacists and pharmacy has to contribute to public health and to the primary care workforce. Something that is, as you explain, we need we need more of that.
00:42:09:11 - 00:42:41:15
Nick Dorich
So recommend for everybody. Go check out this article if you have questions. Are there follow up? Certainly engage with Marie. Take a look at what your state pharmacy association has as far as resources and ways that you can kind of get involved and work with payers and health systems to be engage on this. And we look forward to a positive opportunity for the for pharmacy, but most importantly for patients as we go forward, with that, that does mean for our audience that we have finished today's we have wrapped up today's episode and, we thank you for your time and listening into another episode of the Quality Corner Show.
00:42:41:21 - 00:42:48:21
Nick Dorich
We hope you listen to our next episode. And then before we go, we have one final message from the PQS team.
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