Attaining pharmacist recognition in the United States.

Full text

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2152
Am J Health-Syst Pharm—Vol 65 Nov 15, 2008
COMMENTARiEs Pharmacist recognition
Brian Meyer, M.B.a., is Director; Joe Hill,
M.a., is Director, Federal Legislative Affairs;
and Geralyn TruJillo, M.P.P., is Director, State
Government Affairs, Government Affairs
Division, American Society of Health-System
Pharmacists, Bethesda, MD.
Address correspondence to Ms. Trujillo at
the American Society of Health-System Phar-
Attaining pharmacist recognition
in the United States
Brian Meyer, Joe Hill, and Geralyn TruJillo
Am J Health-Syst Pharm. 2008; 65:2152-3
I
toward recognition of pharmacists
by public and private payers started
with the modernization of state prac-
tice acts that allowed collaborative
n this issue of AJHP, Yuksel et al.1
describe pharmacist prescribing in
Alberta.
In the United States, the journey
drug therapy management (CDTM)
agreements between pharmacists
and prescribers. CDTM is a team
approach to health care delivery, and
it establishes written guidelines and
protocols that authorize the pharma-
cist to initiate, modify, or continue
drug therapy for a specific patient.
Forty-five states allow pharmacists
to manage a patient’s medication
therapy.2 This includes adjusting,
discontinuing, and, in some cases,
initiating therapy.
After states updated their indi-
vidual practice acts, the journey
for pharmacist recognition began
on the national level. Through the
2004 Medicare Modernization Act,
coverage of prescription drugs was
enacted under Medicare Part D.
Medicare Part D has been a positive
step toward recognizing pharmacists
as providers because an element of
Part D coverage includes medica-
tion therapy management (MTM)
services.
Under Medicare Part D, MTM has
not evolved to the level of care that
the profession or the public expect-
ed, but it still provides positive ini-
tial momentum toward pharmacist
recognition. The Centers for Medi-
care and Medicaid Services (CMS)
noted in its implementing regula-
tions that MTM programs “must be-
come a cornerstone of the Medicare
Prescription Drug Benefit.”3 The
current design of Part D does not
provide an alignment of incentives
for the payer, the prescription drug
plan (PDP), or the pharmacist. The
underlying importance of MTM is
the focus on patient-specific care,
but this can be lost amid the mis-
alignment of incentives. MTM ser-
vices are provided by premium rev-
enue, which is paid by CMS and the
Part D enrollee. Standalone PDPs,
in particular, do not place emphasis
on the value of pharmacist services,
which may result in higher drug
costs but potentially lower the over-
all cost of care. Pharmacist services
may also contribute to cost avoid-
ance for Medicare Part A (hospital)
and B (physician) services. Since
PDPs are not rewarded for reduced
Part A and B costs, incentives are
not aligned for an optimal Part D
benefit. These services vary widely
across plans because CMS gave plan
providers significant discretion in
developing their MTM programs. In
fact, the only requirement made by
CMS created an arbitrary threshold
for MTM eligibility. As a result, only
7% of Part D beneficiaries are even
eligible for MTM services.
This brief picture of the journey to-
ward pharmacist recognition might
lead to the belief that pharmacists are
standing still or even moving back-
wards. It is important to remember
that just as in Canada, the changes in
state and federal law will continue to
evolve. The initial work at the state
level to modernize practice acts is
almost complete. In addition, state
programs, including Medicaid, are
recognizing the value of pharmacist
services and compensating phar-
macists for their patient care. This
is clearly shown in the recent ASHP
policy analysis, Pharmacist Provider
Status in 11 State Health Programs.4
At the national level, seven pharma-
cist organizations have formed the
Leadership for Medication Manage-
ment. This coalition, founded by
ASHP and the American College
of Clinical Pharmacy, advocates for
changes to Medicare Part D and
for recognition of pharmacist drug
therapy management services under
Medicare Part B with appropriate
compensation.
Another step toward recognition is
the ongoing discussion by the profes-
sion of whether additional credentials
should be required of pharmacists
under state practice acts as a require-
macists, 7272 Wisconsin Avenue, Bethesda,
MD 20814 (gtrujillo@ashp.org).
Copyright © 2008, American Society of
Health-System Pharmacists, Inc. All rights
reserved. 1079-2082/08/1102-2152$06.00.
DOI 10.2146/ajhp080515
See also page 2126.

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Am J Health-Syst Pharm—Vol 65 Nov 15, 2008
COMMENTARiEs Pharmacist recognitionCOMMENTARiEs self-imposed labels
ment for the provision of advanced
patient care services. Along with this
is the question of whether payers
would require credentials in order
for pharmacists to be compensated
for these services. It is worth noting
the experience of our neighbors to
the north. The challenges faced in
Canada can be echoed in the United
States. The authors rightly noted,
that economic models that reward
pharmacists for dispensing drugs are
outdated and do not complement
the pharmacists’ roles as medication
managers.1 They also stated that the
new practice expectations must be
supported by economic models that
focus on patient care rather than
commodity-driven formulas based
on selling drugs. Critical patient care
issues are at stake and recognizing
pharmacists’ services is a vital step
toward ensuring that appropriate
care is provided by the medication
experts.
Some of the many serious issues
that must be addressed by the new
presidential administration and Con-
gress are health care reform, coverage
for the uninsured, and Medicare sol-
vency. Aligning incentives for stake-
holders under Medicare Part D and
recognition of pharmacist services
under Part B are pieces of the solu-
tion to the Medicare puzzle. These
changes in Medicare would serve as a
guide to other payers.
There are many lessons we can
learn from Alberta’s journey toward
pharmacist recognition. Alberta is
an example of how to successfully
manage change on both a state and
federal level. While the journey is not
complete, United States pharmacists
are on the right path toward achiev-
ing recognition.
1. Yuksel N, Eberhart G, Bungard TJ.
Prescribing by pharmacists in Alberta.
Am J Health-Syst Pharm. 2008; 65:
2126-32.
2. Alliance for Pharmaceutical Care.
Media Advisory. Collaborative drug
therapy management: a coordinat-
ed approach to patient care. www.
pharmacist.com/AM/Template.
cfm?Section=Home2&TEMPLATE=/
CM/ContentDisplay.cfm&CONTENT
ID=16786 (accessed 2008 Oct 3).
3. Centers for Medicare and Medicaid
Services. Medicare program; Medication
prescription drug benefit. Final rule. Fed
Regist. 2005; 70:4193-585.
4. ASHP Policy Analysis. Pharmacist pro-
vider status in 11 state health programs.
www.ashp.org/DocLibrary/Advocacy/
ProviderStatusPrograms.aspx (accessed
2008 Oct 3).
Removing the self-imposed labels
of pharmacists
dale e. enGlisH ii
Am J Health-Syst Pharm. 2008; 65:2153-5
T
centered care concept as a member of
the health care team. As pharmacists
secure provider status with perma-
nent current procedural terminology
codes and continue to provide medi-
cation therapy management services,
they continue to demonstrate the
incredible contribution that phar-
macists can and do make on a daily
basis. Earning a Doctor of Pharmacy
(Pharm.D.) degree has been a solid
building block and has created highly
educated practitioners who under-
stand their roles in the health care
profession and the valuable impact
that they can have on the overall im-
provement of patient care.
As we continue to look to the
future and improve the pharmacy
practice model, it is important for
us to come together as pharmacists
and remove our self-imposed labels
of “staff pharmacist” and “clinical
pharmacist.” These labels and prac-
tice models continue to hinder the
overall progress of the profession like
he profession of pharmacy con-
tinues to evolve and move for-
ward, focusing on the patient-
Dale e. enGlisH ii, PHarM.D., is Director, In-
structional Labs, Northeastern Ohio Universities
Colleges of Medicine and Pharmacy, 4209 State
Route 44, P.O. Box 95, Rootstown, OH 44272
(denglish@neoucom.edu).
Copyright © 2008, American Society of
Health-System Pharmacists, Inc. All rights
reserved. 1079-2082/08/1102-2153$06.00.
DOI 10.2146/ajhp080254
a necrotizing fasciitis eats away at the
flesh. We must look to a better phar-
macy practice model in which labels
are a thing of the past and we can all
be seen for who we are, regardless of
our role. We are all pharmacists and
we all play a critical role in the ulti-
mate care of the patients we serve.
What is defined as clinical phar-
macy? Your current job? If we look
at our current structure, how might
we define the terms “staff” and
“clinical” pharmacists? By traditional
terminology, the generally accepted
use of these terms and the employer-
defined roles, a staff pharmacist may
be the pharmacist who spends his or
her time in the pharmacy processing
orders and caring for the distributive
functions of the medication process.
Are these functions “nonclinical”?
Do these pharmacists use clinical
judgment to assess each order that
they process, or do they use any
clinical judgment to assess any other
situation before giving final approval
for the medications to be dispensed?
Clinical judgment should be used in
all aspects of pharmacy; otherwise,