Medicaid Pilots Focus on Direct Care from Pharmacists

Ahead of a statewide launch in January, Medicaid managed care plans are running pilot programs to designate pharmacists as direct care providers, providing reimbursement for services pharmacists historically performed for patients.

Under 132-SB265 (Dolan), health insurers can reimburse pharmacists for direct care services within their legal scope of practice. Ohio Department of Medicaid (ODM) Director Maureen Corcoran recently told the Prescription Drug Transparency and Affordability Council her agency will fully launch implementation in January 2021. (See The Hannah Report, 6/15/20).

ODM posted Monday a package of draft rules for implementation of the law. The rules can be found at https://tinyurl.com/ycqk4h98.

According to ODM, three plans are running pilots: Buckeye Health Plan, CareSource and UnitedHealthcare.

Announcing the launch of its pilot program earlier this month, Buckeye Health Plan said the program will allow pharmacists to provide more direct patient care to improve the health of people living with chronic conditions. Buckeye started the program at two federally qualified health centers (FQHCs), Ohio Neighborhood Health Services in Cleveland and Primary Health Solutions in Cincinnati, as well as at Christ Hospital in Cincinnati.

“This program expands health care access by increasing the level of care pharmacists can provide at a place where members are already going,” said Steve Province, president and CEO of Buckeye Health Plan, in a statement. “This offers more access, more help and more support to those who often need it the most. We believe in the added value this program provides to our members so much that we’re reimbursing pharmacists participating in the program for this expanded role.”

“We find that our members view pharmacists as trusted healthcare providers, and those participating in this program really value the positive impact that pharmacists can have on their lives and health outcomes,” said Meera Patel-Zook, senior director of pharmacy at Buckeye Health Plan.

CareSource plans to announce the details of its pilot soon.

“Next week, CareSource is expected to announce a six-month pilot program reimbursing pharmacists for clinical services. The program will include two independent pharmacies, one inner city and one rural, and a health system. All participating pharmacists will target diabetes, smoking cessation, asthma, and opioid use/naloxone therapy. The program will be focused on quality and outcomes for the patients served,” the company said in a statement.

An overview of UnitedHealthcare’s pilot says it will target those recently discharged from the hospital and patients with multiple chronic conditions, including diabetes, heart conditions, asthma, chronic obstructive pulmonary disease and others. “The outcome goals of the program include reduction in the number of readmissions, reduction in the number of unnecessary prescriptions, better manage chronic conditions including: A1c control, blood pressure control, statin adherence, and asthma medication adherence,” the program description states.

Antonio Ciaccia, government and public affairs director for the Ohio Pharmacists Association, said economic pressures in retail pharmacy that have led to a focus on higher volume made it difficult for pharmacists to give as much time to the patient care role they’ve historically performed.

Ciaccia recalled the career of his father, a hospital pharmacist in Cleveland. “My education in pharmacy was watching him at 8 o’clock or 9 o’clock at night with a family member or a friend who just got a new diagnosis from a doctor and bevy of medications they were going to take,” he said.

“That was the stuff that I didn’t necessarily, really associate with pharmacy based on just watching him sling pills across the counter,” Ciaccia said. “That was what pharmacists were supposed to be doing but weren’t necessarily given the bandwidth to do.”

Ciaccia said pharmacists he’s talked to who are participating in the pilot run by UnitedHealthcare have, for example, identified diabetics who should have been prescribed statins. That’s important for the patients’ health and also is measured directly in evaluation of the managed care plans’ performance, he said.

He said types of services pharmacists provide can include administration of drugs; running blood pressure or blood sugar checks; or performing a “medication reconciliation” in which patients bring in all their prescriptions for review, which can result in recommendations to drop some medications. In very limited circumstances, a pharmacist can add a drug to a patient’s regimen, per law on pharmacist-physician consult agreements passed in 131-HB188 (N. Manning-S. Huffman).

Ciaccia said discussions on provider designation have helped to improve providers’ partnership with the plans. “To say that we had a friendly relationship with the managed care plans would be the overstatement of the century,” he said. “We’ve been successful in taking those PBM [pharmacy benefit manager] issues we know we’ll probably never find agreement on and say, let’s park those things … and say, what things can pharmacists actually do that will help plans meet their targets and goals.”

Ciaccia said pharmacists’ ability to address patients’ medication adherence problems can help to prevent re-hospitalizations and other poor outcomes. That can keep patients healthier and help the managed care plans address costs and meet population health targets.

“You see a lot of cost in the system as a result of just poor medication adherence, which is an umbrella term for all those little nooks and crannies of issues when a patient is taking the wrong medication the wrong way,” he said.

Ciaccia said he did not expect when the bill passed -- December 2018 -- that it would be 2021 before Medicaid implemented it. But he said he understands ODM has a lot to work on, noting the ongoing rebidding of managed care contracts.

The law applies to commercial insurers as well, but Ciaccia said he’s not aware of much activity related to using pharmacists as direct care providers in that sector.


Story originally published in The Hannah Report on June 30, 2020.  Copyright 2020 Hannah News Service, Inc.