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
“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
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
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,”
“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.