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Patient-centered medical home: Getting paid for services of pharmacist


How do you bill for a pharmacist's service in a patient-centered medical home?

Key Points

A: There is no question that the addition of a pharmacist to the PCMH or accountable care organization improves quality of care, outcomes, and overall patient safety. The 2006 National Ambulatory Medical Care Survey, conducted by the Centers for Disease Control and Prevention's National Center for Health Statistics, found that 72% of office visits involve medication therapy. Additionally, researchers have reported that only 47% of medications used at home were documented in the medical record, and 89% of prescription medications and 76% of OTC medications and herbal treatments had discrepancies between how patients actually were taking the drugs/supplements and how they were recorded in the medical record.

Reimbursement for the services of a pharmacist (or any ancillary service provider) is the greatest barrier to widespread acceptance of pharmacy or other services as part of the PCMH. Billing for the cognitive services of ancillary providers is difficult and frustrating.

The bonus paid to the practice operating as a PCMH typically is capitated (the same amount per patient, per month) and is meant to reimburse the practice for the additional services provided to the patient. This all varies by payer. Some payers pay a capitated amount, others increase reimbursement for certain services (cognitive codes), and others create new codes to report the additional services (American Academy of Family Physicians News Now Special Report: Medical Home Model Calls for New Payment Methods).

The bottom line is that the concept of the PCMH is in its beginning stages, with pilot programs in place nationally. Being able to demonstrate lower admission rates and lower premature mortality rates for those patients with the top chronic diseases-heart disease, cancer, stroke, diabetes mellitus, and respiratory disease-will allow practices to negotiate with insurers for better reimbursement rates.

As the PCMH advances as a concept and shows overall improvement in quality of care and outcomes, reimbursement rates will improve. Clearly, it is much less expensive to proactively treat a patient in an outpatient setting-stressing preventive care, accurate documentation, and adherence with treatment plans through monitoring-than in an inpatient setting after the onset of a catastrophic illness.

The key to all of this, however, is a viable electronic health record (EHR) system. If the practice with which you practice medicine is not currently using one, transition to that medium soon. The outcomes-tracking I have outlined here is nearly impossible without an EHR system.

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Jennifer N. Lee, MD, FAAFP
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