Magazine article Drug Topics

Is Fee for Service Dead?

Magazine article Drug Topics

Is Fee for Service Dead?

Article excerpt


Healthcare is evolving into an interdisciplinary approach, enabling teammate providers with different training and expertise to care for patients to produce the best patient outcomes. Institutions are using transitions-of-care billing codes, and more settings are moving toward a form of payment based on diagnosis-related groups (DRG), which associate costs with the care of a patient with a particular diagnosis, cared for by an interdisciplinary team.

So fee for service (FFS) is dead! Pharmacists are on the team! We don't have to worry about billing for pharmacist services in this new utopia, right? Not quite.

Where will the $$ come from?

Flow will the team pharmacist be paid? Current Procedural Terminology (CPT) codes for DRG and non-MTM services are directed toward payment of federally recognized providers and for current overhead costs incurred by the "team" that currently receives federal recognition. The pharmacist is not officially on this team.

Many commercial carriers follow CMS guidelines for group-care payment, and the pharmacist salary isn't accounted for there, either. Because pharmacists aren't included in the payment calculation and are viewed as nonproviders, the bucket of DRG money has to be split further. In a financial sense, pharmacists either become administrative overhead, take away from the fixed payment already determined without their participation, or, in an inpatient setting, are supported by the doses of meds dispensed in the central pharmacy.

Revenue creation

Pharmacists have no ability to bring money in. This puts us at the disadvantage of having to justify our existence with the more nebulous "cost avoidance" argument: We will decrease costs just by being there. Easy argument, right? Proven in the literature, right? In the eyes of those paying that salary not necessarily.

In the outpatient setting, if you can obtain a contract with a self-insured entity, you can use the Asheville Project to make the cost-avoidance argument. But it's not so easy to get those contracts.

In nongovernmental ambulatory care and community pharmacy, we still have to fall back on revenue creation. For now, low-level Medicare CPT codes, Medicare Part D plans, and MTM CTP codes will have to do.

At this time, however, the lowest "incident to" CPT code doesn't cover the cost of pharmacist services; the Part D plans and other forms of payment structured for pharmacy benefit managers (PBMs) are inadequate; and many payers still do not recognize MTM CPT codes monetarily if a pharmacist performs the services. …

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