Mississippi physicians and pharmacists could find themselves fighting over Medicaid dollars now that the state has become the first to allow pharmacists to submit claims to Medicaid for some disease management services.
Some Mississippi physicians say they're worried about expanding pharmacists' scope of practice because it could put doctors at risk for pharmacists' errors.
Many Mississippi pharmacists and some physicians, however, view the new collaborative effort as a way to better manage patient care and ultimately decrease healthcare costs.
"What we've done is take a careful look and said, 'How can we help? How can we utilize the skills of pharmacists to improve the quality of care for the people who need help?' " says Buck Stevens, executive director of the Mississippi Board of Pharmacy. "We view physicians' practice to be primarily diagnosis; we view pharmacists' practice primarily to be medicine management. They are not competitive, but they are supplementary."
HCFA last spring approved a waiver for qualified pharmacists to bill Medicaid for disease management services for diabetes, asthma, lipids and anticoagulation. To qualify for Medicaid reimbursement, pharmacists must complete a training program and pass a 120-question, two-hour examination for each disease category. To date, about 70 of Mississippi's 2,500 pharmacists have passed the credentialing examination.
Then, in collaboration with physicians, the pharmacists develop a disease management protocol for one of the four categories. The protocol must define what authority the physician is delegating to the pharmacist.
Once the Mississippi Board of Pharmacy approves the protocol, pharmacists can dispense drugs, maintain prescription records, access physician notes and laboratory records, provide advice and consultation on drugs and devices, and modify drug therapy in accordance with the protocol. Participating pharmacists must have a private patient counseling area and have a personal provider number from Medicaid -- existing billing codes will be used. Patient visits are limited to 12 per year, at $20 per visit. The state pharmacy board expects the first protocol to be in place early this month.
Harold Kornfuhrer, director of pharmacy services for North Mississippi Medical Center in Tupelo, acknowledges that some physicians may think the disease management program will create a turf war. "Some people see the protocol as giving authority to other providers to make decisions, but the protocol is really nothing more than guidelines that demonstrate the type of decisions and care (the physician) wants carried out. And that's part of the role we as pharmacists should play with them," he says.
Four pharmacists at the center have completed training and certification and submitted a protocol to the state pharmacy board. "I think everybody knows that in healthcare today physicians are busier, having to see greater numbers of patients, and hopefully (physicians) will see this as a way that pharmacists can assist them in that practice," Kornfuhrer says.
Susan Winckler, director of policy and legislation at the American Pharmaceutical Association, points to a newly diagnosed asthmatic as a perfect case for the disease management program. The physician who has made the diagnosis and started therapy would refer the patient to the pharmacist, she explains. Then the pharmacist would meet with the patient, make sure he or she knows how to use an inhaler, and provide personal counseling about the disease and medication.
"Instead of the two or three minutes you might get with a pharmacist now, this is likely to be a 20- to 25-minute interaction to go through specific things," she says.
Stevens explains that the cost of treating the asthmatic who did not understand how to use an inhaler and ended up in the emergency room would be much greater.
"The truth is, 71% of healthcare dollars is spent on crisis management. Your costs have to do with good crisis management. What we have done is put Band-Aids on cut places. No one has really looked at how we can improve the quality of care," he says. "Two things happen in these collaborative agreements: The number of primary-care visits goes up because you, in fact, have better compliance, and the usage of medication goes up. The savings comes from crisis management dollars."
Mississippi will spend $1.9 billion on Medicaid this year. Helen Wetherbee, executive director of the Mississippi Division of Medicaid, says the state spends approximately $70 million annually on hospitalizations that could be avoided if chronically ill patients were properly managed on an outpatient basis.
Mississippi State Medical Association President Michael Carter, M.D., an otolaryngologist from Greenwood, says he has some concerns about the program but is encouraged that physicians are involved in developing the protocols.
"We're not opposed to it as long as the transaction between the physician and the patient is the fundamental transaction," Carter says. "There are a lot of occupations that can contribute, but it's not something that should be operating autonomously. All of these ancillary providers -- if they were to see their function as ancillary and not try to operate autonomously and practice medicine -- all of them have a lot to contribute."
MSMA lobbyist Charmain Thompson is more forthright in stating her reservations about the program. "There are concerns about liability; there are concerns about a patient not seeing a physician when they would be better-served going back to the physician, rather than a pharmacist," she says. "There are concerns about situations when there is a financial incentive for the pharmacist to change or increase dosage."
The medical association, which represents 3,200 of the state's physicians, plans to introduce legislation in January that would require approval of the protocols from the state board of medical license in addition to the state board of pharmacy, according to Thompson.
J. Edward Hill, a Tupelo family practitioner and American Medical Association trustee, says most physicians are taking a wait-and-see attitude.
"There are some principles that we think need to be followed in any kind of cooperative, coordinated or collaborative program with nonphysicians," he says. "Our feeling about this whole issue would be we're cautiously favorable because it could (result in) better patient outcomes, but we want it monitored very closely."
The program will, in fact, be closely monitored by the Mississippi Division of Medicaid. At 12 and 18 months into the program, the division will analyze results of collaborative interventions, looking at decreased hospital stays, increased compliance, and reports from patients and physicians. HCFA then will determine if the Medicaid waiver could be effective in other states.