The Centers for Medicare and Medicaid Services (CMS) issued a proposed rule during the first week of October 2011 that had major implications for Long Term Care (LTC) consultant pharmacists and pharmacies. The rule was entitled, "Medicare Program; Proposed Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs for Contract Year 2013 and Other Proposed Changes; Considering Changes to the Conditions of Participation for Long Term Care Facilities."
Among many other proposed changes the rule included language targeting LTC pharmacies and consultant pharmacists. CMS states they are concerned with financial arrangements that involve payments from pharmaceutical manufacturers directly or indirectly to LTC pharmacies and in turn the LTC consultant pharmacist encouraging physicians to prescribe the manufacturer's drug(s) for residents. As a result, the arrangements brought into question the ability of the LTC consultant pharmacists to provide impartial reviews of the residents' drug regimens, which in turn raises concerns regarding the quality of those reviews and potential impact on resident health and safety. They are also concerned about the consultant pharmacists’ direct relationships with pharmaceutical manufacturers. CMS also says in verbal conversations with industry representatives, they have been informed that LTC pharmacies typically provide the consultant pharmacists to nursing homes at rates that are well below the LTC pharmacies cost and below fair market value.
CMS was considering requiring that LTC facilities employ either directly or indirectly contract the services of a licensed pharmacist who is independent. CMS considered including a definition of the term "independence” to mean that the licensed pharmacist must not be employed, under contract, or otherwise affiliated with the facility's pharmacy, a pharmaceutical manufacturer, distributor, or any affiliate of these entities. It was CMS’s goal that the consultant pharmacist would be free from any financial arrangements that would inhibit the consultant pharmacist from providing an unbiased review.
In the first week of April 2012 CMS released a final rule and it decided not to pursue the regulation that would have required consultant pharmacists to be independent but rather invited further comments regarding the subject. While for the time being the CMS rule is suspended the idea that the need for quality clinical pharmacy services is strong and will these services will continue to be evaluated by CMS.
What is a Consultant Pharmacist?
The term consultant pharmacist can mean a number of things. The American Society of Consultant Pharmacists (ASCP) defines it as, “pharmacist who is paid to provide expert advice on the use of medications by individuals or within institutions, or on the provision of pharmacy services to institutions.” CMS requires a consultant pharmacist to visit a licensed nursing facility on a monthly basis to provide drug regimen reviews for all patients within the facility. Duties in the facility include documenting proper medication use, making recommendations to prescribers for optimal use, evaluating medication distribution by the nurses to the patients, serving on quality assurance committees and a number of special duties needed by the facility. In a sense any medication related activity at the nursing facility needs the consultant pharmacist to oversee.
While there is no specific criteria for becoming a consultant pharmacist a strong background in geriatric pharmacotherapy is important. Having the knowledge to make quality recommendations and being able to determine what medications and doses should not be used in a geriatric resident will provide a good base. Many consider being a Certified Geriatric Pharmacist (CGP) a good indicator of the level of knowledge and commitment it takes to make a strong consultant pharmacist. The CGP is a NCCA accredited credential used to validate that a pharmacist has demonstrated advanced knowledge in the principles of geriatric pharmacotherapy and provision of pharmaceutical care to the elderly.
It is also important to know the regulatory guidelines set forth by CMS regarding medication use. One important aspect of consulting pharmacy is making sure the nursing facilities are following established guidelines to avoid patient harm and financial penalties for the long term care facility. Long term care facilities are inspected by a state agency (department may vary from state to state) on an annual basis or more often if a complaint or patient injury is needed to be investigated. The department uses direction from The State Operations Manual, Appendix PP, that has rules for proper medication use in long term care facilities and it is these guidelines that the consultant pharmacist will have to be familiar with in order to monitor the facility properly.
While the new rule has been suspended, it is a great step that CMS has asked our profession to be paid specifically for our knowledge and without having ties to drug dispensing. Many experts in the industry think that some form of this rule may continue to be explored in the future. In the meantime independent consultant pharmacists may contract directly with long term care facilities to provide pharmacy consulting services. An independent contractor will have to determine how much it will cost to deliver the service to come up with a fair price to charge the nursing facility for their services. Costs incurred by the pharmacists will include travel time, vehicle wear, technology equipment, technology repair and upkeep, printing costs, etc. These can range depending on how far the facility is and how many residents the facility typically has.
The challenge will be the initial cost to the nursing facility. Traditionally, many nursing facilities have not incurred the full expense of the pharmacist’s time as LTC pharmacies have often used the consulting aspect as a loss leader to keep costs down for their facilities. If the independent consultant pharmacist can demonstrate superior pharmaceutical care a higher price associated with this may be justified in the eyes of the long term care facility. Ways to demonstrate greater service may include pharmacoeconomic reviews for the skilled residents (skilled residents’ care is paid by a per diem from Medicare and any money saved from the procurement of pharmaceuticals would increase the facilities revenue), helping decrease hospital readmissions and helping to make sure medications are properly monitored so facilities can avoid financial penalties during the survey process. If a savvy, entrepreneurial minded independent consultant pharmacist can demonstrate these attributes they may find a lucrative field in consulting pharmacy.