Pharmacy News

California Medicaid To Pay for Five Pharmacist Services Other Than CMM

[December 1, 2016, AJHP News]

Cheryl A. Thompson

BETHESDA, MD 11 Nov 2016—Two bills authorizing the California Medicaid program, Medi-Cal, to pay fees for pharmacist services met different fates in the 2015–16 legislative session.

Assembly Bill 1114 reached the desk of Governor Edmund G. Brown, Jr., who signed the legislation into law on September 25.

Once the California Department of Health Care Services implements the law, Medi-Cal will cover pharmacist services for travel medications, naloxone hydrochloride, self-administered hormonal contraception, vaccinations, and nicotine-replacement products furnished to program beneficiaries.

An appropriations committee analyst had concluded that the bill's fiscal effect would likely be an overall cost savings to the program despite one-time costs to alter Medi-Cal's payment-processing system.

Assembly Bill 2084, authorizing Medi-Cal coverage for comprehensive medication management (CMM), reached an appropriations committee but did not progress.

A committee analyst concluded that the bill would likely increase Medi-Cal's expenses because of the "broad definition of who is eligible [for CMM] and the comprehensive nature of the service."

Further, there was concern as to whether CMM is a good fit for a fee-for-service (FFS) payment system.

"[P]hilosophically it seems CMM is addressing more a question of ‘how' (ensuring medications are optimized and meeting clinical goals) than ‘what' (delivering CMM as a distinct service)," the analyst wrote. "Thus, it does not appear to be something that is neatly defined and billed on a FFS basis."

Although the CMM bill did not fare well at the statehouse this time, California Society of Health-System Pharmacists (CSHP) past president Steven Gray called the experience a good one.

"It was wise to introduce it," he said of the CMM bill, because that "got the conversation going" with legislators.

Of the 17 legislators at the Assembly Health Committee's April 5 hearing on the bill, all voted in favor of it [see May 15, 2016, AJHP News].

Gray was optimistic that the state's pharmacy professional groups will again try to get a CMM bill through the legislative process.

California's system of two-year legislative sessions, he touted, "gives us a chance to build consensus" before time runs out for a new bill.

"I think that's a big reason why we've been so successful in changing [pharmacists'] scope of practice," Gray said.

Gray was president of CSHP when it and the California Pharmacists Association worked toward passage of the 2013 bill that added to pharmacists' scope of practice four of the five services specified in Assembly Bill 1114. He is the pharmacy professional affairs leader for Kaiser Permanente National Pharmacy Programs and Services and 2015–16 president of the Pharmacy Society for Pharmacy Law.

Keith Yoshizuka, chair of CSHP's Government Affairs Advisory Committee, said the organization supported Assembly Bill 1114. He said CSHP sought amendments to ensure that the bill would not jeopardize reimbursement for established pharmacist-provided services, such as blood glucose and anticoagulation monitoring, in the settings where the vast majority of CSHP members practice.

Yoshizuka, an assistant dean at Touro University California College of Pharmacy in Vallejo, credited Gray for pointing out that the bill seemingly excluded any pharmacist not working in a pharmacy from providing services.

On August 15, the bill was amended with the following statement: "This section does not restrict or prohibit any services currently provided by pharmacists as authorized by law."

The scheduled fees for the five pharmacist services are to be 85% of those specified in Medi-Cal's fee schedule for physician services, the new law states.

However, CSHP obtained assurance from the Department of Health Care Services that the bill's wording would not change the reimbursement rate for services provided by pharmacists under collaborative practice agreements with physicians in medical groups, clinics, and health systems, said Tim Valderrama of the Weideman Group in Sacramento.

Valderrama, CSHP's lobbyist at the capitol, said those pharmacist-provided collaborative services are already paid under Medi-Cal's medical benefit at 100% of the physician fee.

To Gray, the purpose of Assembly Bill 1114 was to ensure that pharmacists would be paid for providing the patient care services allowed by the 2013 bill, which did not address payment for pharmacist services.

But he expressed concern as to whether Medi-Cal will cover a pharmacist-provided patient care service if no medication is dispensed.

Gray said he has heard, for example, that a pharmacist needs 20–40 minutes to follow the protocol approved by the California State Board of Pharmacy and the Medical Board of California for furnishing self-administered hormonal contraceptives.

If, after following the protocol, the pharmacist determines that the patient is not an appropriate candidate for self-administered hormonal contraception and should seek follow-up care with her primary care provider, he speculated, how would this pharmacist bill for the time spent providing the service but not dispensing the medication?

Gray said CSHP and other segments of the state's pharmacy profession are already starting to consider how to work with the Department of Health Care Services on implementing the law.


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