There’s both good and bad news when it comes to pharmacists billing for inpatient clinical services, according to a presentation at the 2024 ACCP Annual Meeting, in Phoenix.
First, the bad news: Getting paid for these services “is fraught with insurmountable roadblocks, even in the states where billing for services in the outpatient setting is becoming a norm,” said Maya Campara, PharmD, FCCP, the coordinator of transplant clinical pharmacy services at the University of Illinois Hospital and Health Sciences System, in Chicago.
Dr. Campara noted that pharmacists do not enjoy federal provider status. And even in states that allow direct billing by pharmacists to state or private insurers, hospital or medical staff bylaws may supersede that authority in the inpatient setting.
But here’s some of that good news: Pharmacists can learn a lot from advanced practice provider colleagues, who struggled for decades to earn the privilege to bill for their inpatient work in a fee-for-service payment model.
Additionally, value-based care (VBC) is gaining traction. “The introduction of VBC models has created a tremendous opportunity for clinical pharmacists,” Dr. Campara noted. “We add value to transplant programs, not via a direct billing pathway but indirectly through cost-containment efforts, efficiency optimization and quality improvement—skills that are at the core of every clinical pharmacist’s tool kit.”
Transplant pharmacists “are mandatory members of a transplant team,” Dr. Campara added, per federal regulations enforced by the Centers for Medicare & Medicaid Services (CMS), the largest payor for transplants in the United States. CMS pays flat lump sums for every transplant, and this covers transplant pharmacist salaries.
“This makes our case unique, because CMS pays for our participation in a transplant program,” she said, freeing up funds to hire more transplant pharmacists or develop more services. (For more details on CMS’s Conditions of Participation for transplant programs, see bit.ly/3ZkCX6S.)
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Making the Case for Clinical Pharmacy Services
Once hospital pharmacy leaders have acquired new funds, perhaps through offsets from a value-based billing model, they may wish to hire new positions. This is possible, but not a request to be made lightly. “Hiring people is a big deal,” said Eric Tichy, PharmD, MBA, the chair of the Division of Pharmacy Supply Solutions at Mayo Clinic, in Rochester, Minn. “Pharmacists are well compensated, and labor is the largest percentage of expense in healthcare, so administrators will need to see a return on investment to approve new positions.”
Some returns on investment require a ramp-up of staff, Dr. Tichy noted. It might be worth it to hire a pharmacist who can free up physician time, for example, so that the physician can bill for higher-cost services. This new revenue should offset the costs of hiring the pharmacist at a minimum, and ideally generate new income.
Pharmacists also can add value with current staff, noted Dr. Tichy, who is a member of the Pharmacy Practice News advisory board. Ensuring that a greater percentage of prescriptions are filled in a health system pharmacy brings in new revenue. Shortening inpatient length of stay lowers costs. This should never mean discharging anyone prematurely, but rather optimizing inpatient medication to safely reduce inpatient time and ensure a smooth transition home. “You may not directly be reimbursed for these efforts, but it helps the bottom line of the organization,” Dr. Tichy said. “If there’s a return on investment that’s attributable to pharmacist interventions, then you can use it to justify adding positions.”
For example, positions in endocrinology that focus on diabetes management might fund enhanced medication therapy management services or greater community outreach to encourage preventive care.
Start Small
Whatever the pharmacist’s vision, it will be easier to secure funding after already demonstrating value, Dr. Tichy advised. “You can ask residents or trainees to pilot a concept,” he said, which taps into their enthusiasm while producing data that hopefully convince an administrator to green-light a larger effort.
“It’s critical to understand what administrators value,” Dr. Tichy said, which will generally be efforts that increase income and/or lower costs.
Dr. Campara reported no relevant financial disclosures. Dr. Tichy reported financial relationships with GSK, Lilly, Pfizer, Sanofi and Takeda.
This article is from the January 2025 print issue.