Pharmacy News

Informatics Group Sees Role for Pharmacy in Insurance Exchanges

[March 1, 2013, AJHP News]

Kate Traynor

BETHESDA, MD 13 Feb 2013—Pharmacy informatics proponents want to ensure that the profession is recognized as an essential part of federal and state efforts to establish health insurance exchanges.

An important way to do this, according to the Pharmacy e-Health Information Technology Collaborative, is for health insurance exchange participants to incorporate clinical data from electronic health records (EHRs) into quality measures that now rely on claims-based data.

Claims-based data, according to the collaborative, fail to record patients' use of nonprescription medications, dietary supplements, and some cash purchases. Thus, the data do not produce the clinically complete medication history that is essential to improving patient care.

"Right now, all of our quality measures are based off of claims-based information or specific reporting that quality organizations are asking for, so it's after the fact," said Shelly Spiro, the collaborative's executive director.

"The idea for the future, when we go to a payment-for-performance model, is to be able collect that data directly out of the electronic health record and not have to stop to submit a form for a claim or not have to stop and submit a quality report," she said.

Ideally, she said, the automatically collected data would capture medication management and reconciliation, allergy screening, vaccinations, and other services performed by pharmacists.

Karl Gumpper, director of ASHP's Section of Pharmacy Informatics and Technology, said the collaborative is working to develop the pharmacist–pharmacy provider EHR. Also called the PP-EHR, the system will use standards jointly developed by the National Council for Prescription Drug Programs and Health Level Seven International.

"This should ensure that the PP-EHR would be functional in all pharmacy settings," Gumpper said.

Gumpper said that incorporating pharmacy-specific codes and claims data would create a robust system for documenting pharmacists' services and providing coordinated patient care.

For example, he said, a patient may receive a flu shot at a community pharmacy. The pharmacist then documents the injection in the PP-EHR, which notifies the state's immunization registry, the patient's primary care provider and insurer, and, possibly, the patient's personal health record system.

He said the collaborative envisions having the PP-EHR available as a standalone product or an add-on to an existing EHR system.

"The one requirement to make this all work would be a bidirectional interface and exchange of data between all providers," Gumpper said.

The collaborative, in response to a request for information from the Centers for Medicare and Medicaid Services (CMS), stated December 27 that the inclusion of pharmacists' clinical services in EHR quality reporting will improve health outcomes. The comments call for adopting measures supported by the Pharmacy Quality Alliance (PQA), of which ASHP is a member; ASHP is also a member of the collaborative.

PQA-endorsed measures address a variety of clinical conditions that require drug therapy, including diabetes, hypertension, cardiovascular disease, and asthma, as well as care for the elderly, and medication review and reconciliation.

In comments to the CMS, the pharmacy collaborative stated that the use of this type of data in health insurance exchanges will help meet a federal goal to foster and support the transfer of health information technology (HIT) data.

The goal is one of five described in the Office of the National Coordinator for Health Information Technology's Federal Health IT Strategic Plan, which was finalized in 2011.

The strategic plan emphasizes financial incentives to speed the adoption and meaningful use of HIT throughout the health care system.

In its comments, the collaborative noted that pharmacists collect and report electronic health care quality information and clinical data that are part of meaningful-use initiatives. This occurs even though pharmacists do not directly qualify for federal meaningful-use incentive payments that are available to some health care providers and entities.

Meaningful use requires the adoption, by Department of Health and Human Services (HHS)-designated entities, of qualifying electronic medical record systems that include clinical decision support, performance measurement, and information exchange and the use of these systems to meet HHS-specified objectives.

According to the collaborative's comments, research indicates that pharmacists' participation in meaningful-use-type activities can help prevent unnecessary hospitalizations, a federal priority.

Exchanges. Health insurance exchanges are scheduled to begin facilitating the purchase of private insurance coverage by consumers and small businesses starting in 2014. Open enrollment in the insurance programs begins this October.

By early January, 19 states and the District of Columbia had received conditional approval from HHS to run their own insurance exchange or partner with the federal government to operate a hybrid exchange. The deadline for applying to establish a hybrid insurance exchange was February 15.

In states that do not establish their own insurance exchange or partner with the federal government, HHS will establish so-called federally facilitated exchanges. HHS is also obligated by statute to establish exchanges in states whose planned marketplaces are not expected to be operational by January 1, 2014.

HHS is responsible for developing standards by which insurance exchange participants must collect and transfer health care quality data and other important information. Quality data on health plans that participate in the exchanges will be made publicly available.

Quality reporting standards for health plans in the exchanges go into effect in 2016. Data related to the accreditation of plans may be available before then.

Prescription drugs and chronic disease management are among the 10 essential benefits that must be included in all insurance plans in the exchanges.

Provider status. The collaborative's comments did not directly address the idea of attaining recognition for pharmacists as health care providers under Medicare. But Gumpper said the ideas put forth by the collaborative help lay the groundwork for achieving that goal.

For example, he said, the collaborative's proposed PP-EHR system would allow pharmacists to collect and analyze data to support the request to be considered health care providers, eligible providers for meaningful-use incentives, or both.

Gumpper also said the PP-EHR system would also ensure that pharmacists' services would be documented in patient-centered medical home and accountable care organization models that CMS is supporting.


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