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9/19/2000

Iowa Medicaid to Begin Paying Pharmacists in Case Management Project

Nancy Tarleton Landis

In October the Iowa Medicaid program will begin reimbursing participants in a pharmaceutical case management (PCM) project. University of Iowa researchers will identify eligible patients (Medicaid beneficiaries who take four or more regularly scheduled nontopical medications, do not live in nursing homes, and have at least 1of 12 specified diseases) and will inform participating pharmacists of the eligibility of a patient under their care for PCM. The project will run through 2002, and the university researchers will evaluate the impact of PCM services.

Cheryl Clarke, a pharmacist and senior vice president for clinical and quality assurance services of the Iowa Pharmacy Association, said health-system pharmacists in ambulatory care pharmacy sites were among those applying to participate. All Medicaid pharmacy providers in the state were eligible to apply. 

When notified that a patient is eligible for PCM, the pharmacist will encourage the patient to participate and will contact the patient's physician. Once all agree to participate, the team will decide how to communicate with each other, the pharmacist will perform an initial assessment and propose a plan, the physician will review these, and the team will establish an appropriate time for a follow-up assessment. If the goals of the plan are achieved and no new medication-use problems arise, the pharmacist will schedule a six-month preventive assessment with the patient. If new problems do arise, the process can be restarted. 

Pharmacists will submit claims for their services on Health Care Financing Administration form 1500. Payments (for services to each patient) will be $75 for the initial assessment, $40 for follow-up (maximum of four per 12 months) and new-problem (maximum of two per 12 months) assessments, and $25 for preventive assessment (maximum of one per six months). 

Clarke said it would be determined by the end of August which pharmacy and pharmacist applicants were eligible. Pharmacy criteria included having a private patient consultation area and having a problem-oriented, longitudinal patient record system. Pharmacist applicants were required to submit five care plans (single SOAP notes [with subjective and objective evaluation, assessment of the patient, and a plan for optimal drug therapy] or encounter notes on one or more patients) demonstrating the pharmacist's ability to document patient care. 

Pharmacist applications were contingent on completion of a training program approved by the state Department of Human Services (DHS) and meeting the criteria of the project's advisory committee. Initially approved were any Pharm.D. program and that of the Iowa Center for Pharmaceutical Care. Additional programs gaining approval were broad based (e.g., ASHP's ambulatory care clinical skills program and an APhA advanced practice institute), rather than focused on a single disease, Clarke said. 

State legislation established the project and called for an advisory committee representing the state medical society, state pharmacists association, and DHS. The state's share of the costs of evaluating the PCM services provided will come from the Iowa Pharmacy Foundation (IPF). The McKessonHBOC Foundation and the Community Retail Pharmacy Coalition's Institute for the Advancement of Community Pharmacy have joined IPF as funding partners. Including the federal match of 50%, the evaluation costs will be about $600,000 over three years. 

Clarke said the advisory group has been meeting for more than a year, hammering out exactly how requirements should be stated. The group includes four pharmacists (two practicing in community settings, one from a hospital, and one from long-term care). The state medical society also had four slots on the committee. Clarke said two physicians, representing family medicine and osteopathic medicine, have actively participated.