Professional Practice
Clinical pharmacists are licensed professionals with
advanced education and training who practice in all
types of patient care settings. They participate as
members of the health care team to provide high-qual-
ity, coordinated, patient-centered care to ensure that
individuals and populations achieve the best possi-
ble outcomes from their medications. Clinical phar-
macists assess medication-related needs, evaluate
medication therapy, develop and implement plans of
care, and provide follow-up evaluation and medica-
tion monitoring in collaboration with other members
of the health care team. In the course of this prac-
tice, clinical pharmacists interpret diagnostic and lab-
oratory tests, identify the most appropriate drug and
nondrug therapies, and teach patients and caregiv-
ers about medications and how to use them. They
also serve as health care researchers, university and
college faculty, medication information specialists,
organizational leaders, consultants, and authors of
books and articles on pharmacology and medication
therapy.
Education
Today’s clinical pharmacists complete 6–8 years of
undergraduate and professional education leading to
the doctor of pharmacy (Pharm.D.) degree, including
2–3 years of coursework that emphasizes pharma-
cology and the clinical assessment, monitoring, and
treatment of disease; and 1–2 years in supervised,
direct patient care settings, where, as members of the
health care team, they engage in the assessment,
treatment, monitoring, and teaching of patients. They
also complete 1–2 years of accredited postgraduate
residency training as licensed clinical practitioners,
where they work in team-based settings under the
guidance of expert practitioners in clinical pharma-
cy and other health disciplines. Clinical pharmacists
achieve board certication in their area(s) of special-
ization and maintain competence through recertica-
tion, mandatory continuing education, and self-direct-
ed continuous professional development.
Accountability
As accountable members of the health care team,
clinical pharmacists establish and maintain written
collaborative practice agreements with individual
physicians, medical groups, or health systems and/
or practice under formally granted clinical privileges
from the medical staff or credentialing system of the
organization in which they practice. These agree-
ments, together with state pharmacy practice acts,
confer specic authorities, responsibilities, and ac-
countabilities to the clinical pharmacist. Clinical phar-
macists are committed to promoting quality care that
improves patients’ health outcomes. This is accom-
plished by leading and participating in health care
organizations, conducting research, disseminating
research ndings, and applying these ndings to clin-
ical practice.
Responsibility
Clinical pharmacists have a covenantal, “ducial” re-
lationship with their patients. This relationship relies
on the trust placed in the clinical pharmacist by the
patient and the commitment of the clinical pharmacist
to act in the best interests of individual patients and
patient populations. Clinical pharmacists exhibit the
traits of professionalism: responsibility, commitment
to excellence, respect for others, honesty and integ-
rity, and care and compassion. They subscribe to the
pharmacy profession’s code of ethics and adhere to
all pharmacist-related legal and ethical standards.
Clinical pharmacists also assume responsibility for
advancing their discipline through involvement in pro-
fessional societies and participation in health policy
at local, state, national, and international levels.
Practice Advancement
Issue Brief
1
Payment Models, Part 2 August 2018
Purpose
ACCP Pracce Advancement Issue Briefs are developed
and published to provide concise informaon and
insights for clinical pharmacists and their medical and
pracce administraon colleagues involved in direct
paent care. They are intended to help support the
development, advancement, and posioning of clinical
pharmacists as integrated direct paent care providers
within team-based medical pracces and delivery
systems. The issue briefs are regularly updated to ensure
alignment with developments in the advancement of
clinical pharmacy pracce.*
The informaon contained in these issue briefs can
be useful in both inial and ongoing discussions and
decisions about the scope of services and collaborave
pracce responsibilies of clinical pharmacists,
parcularly when physicians or medical administrators
are exploring or being encouraged to consider
incorporang or expanding clinical pharmacists
within pracces. The greatest ulity and value of this
informaon may lie in supporng specic conversaons
with medical directors, nance and revenue directors,
pracce managers, and others involved in the business
operaons of pracces once the decision to incorporate
or increase the number of clinical pharmacists within
the pracce has been made.
Background
The Medicare Access and CHIP Reauthorizaon Act
of 2015 (MACRA) established compensaon models
focused on shiing health care from fee-for-service to
value-based care with a payment approach called the
Quality Payment Program (QPP). The QPP is focused
on rewarding the delivery of high-quality paent care
through two avenues: the Merit-Based Incenve
Payment System (MIPS) and advanced Alternave
Payment Models (advanced APMs).
1
How Pharmacists Can Add Value Under MIPS
Inially, most eligible providers will fall into MIPS, which
aims to shi payment to Medicare Part B clinicians using
a performance-based payment model. The pracce will
receive bonuses or penales, depending on the quality
and cost of the care provided. CMS determines the
payment adjustments according to a MIPS composite
score with four performance categories: quality,
promong interoperability (PIs), improvement acvies
(IAs), and cost.
2,3
MIPs-eligible clinicians will have to choose and report
the acvies and measures most meaningful to their
pracce. Although pharmacists are not currently
MIPS-eligible clinicians, they can contribute to the
key performance categories, given that pharmacists
Payment Methods in Outpatient Team-Based Clinical
Pharmacy Practice, Part 2: MACRA for Pharmacists
*ACCP Clinical Pracce Advancement Resources include issue briefs, products, services, and educaonal resources essenal for integraon
of clinical pharmacy services into contemporary team-based health care delivery. Topic areas include, but are not limited to, Standards of
Pracce; Clinical Services Operaons (e.g., payment mechanisms, collaborave pracce agreements and business structures); Medicaon
Use Quality Improvement through Outcome Measurement; and Leadership in Pracce Advancement and Transformaon.
2
Payment Models, Part 2 August 2018
can directly inuence many of the medicaon-related
measures (Table 1) such as chronic ancoagulaon
therapy, persistence of β-blocker treatment aer
a heart aack, and adherence to anpsychoc
medicaons for individuals with schizophrenia. While
Table 1 specically analyzes these medicaon-related
measures, pharmacists can also indirectly contribute
to many more of the quality and improvement acvity
measures, such as managing pain control for paents
within 48 hours, establishing standard operaons to
manage transions of care, and engagement of paents,
family and caregivers in developing a plan of care.
Chronic care management consumes 37% of primary
care providers’ me. This oen entails managing com-
plex medicaon regimens.
4
Pharmacists who are inte-
grated into a value-based model can focus on the med-
icated-related measures of MIPS so that physicians and
other members of the care team can focus on their
respecve measures to achieve highest value and cost
savings. Pharmacists can also play an essenal role in
developing and priorizing services in order to align
them to the performance measures through discussions
with the organizaon’s leaders.
5
In addion to contribung directly to the MIPS
performance measures in a wide range of primary care
and specialty pracces, pharmacists have an enhanced
opportunity to contribute in paent-centered medical
homes (PCMHs),
6
which automacally receive full credit
in the IA category.
7
Because IAs contribute 15% to the
composite score for payment, it would be strategic for
pharmacists to leverage their value and integrate into
PCMH sengs, given that PCMHs are beer organized
to meet quality measures.
One of the most valuable ways pharmacists can con-
tribute to the PCMH is through providing comprehen-
sive medicaon management (CMM) services. CMM
is dened as the standard of care that ensures each
paent’s medicaons are individually assessed to deter-
mine whether they are appropriate for the paent,
eecve for the medical condion, safe given the
comorbidies and other medicaons being taken, and
able to be taken by the paent as intended.
8
Each year,
4.5 million adverse drug events are esmated to occur
in the ambulatory seng, associated with 400,000
hospitalizaons.
9
Return on investment of medicaon
management services has ranged from 3:1 to 12:1
annually, with the ability to decrease hospital
admissions, physician visits, emergency department
admissions, and the inappropriate use of medica-
ons.
10,11
By integrang CMM into a PCMH, paents’
medicaon use can be opmized, resulng in increased
quality and payment for the medical pracce.
6
How Pharmacists Can Add Value Under
Advanced APMs
Advanced APMs, such as the Next Generaon ACO
Model, Oncology Care Model, Comprehensive Primary
Care Plan program, and Comprehensive ESRD Care
Organizaons, use a payment approach that provides
added incenves to pracces that provide quality and
cost-ecient care to paents. Pracces can receive
higher bonuses in advanced APMs than in MIPS
because of the increased risk incurred by the pracce in
advanced APMs.
12
Currently, PCMHs are not considered
advanced APMs under MACRA. However, many of the
requirements to be a PCMH will posion pracces to
meet the requirements of an advanced APM. Having
pracces shi to an APM model is the ulmate goal
of MACRA. Therefore, pharmacists who can integrate
CMM within PCMHs can also contribute to the cost
savings in advanced APMs.
To sustain and enhance their revenue stream, providers
are adapng their business model to ensure value
generaon. The lack of discrete payment and billing for
pharmacists’ services has been a historical barrier to
integrang pharmacists into team-based care. However,
Table 1. Medicaon-Related MIPS Performance
Measures
Performance Measure
Category
a
% MIPs
Composite
Score
a
% Medicaon-
Related
Measures
b
Quality 50 ~25
Improvement
Acvies
15 ~25
Promong
Interoperability
25 ~20
Cost
c
10 N/A
a
Department of Health and Human Services, Centers for Medicare &
Medicaid Services (CMS). The quality payment program. Available from
www.qpp.cms.gov. Accessed August 29, 2018.
b
CMS measures in each category (275 for quality, 114 for improvement
acvies, 15 for promong interoperability) determined, according to
clinical judgment, to be medicaon related. The total number of medicaon-
related measures for each category was used to determine the percentage
of medicaon-related measures for the respecve category.
c
The two cost measures [Medicare Spending Per Beneciary (MSPB) and
Total Per Capita Costs (TPCC)] are not directly medicaon-related, however,
by contribung to the measures in the other categories, pharmacists may
help decrease these measures.
3
Payment Models, Part 2 August 2018
the MACRA environment allows pharmacists to be
increasingly integrated into the value-based model in
team-based pracces. For example, MACRA provides
an economic raonale for pracces to pay a salary for
pharmacists to be part of their team to drive health
outcomes and generate value-based revenue for the
pracce. Moreover, pharmacists can be embedded in
primary care pracces through a co-funded partnership
between the pracce and a health system or pharmacy
school. Organizaons may also create a shared resource
contractual agreement in which the pharmacist provides
medicaon management services for mulple pracces
that share the overhead costs.
5
As pharmacists’ involvement in value-based care
evolves and unl other payment mechanisms are in
place, pharmacists can now be seriously considered
for inclusion in team-based pracces because of the
improved health outcomes and enhanced value they
have been shown to produce. MACRA and its impact on
transioning health care to a value-based environment
posively incenvizes pracces to integrate pharmacists
into the team-based care structure.
References
1. Centers for Medicare & Medicaid Services (CMS). Medicare
program; Merit-Based Incenve Payment System (MIPS) and
Alternave Payment Model (APM) incenve under the physi-
cian fee schedule and criteria for physician-focused payment
models (81 FR 77008). Federal Register. November 4, 2016.
2. Manchikan L, Helm S II, Calodney AK, et al. Merit-
based incenve payment system: meaningful changes
in the nal rule brings cauous opmism. Pain Physician
2017;20:E1–E12.
3. American Academy of Family Physicians (AAFP). Resources
for the Medicare Access and CHIP Reauthorizaon
Act (MACRA). Available from www.aafp.org/pracce-
management/payment/medicare-payment.html. Accessed
August 28, 2018.
4. Ghorob A, Bodenheimer T. Sharing the care to improve
access to primary care. N Engl J Med 2012;366:1955–7.
5. Smith MA. Implemenng primary care pharmacist ser-
vices: go upstream in the world of value-based payment mod-
els. Res Social Adm Pharm 2017;13:892–5.
6. Smith MA, Bates DW, Bodenheimer T, Clearly PD. Why
pharmacists belong in the medical home. Health A
2010;29:906–13.
7. Department of Health and Human Services, Centers for
Medicare & Medicaid Services (CMS). Quality payment pro-
gram. Available from www.qpp.cms.gov. Accessed August 28,
2018.
8. Paent-Centered Primary Care Collaborave (PCPCC). The
paent-centered medical home: integrang comprehen-
sive medicaon management to opmize paent outcomes.
Available from www.pcpcc.org/sites/default/les/media/
medmanagement.pdf. Accessed August 28, 2018.
9. Sarkar U, Lopez A, Maselli JH, Gonzales R. Adverse drug
events in US adult ambulatory medical care. Health Serv Res
2011;46:1517–33.
10. Ises BJ, Schondelmeyer SW, Artz MB, et al. Clinical
and economic outcomes of medicaon therapy manage-
ment services: the Minnesota experience. J Am Pharm Assoc
2008;48:203–11.
11. Cipolle R, Strand L, Morley P. Pharmaceucal care prac-
ce: the clinician’s guide. New York: McGraw-Hill, 2004.
12. Casalino LP. The Medicare Access and CHIP Reauthorizaon
Act and the corporate transformaon of American medicine.
Health A 2017;36:865–9.
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Disclaimer: This brief is provided for informaonal purposes only. It does not take into consideraon your specic circumstances or the
laws and regulaons of applicable jurisdicons. It should not be construed as legal or professional advice, or as a substute for obtaining
legal or professional advice. Addionally, ACCP disclaims all liability regarding any acons taken or not taken based on this brief.
Copyright ©2018 by the American College of Clinical Pharmacy. All rights reserved. This publicaon is protected by copyright. No part of
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