Shaping Practice in Accordance w/Regulators & Payers

Shaping Practice in Accordance w/Regulators & Payers

Pharmacy managers and all pharmacists must be cognizant of the prevailing laws governing practice. However, their awareness and behaviors must transcend merely what is legal and also consider the various agencies and external programs overseeing or incenting pharmacy practice.

The organizations that sponsor health plans and help pay for patients’ prescriptions have much to say about what is desired from pharmacies. The Centers for Medicare and Medicaid Services (CMS) oversees the Medicare and Medicaid programs, both of which account for a considerable portion of prescriptions and medication orders dispensed in community and inpatient settings. CMS has developed a Five-Star Quality Rating System to evaluate the performance of health plans and to some extent the performance of pharmacies in the network of those plans. The rating system considers patient adherence to medications as a key evaluative outcome.

A study by George et al used the Theory of Planned Behavior to determine what pharmacists might suggest to improve these ratings.1 Focus groups of these pharmacists noted that the Star Ratings program could take a closer look at patient safety, thus rewarding participating health plans and pharmacies in averting untoward patient outcomes. The focus group participants also highlighted the importance of pharmacy managers properly evaluating various technologies available to enhance practice and the financial penalties that pharmacies might encounter if not compliant with CMS Star Ratings objectives. The participants in the study believed that more education and training of pharmacists to help them understand these Star Ratings and other such programs were critical.

Additional information on Compliance with Regulations and Regulatory Bodies and Management Functions can be found in Pharmacy Management: Essentials for All Practice Settings, 4e. If you or your institution subscribes to AccessPharmacy, use or create your MyAccess Profile to sign-in to Pharmacy Management: Essentials for All Practice Settings, 4e. If your institution does not provide access, ask your medical librarian about subscribing.

1George DL, Smith MJ, Draugalis JR, et al. Community pharmacists’ beliefs regarding improvement of Star Ratings scores using the Theory of Planned Behavior. J Am Pharm Assoc. 2018;52:21-29.