Reimbursement for nondistributive pharmaceutical services in hospitals

Area of Science:

• Health Services Research
• Pharmacy Administration

Background:

• Reimbursement for clinical pharmacy services is a significant challenge.
• Existing models for supporting clinical services include cost allocation and revenue subsidization.

Purpose of the Study:

• To review the literature on third-party payer reimbursement for clinical pharmacy services.
• To identify successful strategies and guidelines for obtaining reimbursement.
• To propose a framework for securing reimbursement.

Main Methods:

• Literature review of published reports on clinical pharmacy services with third-party reimbursement.
• Analysis of successful reimbursement strategies and published guidelines.
• Development of an eight-point guide for obtaining reimbursement.

Main Results:

• Successful reimbursement has been achieved for services in cardiac rehabilitation, patient education, pharmacokinetics, and lab interpretation.
• Key elements for successful reimbursement include administrative commitment, cost-benefit analysis, and payer requests.
• An eight-point guide is recommended for obtaining reimbursement.

Conclusions:

• Third-party payer reimbursement is a positive step for clinical pharmacy services.
• Separating clinical service charges from drug product charges is recommended.
• Further research and program development are necessary to advance reimbursement efforts.