Pharmacy Participation and Claim Characteristics in the Wisconsin Medicaid Pharmaceutical Care Program from 1996 to 2007

BACKGROUND: Under the 1995 Wisconsin Act 27, the biennial budget, Wisconsin Medicaid was required to develop an incentive-based pharmacy payment system for pharmaceutical care (PC) services. Started on July 1, 1996, the Wisconsin Medicaid Pharmaceutical Care Program (WMPCP) is the longest currently ongoing Medicaid program to compensate pharmacists for nondispensing services. The program reimburses pharmacies for providing PC services that increase patient compliance or prevent potential adverse drug problems by paying an enhanced PC dispensing fee. Pharmacists can bill for PC services provided to Wisconsin Medicaid fee-for-service and SeniorCare (i.e., state prescription drug assistance program for low-income seniors) beneficiaries. OBJECTIVES: To examine trends in (a) the number of pharmacies participating in the WMPCP and the intensity of participation among participating pharmacies; and (b) frequencies of reason, action, result, and level-of-service (time) codes associated with PC service claims from July 1, 1996, through June 30, 2007, which represents Wisconsin state fiscal years (SFYs) 1997 through 2007. METHODS: A retrospective, longitudinal, and descriptive research design was used to analyze all paid claims for PC services provided to Wisconsin Medicaid fee-for-service and SeniorCare recipients during SFYs 1997 through 2007. The total number of paid PC claims and the average number of claims paid per pharmacy were examined to determine trends in pharmacy participation. Mean annual reimbursement amounts for PC per claim and per pharmacy were calculated. Reason, action, result, and level-of-service (time) codes that appeared in the claims were grouped into categories and analyzed to characterize the total number of claims paid overall and per SFY. RESULTS: During the study period, one-half (n = 601) of the approximately 1,200 licensed pharmacies in the state of Wisconsin were paid for a claim through the WMPCP. However, intensity of participation in the WMPCP was low, with 57% of all participating pharmacies being paid for 10 or fewer PC claims and 19% paid for only 1 PC claim over the 11-year study period. The growth in claims per year coupled with smaller growth in the number of participating pharmacies resulted in a trend of growth in the mean number of claims per participating pharmacy in the program. The proportion of total WMPCP claims accounted for by the top 10 pharmacies with the highest volume of PC claims varied from 46.6% to 80.2% per year. Patient behaviors (e.g., early or late refills) and drug use issues/problems (e.g., patient complaints or symptoms) were the most common reasons for pharmacists to provide PC services (62% of all PC claims), although drug choice reasons (e.g., product selection opportunity) were more common after 2004. The majority (55.1%) of PC services took 15 minutes or less of pharmacists’ time. The total dollar amount paid to pharmacies for PC services was $876,822 between SFYs 1997 and 2007, with an overall mean of $1,459 paid per participating pharmacy. CONCLUSIONS: Trends in pharmacy participation and claims volume showed growth, albeit limited, in PC program participation with a majority of paid claims dealing with patient behaviors and drug use issues or problems that consumed a small amount of pharmacists’ time (15 minutes or less). The intensity of participation (claims per pharmacy) increased over time, suggesting that some pharmacies may have developed effective systems for participating and successfully submitting claims to WMPCP for enhanced dispensing fees. Further evaluation of the impact and implications of this program for patients, pharmacists, and the state is needed to gauge overall program success and provide evidence or guidance for continued or expanded PC initiatives.