Nursing homes, however, continue to receive per diems under the program. The same holds true for physicians, some of whom are not even reimbursed through TennCare. These physicians also have little incentive to work with pharmacists to manage costs through a comprehensive and therapeutically sound formulary. Payers are beginning to ask MCOs and providers to offer them a comprehensive package of benefits for a single rate per member per month. In time, this will extend to the long-term care benefit.
Payers recognize that attempts to manage care by focusing on a single component of care are failing.
For example, reducing utilization of drugs in isolation, may only rob patients of the treatments they need to keep them out of more expensive settings like hospitals. This integration requires a corresponding reimbursement arrangement. MCOs' capitated rates should reward long-term care pharmacists who demonstrate that their consulting services reduce overall health care costs. The more that is known about gender, age, health care utilization, and drug utilization, the more accurate the capitated rate or the fairer the risk sharing. Sharing of this information, especially if the capitation rate or risk sharing crosses provider groups, encourages better understanding of patients and better management of their needs.