Pharmaceutical reimbursement: an overview.

PURPOSE

The Medicare program authority, structure, and current and proposed rules for and rates of pharmaceutical reimbursement; billing issues; proposed expansion of accepted compendia and off-label drug uses; problems with the cost basis for reimbursement; concerns of and need for collaboration among various participants in the health care revenue stream; and implications for pharmacists are described.

SUMMARY

Pharmaceutical reimbursement rates have decreased over the past several years as the Centers for Medicare and Medicaid Services (CMS) has striven to maintain neutrality in the federal budget. Now, health systems that fail to report quality indicators can incur financial penalties. Also, smaller payments for cases involving medical errors have been proposed. Efforts by pharmacists to improve the billing process can increase revenue. It is anticipated that rules proposed for 2008 will result in CMS acceptance of a greater number of compendia and off-label uses. Receiving reimbursement for drug handling costs is an important issue for pharmacists. Collaboration among pharmacists and other participants in the health care revenue stream is needed to improve the health care delivery system and ensure that money is wisely spent.

CONCLUSION

An understanding of the complexities of Medicare pharmaceutical reimbursement can help pharmacists improve the financial viability of their institutions.