In October 2011, CMS indicated that it was considering mandating the separation of a facility’s consultant pharmacist from its long term care dispensing pharmacy. In April 2012, CMS reached the conclusion that this transition would be disruptive and would not solve the issue of chemical restraints.

Instead, CMS is extending the comment period and encouraging the separation but not insisting on it. CMS has restated the importance of paying “fair market” value for consulting services. Additionally, CMS is encouraging the consultant pharmacist and the facility to reach an integrity agreement to avoid any conflict in interest.

For more information on this issue, please see Dr. Karl Steinberg’s CALTCM Wave article from October 2011. See the condensed document attached. (Summary starts on page 147)

If you have opinions or insights into the questions CMS is now asking on this topic, please make comments directly via their website. They really do read the comments and consider them, so this represents an opportunity to impact policy.

Comment from Anonymous

Just as physicians are not allowed to own pharmacies, pharmacists who influence prescribing, or actually prescribe, under collaborative practice agreements as I do in California, should not be allowed to own or be employees of the pharmacy that profits from the medications prescribed. There is too much room for conflict of interest and hampers the strength of independent consultant pharmacists whose sole responsibility is to keep the patient at the center and does not answer to the corporation who profits from drug utilization... profit is lost, even with a simple drug discontinuation of a "drug to avoid in the elderly". I do not question the integrity of the current corporate pharmacists who work for these pharmacies, but I've worked long enough to know that the way incentives/pay/bonuses are packaged/structured... it seldom is about the patient, and is more about the bottom line and right now, the bottom line is directly tied to the # of pills in a bottle.

Comment from Douglas Barcon, Pharm.D.

In the CMS response regarding LTC consultant pharmacists, there was concern regarding the sparcity of outcomes data from the monthly drug regimen reviews to enable CMS to judge the effectiveness of those reviews. This is an open invitation to collect outcomes data to assess and improve the medication use process and discover where there are breakdowns in those processes. In acute care hospitals, the pharmacists are continually collecting data on pharmacist interventions, which includes the type of intervention and the prescriber's ID. That data is analyzed and reported to the hospital's Pharmacy and Therapeutics Committee and used to improve medication safety. Data from pharmacist interventions within the long term care pharmacy itself and physician responses should also be collected, reported, and acted on in addition to the consultant pharmacists reports and drug regimen reviews in long term care facilities to show the full value of pharmacy services.

The CMS response after receiving comments on separating the consultant pharmacists from the long term care pharmacy included, "Until the next opportunity for us to propose a regulatory change, we will closely evaluate the number of deficiency citations for unnecessary drug use and will monitor the two new performance measures to track the use of antipsychotics in LTC facilities and expect to see significant improvement."

In extending the comment period CMS stated, "We will only consider public comments on the issues specified in section II.B.5 of this final rule with comment period, Independence of LTC Consultant Pharmacists, if we receive them at one of the addresses specified in the ADDRESSES section of this final rule with comment period, on June 11, 2012" and "In commenting, please refer to file code CMS-4157-FC."