Third Party Reimbursement for Pharmacist Services: Why Has It Been So Difficult to Obtain and Is It Really the Answer for Pharmacy?

Abstract

Objectives

To describe three models of how health insurance coverage can develop for health care goods and services and apply them to pharmacist services. Also, to raise readers’ awareness of the costs/tradeoffs involved in receiving third party reimbursements of insurance coverage from a health provider perspective.

Data Sources

Insurance theory and literature.

Summary

The three models for developing health insurance coverage are the risk-pooling model, the demand model, and the cost containment model. The risk-pooling model does not apply to coverage for pharmacist services because the cost of such services is not catastrophic and unpredictable. Applying both the demand model and the cost containment model to developing coverage for pharmacist services presents some challenges, but the demand model has been used more successfully to obtain insurance coverage for other health care goods and services. Potential costs and tradeoffs to the health care provider associated with insurance coverage are higher administrative costs, lower reimbursement rates, and loss of professional autonomy.

Conclusion

If pharmacists want to increase third party coverage for their services, the best approach may be to increase patient demand for insurance coverage by promoting and charging for pharmacist services. However, pharmacists should seriously consider whether the benefits of such coverage for their services outweigh the costs.