Pharmaceutical services have become an integral component in the delivery of adequate, appropriate health care as more and more people are served in out-of-facility settings which are controlled to a great extent by health maintenance organizations and other types of health care programs. As a result, pharmacists are playing an even greater role in the health care setting as they provide invaluable information on such things as drug interactions, personal care, and counseling. But, as a result of changing pricing and reimbursement structures and increasing responsibilities, many of which are non-reimbursable, many small pharmacies are being forced to close or to join large chain operations to remain open. As a result of a year-long study of these issues, the Joint Subcommittee to Study the Demise of Independent Pharmacies (HJR 158, 1996) made a number of recommendations: (Appendix A)

• Direct, by resolution, the Department of Medical Assistance Services and the Department of Personnel and Training to initiate pilot programs to examine the effect of paying pharmacists for delivering cognitive services to their patients. The Departments are requested to cooperatively work with various professional groups to identify the range of services which would be eligible for reimbursement, the payment levels, and the filing procedures, and to develop an evaluation to determine the potential overall savings in health care expenditures for Medicaid and state employee recipients.

• Adopt statutory language which would recognize pharmacists as "health care practitioners" and "health care providers" to allow pharmacists to bill and receive compensation from HMOs, insurance companies, and other third-party payers for counseling and other cognitive services.

• Introduce legislation to prohibit the practice of drug switching of chemically dissimilar drugs in the Commonwealth.

• Require the Department of Personnel and Training and the Department of Medical Assistance Services to take steps to ensure that programs under their purview comply with the Pharmacy Freedom of Choice statute in the Code of Virginia and to require compensation to pharmacies which allows them a reasonable profit as participating providers.