Transcript Click here for the PowerPoint presentation.

Integrating Pharmacists
into Innovative & Evolving
Care Delivery Models
Bob Davis, PharmD, FAPhA
Professor and Chair
Kennedy Pharmacy Innovation Center
University of South Carolina
Columbia, South Carolina
Disclosure
I do not have (nor does any immediate family member
have) actual or potential conflict of interest, within the
last twelve months; a vested interest in or affiliation
with any corporate organization offering financial
support or grant monies for this continuing education
activity; or any affiliation with an organization whose
philosophy could potentially bias my presentation.
Learning Objectives
1.
Describe the key attributes of the new team-based care delivery
models such as accountable care organizations (ACO) and patientcenter medical homes (PCMH).
2.
Identify key outcome measures tied to pay for performance or
shared savings programs impacted by pharmacist participation.
3.
Explain general requirements for physician billing for pharmacist
patient care services.
4.
Describe payment methods and various billing codes used for
pharmacist patient care services.
5.
Discuss successful examples of pharmacist inclusion in team-based
care models and the benefits realized by the organization.
6.
Describe how to make the business case for pharmacist inclusion in
team-based care models.
4
Self-Assessment Questions
What services can a pharmacist bill Medicare?
a)
b)
c)
d)
e)
Chronic Care Management (CCM)
Durable Medical Equipment
Transitional Care Management (TCM)
“Incident to” Evaluation/Management
All the above
Self-Assessment Questions
Requirements of “incident to” billing include EXCEPT:
a) Commonly furnished in a physician’s office.
b) Furnished by supervised auxiliary personnel
employed by physician or practice.
c) Physician must be present in room when services
are provided by auxiliary personnel.
d) Conducted within the Scope of Practice of the
auxiliary personnel (e.g. pharmacist).
Self-Assessment Questions
What are examples of patient care outcomes that
pharmacists can impact and generate revenue?
a) Achieve targeted A1c, LDL, and BMI in patients
with multiple complex chronic conditions.
b) Reduce the use of high risk medication (Beer’s
List) in the geriatric population
c) Achieve and maintain targeted INR in patients on
warfarin.
d) All of the above
The Need for Pharmacists
Medication related morbidity cost the US over $250B annually
Patients with chronic conditions take an average of 5 prescription
medications concurrently
Only 33%-50% of patients with chronic conditions
adhere to the medication treatment plan
Most common reasons a patient on medication visits their
physician:
 Medication dosage titration
 Add new medication
 Medication outcomes monitoring
 Medication-related adverse event
32% of adverse events leading to hospital
admissions are related to medication
8
Evolving Care Models
Decentralization of simple care process closer to patient
More interdependent, collaborative, structured care
Embracing a care system where clinician's skill and location is
matched to the difficulty of the problem
Performance driven payment models
Facilitated with new technology enablers
Innovation Creating Change
9
Exploring Pharmacists’ Role in a
Evolving Care Models
Pharmacist-provided educational and behavioral counseling
can contribute to better outcomes in chronically ill patients.
Pharmacist-provided medication reconciliation can reduce
medication discrepancies and improve transitions of care.
Collaborative care models with a pharmacist can alleviate the
demand on physicians and facilitate patient access to services
related to medication management.
Avalere Health LLC, 2014
10
Accountable Care Organization (ACO)
Health care organization that is accountable for 100% of
expenditures and care for a defined population of patients.
Sponsoring organizations may include
 Hospitals
 Physicians
 Pharmacies
Provide evidence-based care in a collaborative and
coordinated open network model.
ACOs are typically not insurance companies but held to a
fixed pre-payment amount and bonus eligible.
11
Accountable Care Organization (ACO)
Focus:
Measurement of quality and cost
Chronic conditions
Distribution of cost savings to providers
Payment methods:
Bundled payments with performance payments
Shared savings
Capitation PMPM
FFS with withhold and physician performance bonus
Aligned with Patient Centered Medical Home (PCMH)
12
Patient Centered Medical Home
“Neighborhood”
Social Workers
Nutritionists
Physicians
Patient
Centered
Accessible
Quality
Commitment
House graphic retrieved from:
https://openclipart.org/image/2400px/svg_to_png/172843/Puzzle-house.png
Titles excerpts from: https://pcmh.ahrq.gov/page/defining-pcmh
13
NP, PA
Community
Coordinators
PCMH Quality & Pharmacists
PCMH 1: Enhance Access and Continuity
Enhanced access to care and clinical advice (Productivity)
Team-based care (standing orders, self management, refills)
PCMH 2: Identify and Manage Patient Populations
Clinical Data (Med Rec, allergies, adverse effects)
PCMH 3: Plan and Manage Care
Evidence-based Guidelines (medication related)
Identify High Risk Patients
Care Management (treatment goals, assessment of goals)
Medication Management (Med Rec, Pt Rx Education, assess
response to meds, document OTC, herbals, and compliance)
PCMH 6: Measure and Improve Performance
NCQA Standards
14
Pharmacist Patient-Centered Care Model
ACO
PACE
MTM
Retail Clinic
Care
Manager
Adherence
Pharmacist
Ambulatory
Center
Collaborative
Teams
PCMH
Facilitated
Network
(intuitive)
Physician
Extender
Care
Coordinator
Telehealth
Network
Facilitator
Hospice
LTC
Providing care where people gather
15
Pharmacist Value
Quality of patient care
Patient satisfaction
Practice revenue
Physician productivity
Cost avoidance
Reduced hospitalizations and ED visits
Reduced medication costs
Image from cover of Avalere report located at
http://avalere.com/expertise/life-sciences/insights/exploringpharmacists-role-in-a-changing-healthcare-environment
16
Always Remember the Value Game
http://www.communitycarenc.com/media/related-downloads/treo-solutions-report-on-utilization.pdf
17
Key Outcome Measures in
Fee for Value Programs:
(Measures that Matter)
Triple Aim
Lower Cost
http://www.ihi.org/engage/initiatives/tripleaim/Pages/default.aspx
19
Quality Measure Programs
MN
Measures
Meaningful
Use
Medicaid
Value Based
Purchasing
CAHPS
HEDIS
PQRS
Enhanced
MTM
STARs
MSSP/
Pioneer/
Next Gen
Measurement Overload!
ACO
20
PQRS Measures- 2015
Effective Clinical Care
•
•
•
•
•
Diabetes: Hemoglobin A1c Poor
Control (A1C >9)
Diabetes: Low Density Lipoprotein
(LDL-C) Control (<100 mg/dL)
Heart failure: ACE Inhibitor or ARB
Therapy, B-blocker therapy
Coronary artery disease:
Antiplatelet Therapy
Anti-depressant Medication Mgmt
58°
Patient Safety 58°
Raleigh
TODAY
Clear
• High-risk
medicationsRaleigh
in
CLOUDY
Clear
65°/43
elderly
65°/43°
64°
°
•Weather
Adherence
toWeather
antipsychotic
medications/schizophrenia
Efficiency and Cost
Reduction
Appropriate
treatment/testing
Community/
Population health
CALENDAR
CALENDAR
• Preventive care and
screenings
• Flu, pneumovax,
pain, depression
Communication and
Care Coordination
• Medication rec
• Post discharge med
24°
WORLD
Person-/Caregiverrec
(>65yr)
TODAY
Raleigh
WEATHER
CLOUDY
• Advanced
care planRainCentered Experience
45°/17°
SEARCH
(>65yr)
Weather
64°
Weather
CAHPS
21
HEDIS Measures
•
Persistence beta-blocker treatment after heart attack
•
Controlling high blood pressure
•
Comprehensive diabetes care
•
Cancer Screenings (Breast, cervical, colorectal)
•
Medication management (Antidepressant, COPD, asthma)
•
High risk medications in the Elderly
•
Annual monitoring - persistent medications
– (ACEI/ARB, digoxin, diuretics)
•
Flu and pneumovax vaccinations
•
CAHPS survey
•
Statin Therapy for Patients with Diabetes & CVD (NEW)
http://www.ncqa.org/Portals/0/HEDISQM/Hedis2015/List_of_HEDIS_2015_Measures.pdf
22
HEDIS
2016
ACOs Measures
Patient experience (CAHPS)
Preventive health
• Timely care, appointments & info
• Doctor communication
• Patient rating of doctor
• Access to specialists
• Health promotion & education
• Health status/Functional status
• Stewardship of Patient Resources
• Shared decision making
• Influenza immunization
• Pneumococcal vaccination
• Adult weight screening/Follow up
• Tobacco use assessment and cessation
• Depression screening
• % adults with blood pressure screen, past 2 yrs
•Colorectal cancer screening
• Mammography screening
•Depression remission at 12 months
At-risk populations
Care coordination/Safety
• Hypertension – Blood pressure control
• Heart Failure – Beta Blocker for LVSD
• CAD – ACE and ARB Therapies
• Diabetes - Hemoglobin A1c poor
control
• Diabetes –Eye exam
• IVD- Use of Aspirin or another
Antithrombotic
• COPD (PQI#5)
• Congestive heart failure (PQI#8)
• Risk standardized, all condition readmission
• Screening for fall risk
• SNF 30 day all cause readmission measure
• Med reconciliation at each visit
• All cause unplanned admission for DM
• All cause unplanned admission for HF
• All cause unplanned admission for MCC
• PCPs meeting MU requirements
23
How Can Pharmacists
Impact Outcome Measures
Comprehensive Medication Management
Focus on the most complex patients
Multiple conditions not at goal
High utilization/risk
Example Metrics:
Diabetes: Hemoglobin A1c <8
Hypertension: Systolic and diastolic control
LDL: LDL<100 and statin therapy adherence for diabetics
High Risk: Falls or elderly patients on Beer’s List medication
25
Comprehensive Medication Management
Focus medication management on a single condition
Hepatitis C
Arthritis
Oncology
Asthma/COPD
Coumadin
Example Metrics:
Hepatitis – Viral titer, cure rate, adherence
Medication Management -Antidepressant, COPD, Asthma
Coronary Artery Disease: Antiplatelet therapy
26
Medication Utilization and Patient Safety
Review pharmacy data for better management opportunities
Brand to generic opportunities
Safety alerts
High risk meds
Best practice algorithms
Example Metrics:
Reduce high risk medications in the elderly
Heart Failure: Use of ACEI, ARBs, B-Blocker therapy
Use of aspirin or another antithrombotic
27
Chronic Care Management & Wellness
Management/Educational Programs
Hypertension
Asthma/COPD
Adherence program
Diabetes
Annual Wellness
Care Plans
Flu, pneumovax, Zoster, TDAP, etc
Example Metrics:
Medication adherence for diabetes, RAS antagonists, statins
Vaccination rates
28
Continuum of Care Services
Transitions of Care Services
Collaborative efforts to reduce readmissions
through improved medication management,
reconciliation, and patient education
Example Metrics:
Unplanned readmission for DM
Unplanned readmission for HF
Unplanned readmission for multiple chronic conditions
Medication Reconciliation Post Discharge
29
Patient Care Services
Payment Methods:
(Understanding Billing)
Whose language do we need to understand?
Federal
Medicare
Commercial or
Private
State
Part A
Medicaid
Employer
based
Part B
Insurance
exchanges
Group
Part C
Individual
Part D
31
Center for Medicare and Medicaid Services
Medicare Part A
• Universal benefit
• Hospitals,
Health Systems
• Long Term care
• Hospice and
Home Health
Hospital
Medicare Part
B
• Must Opt out
• Must have
contributed to
Social Security
• Outpatient
services
Provider
Medicare Part
C
Medicare Part
D
• May opt in
• Medicare
Advantage
• Administered by
commercial
players
• May opt in
• Administered by
commercial
players (PDPs)
Commercial
Players
32
PDPs
Payment Models
Fee for Service:
FFS
Payment for professional services in which the practitioner is
paid for the specific service rendered.
Pay for Performance: FFV
Financial incentives to clinicians for achieving patient-focused
high value health outcomes based upon evidenced-based
defined measures.
FFV
Shared Savings:
Financial incentives for clinicians to reduce health care
spending for a defined patient population by offering them a
percentage of net savings.
FFV
Bundled Payments:
Single payment to providers for all services to treat a given
condition or provide a given treatment.
33
From Volume to Value
Medicare FFS Payments
120%
100%
80%
Traditional FFS
60%
Value Oriented
Payment
40%
20%
0%
2013
2014
2015
2018
http://www.catalyzepaymentreform.org/how-we-catalyze/national-scorecard
34
FFS
Fee for Service Model
Provides payment for professional services in which the
practitioner is paid for the specific service rendered.
Payment is dependent on the quantity
rather than quality of care.
Payment is established based on
Evaluation and Management (E&M)
codes.
Adverse incentive to drive volume.
more services = more money.
Example: Physician Office Visits
35
Quantity Driven Model
Pay for Performance
FFV
Provides financial incentives to clinicians for achieving
patient-focused high value health outcomes based upon
evidenced-based defined measures such as:
Clinical outcomes
•
•
•
A1c to control
Lowering blood pressure
Smoking cessation
Quality Driven Model
Select care processes
•
•
•
Measuring blood pressure
Testing A1c
Mammograms
Quality Bonus
Example: Achieving Quality Goals
36
FFV
Shared Savings
Provides incentives for clinicians to reduce health care
spending for a defined patient population by offering them a
percentage of net savings resulting from their efforts.
Based on comparison with a control group.
For reducing potentially avoidable complications (PAC)
associated with treating a chronic condition.
Quality Driven Model
Savings
Example: Reduced Hospital Re-admissions
37
FFV
Bundled Payments
Bundled payment is a market-driven single comprehensive
payment to providers and/or health care facilities to treat a
condition or provide a treatment.
Providers to assume financial risk for the cost of services for a
particular treatment or condition, as well as costs associated
with preventable complications.
Ambulatory Care Pilots
Quality Driven Model
Example: Chronic Care Management
38
Pharmacist Billing for Services
Pharmacists have limited
options as a PROVIDER
Consider Pharmacists as
AUXILLARY PERSONNEL or
CLINICAL STAFF
“incident to”
DME
Note:
Federally Qualified Health Centers (FQHC) and Rural Health Care
Initiatives (RHI) have a Prospective Payment System (PPS) that
includes a bundled payment for Auxiliary Personnel and Clinical
Staff that may prohibit pharmacist billing.
39
CMS Policy on “Incident to” and
Pharmacists
In March 2014 responding to an inquiry from the AAFP
regarding physicians billing for “incident to” services
provided by pharmacists, Marilyn Tavenner, CMS
Administrator, stated:
“…we confirm your impression that if all the requirements
of the "incident to" statute and regulations are met, a
physician may bill for services provided by a pharmacist
as "incident to" services…”
YES!
40
Auxiliary personnel…
...means any individual who is acting under the supervision
of a physician, regardless of whether the individual is an
employee, leased employee, or independent contractor of
the physician, or of the legal entity that employs or contracts
with the physician.
Clinical staff…
…is a person who works under the supervision of a
physician or other qualified health care professional and
who is allowed by law, regulation, and facility policy to
perform or assist in the performance of a specified
professional service, but who does not individually report
(bill) that professional service.
Source: Current Procedural Terminology Codebook 2016, Instructions for Use
of the CPT Codebook, page xii, published by AMA.
41
Supervision
General Supervision - procedure is furnished under the
physician’s overall direction and control, but the physician’s
presence is not required.
Direct Supervision - the physician must be present in the office
suite and immediately available to furnish assistance and
direction throughout the performance of the procedure. It does
not mean that the physician must be present in the room when
the procedure is performed.
Personal Supervision – a physician must be in attendance in the
room during the performance of the procedure
Source: 42 CFR 410.32(b)(3)(i)-(iii)
42
South Carolina Law and Scope of Practice
Delegation Medical Acts:
SC Medical Practice Act provides for the delegation (…to a physician
assistant, …or other practitioner authorized by law under approved
written scope of practice guidelines or approved written protocols as
provided by law in accordance with the applicable scope of
professional practice) of certain medical acts.
Source: http://www.llr.sc.gov/pol/medical/PDF/Laws/MPAChapt47.pdf
Pharmacist Scope of Practice:
The South Carolina Board of Pharmacy confirms that the scope of
pharmacy practice… permits a SC licensed pharmacist, in collaboration
with a SC licensed physician, to obtain a patient medical history,
evaluate laboratory results, conduct limited examinations, and make
medical decisions pursuant to a medical order.
Source: http://www.llr.state.sc.us/POL/Pharmacy/Minutes/March_18_2015_motions.pdf
Pharmacist Revenue Services
Traditional role
Medication distribution
MTM-Contraindications and drug–drug interactions
Patient education about medications
Emerging Role
Comprehensive Medication Management
Chronic Care Management
Annual Wellness Visits
Transitional Care Management
Diabetes Self-Management Training
44
Annual Wellness Visits (AWV)
Free, preventative service for Medicare
beneficiaries.
Direct
Supervision
Eligible for one AWV per year after IPPE.
Two types:
Initial Wellness Visit
Subsequent Wellness Visit
Provided by physician, non-physician provider, or
professionals under direct supervision of physician.
https://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNProducts/downloads/AWV_chart_ICN905706.pdf
45
Chronic Care Management (CCM)
General
Supervision
CPT Code
Non-face-to-face service provided to Medicare beneficiaries
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/Downloads/ChronicCareManagement.pdf
46
Transitional Care Management (TCM)
Medicare: supports a patient discharged from inpatient care
reenter the community while preventing post discharge adverse
events and readmission within 30 days.
Direct
Supervision
Key Components
Contact by licensed clinical staff with 2 days of discharge.
Face-to-face visit with qualified provider within 7-14 days of
discharge depending on complexity.
At face-to-face visit Clinical Staff may:
 Communicate with beneficiary’s physician and community services.
 Provide education to the beneficiary, family, or caretaker to support
self-management and independent living.
 Assess and support treatment regimen adherence
and medication management.
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/Downloads/Transitional-Care-Management-Services-Fact-Sheet-ICN908628.pdf
47
Diabetes Self-Management Training
DSMT educates patients in self-management of diabetes and
includes instructions in self-monitoring of blood glucose; diet
and exercise education; individualized insulin treatment plan,
and coaching.
General
Supervision
Program requirements:
Accreditation from AADE or ADA
Partnership with a Medicare Provider
Patient has documented diabetes diagnosis
Qualified provider referral
Training
YR-1: One (1) hour individual and nine (9) hours in group
YR-2: Two (2) hours any combination
http://www.aoa.gov/AoA_Programs/HPW/Diabetes/Index.aspx
48
“Incident to” Established Patient Visits
An integral part of the physician’s professional
service;
Included in the physician’s bill;
Direct
Supervision
Commonly furnished in physician’s offices or clinics;
Furnished by supervised auxiliary personnel
employed by the physician, office or clinic;
Compliant with State law;
Conducted within the personnel’s Scope of Practice
Not covered under another benefit category.
Sources: https://www.gpo.gov/fdsys/pkg/FR-2015-11-16/pdf/2015-28005.pdf
pages 71065-71068 and 71372; and 42 CFR 410.26.
49
Physician-Based Outpatient Clinic
Physician outpatient clinic that is not financially tied
to a hospital.
Physician group operates practice under a separate
business tax ID number.
Hospital
X
50
Physician Outpatient
Clinic
Hospital-Based Outpatient Clinic
Physician outpatient clinic that is financially tied to
a hospital (one tax ID number)
Physician Outpatient
Clinic
Hospital
51
“Incident to” = Facility Fee
“Incident to” provided by a pharmacist in a hospital-based
clinic can ONLY be billed to Medicare within a Facility Fee.
When a recognized provider
sees a patient in a hospitalbased outpatient clinic
Bills a Professional Fee for
cognitive services
Bills a Facility Fee for use of
facility and personnel
Facility Fee Billing:
CPT G0463 on CMS1450
Payment received as APC code 5012 = $102
52
Billing and Coding Exercise:
What E/M Code?
“Incident to” E/M Billing Steps
1. Determine Established Patient
 Physician visit within 3 years
 Exact same specialty
2. Determine Medical Necessity
 Referral with objective, goal, follow-up
3. Determine Nature of Presenting Problem
4. Define Level of Service (Complete 2 of 3 Key Components)
 History
 Exam
 Medical Decision Making
5. Evaluate Counseling Time (50% counseling factor)
6. Document Activities
7. Select Code
 99211-99214
Source: Current Procedural Terminology Codebook 2016, page xxii, AMA.
Must satisfy at least 2 of 3 Key Components.
Incident to Codes for Pharmacist Services
99211
Does not require supervision of physician
No history, exam, or medical decision required
Less than 10 minute patient encounter
99212 Problem Focused
History of present illness
Exam of one organ system
Straight forward, minimal complexity medical decision
10-20 minute patient encounter
99213 Expanded Problem Focused
History of present illness, review of systems
Exam of two or more organ systems
Low complexity medical decision
20-30 minute patient encounter
99214 Expanded Problem Focused
History of present illness, review of systems, social history
Exam of two or more organ systems
Moderate complexity medical decision
Greater than 30 minute patient encounter
Levels of Risk for Complications
Additional Workup
Presenting Problem(s)
Level of Risk
PharmD
PharmD
PharmD
PharmD
PharmD
2 of 3 Components are needed to determine MDM Complexity
Proprietary—DO NOT REPRODUCE
Medical Decision Making
Refers to complexity of establishing a diagnosis or
selecting/managing therapy options measured by:
Number of possible diagnosis or treatment options.
Amount or complexity of medical records, test and history that
must be reviewed and analyzed.
Risk of significant complications, morbidity, and/or mortality,
comorbidities, and management options.
Low
1 Stable Chronic illness
Stable drug management or OTC use
Moderate
1 Chronic illness w/mild exacerbation, or 2 stable chronic
Monitoring or adjusting drug management
High
1 Stable Chronic Illness w/severe exacerbation
Drug management requiring intensive monitoring
57
Case/Exercise
Joe
Jane
Documentation Guidelines:
Established Patients
Must meet or exceed 2 of 3 Key Components
Consider Nature of Presenting Problem
Modified from:
http://www.aafp.org/fpm/2003/1000/fpm20031000p31-rt1.pdf
Proprietary—DO NOT REPRODUCE
Outpatient Revenue
Code
Description
Payment
99211
Procedural
$18
99212
Problem Focused
$42
99213
Expanded Problem Focused
$72
99214
Comprehensive Problem Focused
$104
99490
Chronic Care Management
$42/mo
99495
TCM Moderate Complexity
$135 - $164
99496
Code
TCM
High Complexity
Description
$198 - $231
Payment
G0438
AWV - Initial
$166 – one lifetime
G0439
AWV - Subsequent
$111 – each year
Code
Description (First Year) Allowable
Range/Unit
G0108
• Individual
• Allows up to1 hour
• 2, 30m units
$46 - $71 /u
• Group (2 or more)
• Allows up to 9 hours
• 18, 30m units
$12 - $20 /u
per individual
DSMT
G0109
DSMT
60
Making the Business Case
for Pharmacist Integration
Case Development:
Today you are attending an educational program on
pharmacist‘s value in Comprehensive Medication Management
including discussion on productivity, quality data, and billing
for services…
Comprehensive Medication
Management Pharmacists
Key Daily Duties:
Managing chronic patient medications
Nutritional counseling
Patient education on proper
self-medication
Paul
Fleming
Ashton
Glasgow
Kerri
Hatcher
62
63
Quality-LDL Improvement
Patients with LDL-C >130
Patients with LDL-C >80
16.2%
22.5%
79.1% Patients Improved
86.2% Patients Improved
-186 patients – retrospective chart reviews
- Evaluation period November 2013-October 2014
- Minimum 2 pharmacist visits and pre/post LDL-C
64
Anticoagulation Management Program
67 Unique Patients
411 Patient Visits
Large VA Study 58% Best Practice
Rosendaal Method
Low Range
High Range
Evaluation period November 2014-May 2015
65
2
3
Satisfaction (5-point Likert scale)
Willingness to Recommend/Refer
Provider
4.7
Patient
4.9
Staff
5.0
15% of patients volunteered they would change
behavior based on pharmacist’s coaching.
66
Cost Avoidance
Month
April
May
June
Encounters
205
197
200
Typical Interventions
Interventions
909
969
990
$ Avoidance Avoid/Encounter
$139,260
$
679.32
$148,379
$
753.19
$151,531
$
757.66
$1.8M Annually Projected
•
•
•
•
•
Medication reconciliation
Allergy identified, clarified or prevented
Lab/test evaluation, patient consultation or recommendation
Medication change of dose adjustment
Patient counseling-self care: diet, exercise, checking blood sugars,
OTC recommendation, smoking cessation
• Adverse effect identified/remedied
Average savings per intervention was $153
Studies by Suh, Classen, and Bates and used by Pharmacy OneSource Quantifi
software for reporting financial impact of pharmacist clinical interventions.
67
Physician Productivity
Provider
MDA
MDB
MDD
MDT
MDV
AVERAGE
2013
2014
% Increase
Payment/ Payment/ Payment/
Work Day Work Day Work Day
$2,741
$3,499
27.7%
$3,100
$3,701
19.4%
$2,602
$3,385
30.1%
$2,582
$3,000
16.2%
$2,878
$3,177
10.4%
$2,781
$3,352
Contributing Factors:
1. Fee Increase November 2013
2. More New Patient Visits
3. More Complex Visits
20.6%
2013 Q2 2014 Q2
Visits/Day Visits/Day
24.2
25.0
31.1
31.2
23.5
23.7
23.5
24.8
24.0
22.7
25.3
20.6%
68
25.5
% Total
Referrals
to PharmD
46%
9%
27%
11%
7%
100%
Pharmacist Capacity and Revenue
Nov 2013 Feb 2014 May 2014 Aug 2014 Oct 2014
Patient Encounters
115
Encounters/Day
6.4
Capacity Used
34%
Encounters Billed
17%
Revenue Collected
$ 1,025 $
219
197
231
218
11.5
9.9
11.0
11.2
46%
59%
83%
72%
15%
63%
71%
69%
1,830 $ 3,641 $ 7,490 $ 7,398
69
PCMH Pharmacist Benchmarks
Annual Work Days
= 240
PharmD Visits to Impact Quality Gap = 1.5
Average Patient Contact Time
= 24 min
Physician Referral Rate of Total Visits
= 12.5%
Time to establish full referral patterns
= 6-9 mo
70
Returning Home…An Opportunity
There is a PCMH in your geographic area and you have a
strong relationship with one of the physicians.
Lead practice physician has expressed interest in
understanding how pharmacists might participate in
improving patient outcomes.
You wish to launch business from your community
pharmacy location to better manage start up cost.
Where do you start?
71
Building the Business Case
Assess
Leadership
Demographics
Needs
Resources
Revenue
Outcomes
Compensation
Develop
Customer
Value Proposition
Key Activities
Cost Structure
Key Resources
Revenue Streams
Key Partners
Financial Model
72
Present
Assessment
Value Message
Proposal
Business Case: Assess
Leadership:
What is the Practice or ACO vision and mission?
Describe their collaborative approach to patient care?
Needs:
What could improve the quality of patient care?
What could enhance practice financial performance?
What could improve productivity of your physicians?
What improves satisfaction of providers and patients?
73
Business Case: Assess
Performance Measures:
What practice performance measures are keys to success?
Practice Demographics:
What is Provider, Payer, and Disease Mix?
Technology:
How will pharmacist be integrated with EHR and Billing?
Revenue Sources:
Practice participation level in FFS, FFV, P4P, and SS?
Compensation:
What provider quality incentive options exist?
74
What We Learned…Assessment
Privately held PCMH with 4 FP-MDs, 2 ANPs, part-time
nutritionist and psychologist. Refer to hospitalist.
Vision reflects strong balance between patient, quality,
satisfaction, and revenue.
Performance metrics for diabetes management and
readmissions are at average or below state benchmarks.
Practice engaging in fee for value (FFV) and pay for
performance (P4P) models.
Providers experiencing burnout from patient load and
managing chronic diseases.
Key challenge is balancing need to improve quality while
protecting revenue and personal time.
75
XYZ FAMILY PRACTICE
DEMOGRAPHICS
•
•
•
•
•
•
ESTIMATED TOTAL PATIENTS
ANNUAL VISITS BILLED
PATIENTS UNCONTROLLED A1c
PATIENTS ON HIGH RISK MEDS
PATIENTS ON STATINS
1,500
COLLECTION RATE
55%
PAYOR
MIX
Medicare
28.5
Commercial
44.9
Medicaid
2.9
PCMH
18.8
Self
4.9
Total 100.0
DISEASE
Diabetes
Hypertension
Lipid Disorder
Anticoagulation
Heart Failure
Asthma/COPD
= 17,000
= 20,500
= 1,750
= 350
=
=
MIX
40.5
44.9
35.6
15.8
4.9
14.5
76
Fee for Service
Chg/Visit Visit Min
PCMH Medication Therapy Management
99605 $
30
15
99606 $
25
15
99607 $
20
15
Description
BCBSSC program-Collaborative, face to face
comprehensive medication management, self
care management counseling, device training,
evaluate outcomes.
Evaluation & Management-"incident to"
99211 $
20
15
99212 $
50
30
99213 $
80
45
99214 $ 120
60
Collaborative, face to face comprehensive
medication management, self care
management counseling, device training,
evaluate outcomes.
Transitional Care Management
99495 $ 155
99496 $ 219
High-risk patient, medication list verification,
30 discharge plan reinforcement, medication
60 reconciliation and management.
Diabetes
51
18
Diabetes education, nutrition and medicatoin
60 management through team based group
30 sessions
108
162
Medication risk factors, metrics and vitals,
60 immunizations, medication review, and
75 cognitive, mobility, and depression screenings.
G0108 $
G0109 $
CMS Annual Wellness
G0438 $
G0439 $
Chronic Care Management
99490 $
42
Patient care plan, non-face to face care
30 coordination and medication management
77
Pay for Performance (P4P) Contracting
Practice PMPM
Standard Results Rate
Measure
Definition
A1c Control Diabetes
Most recent A1c<9
# of patients taking a high
risk medication
Hospital readmission acute
and chronic
High Risk Medications
Readmission rate <30D
Adherence-Statins
Refill statins on time
78
>84%
72.5%
$ 0.25
<3%
6.8%
$ 0.25
<12%
14.0%
$ 0.75
>73%
69.5%
$ 0.50
Next: Develop Business Case
Customer Segments (Who we help)
◦ Physician - (patient 2nd)
Value Proposition (How we help)
◦ Revenue, Quality
◦ Provider Productivity, Satisfaction
Key Activities (What we do)
◦ Medication management, education, care standardization
Key Resources (What we have)
◦ Knowledge, treatment pathways, operating system
Adapted from Business Model You by Clark, Osterwalder,
and Pigneur, publisher Wiley & Sons.
79
Business Case: Development
Key Partners (Who helps us)
◦ Payers, Colleges of Pharmacy
Cost Structure (What we spend)
◦ Salaries, facilities, equipment
Revenue Streams (What we get)
◦ FFS, P4P
Financial Model
◦ Forecast, Managing Risk
Graphic from Business Model Canvas https://canvanizer.com
80
MEDICAL CHARGES
XYZ Primary Care
1st QTR
60
Revenue
2nd QTR
60
Revenue
3rd QTR
60
Revenue
4th QTR
60
Revenue
TOTAL
240
Revenue
Working Days
Fee for Service
Chg/Visit Visit Min
PCMH Medication Therapy Management
99605 $
30
15
99606 $
25
15
99607 $
20
15
$
$
$
1,800 $
$
1,200 $
3,600 $
$
2,400 $
3,600 $
1,500 $
2,400 $
3,600
3,000
3,600
$
$
$
12,600
4,500
9,600
Evaluation & Management-"incident to"
99211 $
20
15
99212 $
50
30
99213 $
80
45
$
$
$
1,200 $
3,000 $
4,800 $
2,400 $
6,000 $
7,200 $
2,400 $
9,000 $
9,600 $
1,200
9,000
12,000
$
$
$
7,200
27,000
33,600
CMS Annual Wellness
G0438 $
108
60
$
1,530 $
1,530 $
3,060 $
3,060
$
9,180
42
25
$
5,040 $
6,300 $
7,560 $
8,820
$
27,720
55%
$
$
18,570 $
10,214 $
29,430 $
16,187 $
39,120 $
21,516 $
44,280
24,354
$ 131,400
$ 72,270
$
$
$
$
$
2,550
1,125
1,875
5,550
15,764
5,100
2,250
3,750
11,100
27,287
5,100
2,250
3,750
11,100
32,616
$
$
$
$
$
5,100
2,250
3,750
11,100
35,454
$ 17,850
$
7,875
$ 13,125
$ 38,850
$ 111,120
Pharmacist Allocated Time
Pharmacist Expense
133,000
$
0.44
14,778 $
0.69
22,906 $
0.93
31,033 $
1.04
34,728
$ 103,444
PROFIT/LOSS
$
986 $
4,381 $
1,583 $
726
Chronic Care Management
99490 $
Total Charges
Collection Rate
Performance Bonus
PMPM
A1c Control <9 $ 0.25
Statin Adherence>75% $ 0.50
High Risk Med s<3% $ 0.25
TOTAL P4P/Quarter
TOTAL COLLECTED REVENUE
$
$
$
$
$
$
$
$
$
$
$
7,676
Model uses PCMH Pharmacist Benchmarks, PCMH Demographics, and Pharmacist
Capacity data to forecast number of average visits per day and calculate revenue
81
Self-Assessment Questions
What services can a pharmacist bill Medicare?
a)
b)
c)
d)
e)
Chronic Care Management (CCM)
Durable Medical Equipment
Transitional Care Management (TCM)
“Incident to” Evaluation/Management
All the above
Self-Assessment Questions
Requirements of “incident to” billing include EXCEPT:
a) Commonly furnished in a physician’s office.
b) Furnished by supervised auxiliary personnel
employed by physician or practice.
c) Physician must be present in room when services
are provided by auxiliary personnel.
d) Conducted within the Scope of Practice of the
auxiliary personnel (e.g. pharmacist).
Self-Assessment Questions
What are examples of patient care outcomes that
pharmacists can impact and generate revenue?
a) Achieve targeted A1c, LDL, and BMI in patients
with multiple complex chronic conditions.
b) Reduce the use of high risk medication (Beer’s
List) in the geriatric population
c) Achieve and maintain targeted INR in patients on
warfarin.
d) All of the above