7/29/2013. What is your field of practice? What is your familiarity level with Patient Centered Medical Homes (PCMH)? Where do you work?

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1 Nicholas Olson, PharmD, AAHIVP Prepared for Western States AETC July 2013 What is your field of practice? a. Pharmacist b. Nurse c. Provider d. Mental health e. Case Management f. Administrator g. Other Where do you work? a. Hospital/academic medical center clinic b. Inpatient c. Independent/Ryan White Funded clinic d. FQHC e. Social service agency/aso f. Private practice clinic g. Other What is your familiarity level with Patient Centered Medical Homes (PCMH)? a. I participate in this type of practice model b. I am familiar, but don t practice in this setting c. I am aware of them, but am not sure what they are d. I an unfamiliar with this practice model Do you work with pharmacists with expertise in HIV care? Yes No Do you have a pharmacist working in your clinic? Yes No What questions would you like to have answered today? The learner will gain ideas as to how to efficiently utilize pharmacist skills in clinic settings. The learner will learn how to structure pharmacist-run clinics via electronic medical records and collaborative practice agreement. The learner will be able to effectively describe and explain the history and present role pharmacists have in providing direct patient care in medical clinic settings specifically in the areas of: 1. Regulatory issues 2.Billing and reimbursement 3.Liability 4.Training/education The learner will be able to define the different roles pharmacists can play in medication procurement in an in-clinic setting. 1

2 Discussion of enhanced roles for pharmacists Advanced trainings MTM, CPA, CDTM Literature review of pharmacist interventions Primary care HIV Integration of clinical pharmacy practice Billing and reimbursements Work flow examples Roles in drug procurement Giberson S, Yoder S, Lee MP. Improving Patient and Health System Outcomes through Advanced Pharmacy Practice. A Report to the U.S. Surgeon General. Office of the Chief Pharmacist. U.S. Public Health Service. Dec Endorsed by Dr. Regina Benjamin Discusses the essential role of pharmacists in the delivery of patient care Calls to action for Policy and legislative changes to remove barriers Enhanced reimbursement structures Expansion to all pharmacists Health-care reform (ACA) Patient Centered Medical Homes Institute of Medicine Report: Preventing Medication Errors American Academy of Family Physicians position paper 2 1. Institute of Medicine. Preventing Medication Errors: Quality chasm series. Washington, DC: National Academies Press; American Academy of Family Physicians. Available at: Accessed July 14th billion prescriptions written in $200 billion in annual expenditure on drug related morbidity and mortality 1 Patient requiring additional therapy Appropriate drug titration Side effect management and monitoring Drug interaction evaluation HIV management fits chronic disease model 2 1. The Patient Centered Medical Home: Integrating Comprehensive Medication Therapy Management to Optimize Patient Outcomes. Report by the Patient Centered Primary Care Collaborative Chu C, Selwyn PA. J Urban Health Mar 1 Carolyn Chu and Peter A. Selwyn. An Epidemic in Evolution: The Need for New Models of HIV Care in the Chronic Disease Era. Journal of Urban Health: Bulletin of the New York Academy of Medicine, Vol. 88, No

3 Greater amount of people being tested earlier People starting on HIV therapy earlier More potent antiretroviral therapy (people living longer) + No change in infections rates Increased number of people living with HIV requiring treatment $ 2000 per x 12 Months $24K per = month year HIV meds monthly cost Now take a newly diagnosed 20 year old: $ $24K per year HIV meds yearly cost x 30 years = $ 720,000 Health outcomes 34 patients UCSF HIV clinic 253 pharmacist interventions Baseline: CD4: 229 +/- 183 VL: 103K 88% AIDS dx Results 100% recommendation acceptance 54 CD4/mcl 1.02 log VL March et al. Am J Health-Syst Pharm. 2007; 64: Adherence Outcomes Henderson et al. AIDS Patient Care STDs 2011;25(4): Ma A et al. AIDS Care 2010;22(10): Drugs don t work in people who don t take them -C Everett Koop Study Population Outcome Measures Results Roughhead et al. Circ Heart Fail Sep;2(5): Machado et al. Ann Pharmacother Nov;41(11): Machado et al. Ann Pharmacother Sep;42(9): Australian VA Patients with pharmacist chart reviews (n= 273) vs. patients w/o (n= 5444) Meta analysis of 28 hypertension clinic pharmacist intervention trials vs. nonpharmacist interventions Meta analysis of 23 lipid lowering clinic pharmacist intervention trials vs. nonpharmacist interventions Recurrent hospitalization with in one year Decrease systolic BP, diastolic BP, quality of life, adherence Decreases in TC, LDL, HDL, TG, QoL and adherence Pharmacist group= 5.5% vs. non-reviewed group 12% (p=0.003 ) Sensitive to 11 mmhg systolic decrease (p<.002), non-sensitive for other measures Sensitive: decrease TC (34.3 ± 10.3 mg/dl; p < 0.001), LDL (17.5 ± 10.9 mg/dl; p = 0.109) adherence. Non sensitive: QoL Minimum of 6 years 2 years prerequisite 4 years in within school 1 year of clinical practice Ambulatory and inpatient Fields of study Traditional: dispensing, counseling, compounding, practice management Progressive: direct patient care, research, managed care, clinical specialties Residency PGY1 Specialty Residency PGY2 Fellowships Advanced Certifications Clinical Pharmacist Practitioners APhA and ASHP certifications BCPS certifications American Academy of HIV Medicine 3

4 Board Certification in Pharmacotherapeutic Specialties (BCPS) ID Oncology Psych Pharmacotherapy Ambulatory care- new 2012 AAHIVP Integrative care and care coordination Medical Dental Social Mental health/substance abuse Transitional care Pharmaceutical National Committee for Quality Assurance. Available at: Accessed July 14 th 2013 Healthcare team Whole person care Coordinated care Enhanced patient access Utilize health information technology Increase patient engagement Measure quality and safety Invoke payment reform to support Model of care approach 1. Appropriateness 2. Effectiveness 3. Safety 4. Adherence Evaluates medication therapies as a whole taking in account patient specifics Interactive, integrated and collaborative Assessment of medication-related needs Motivational interviewing Family involvement Identify patients medication related problems OTC, herbal/complementary therapies Develop care plan with goals and interventions Medication Action Plans Communication with providers Follow up to determine outcomes and adjust Payment for services rendered PCMH Principle Team-based care Whole person care Coordinated care Enhanced patient access Use of Health information Tech. Measured quality and safety MTM Principle Pharmacist part of the Care team either in clinic or in the community. Collaborative agreements. Family involvement. Two way communication Assessment of OTC, complementary therapies. Tailored Medication Action Plan Transitional planning, provider interaction In-between provider visits, extension to community pharmacy Health information exchanges, EMR, PDMP Systematic and evidence-based approach Payment reform MTM fee for service and PCMH outcome bonuses Adapted from: Smith M and Nigro S. The Patient Centered Medical H0me. PSAP-VII Science and practice of Pharmacotherapy

5 1. Identify need Poly-pharmacy, HIV adherence, other chronic disease measurement outcomes 2. Affiliation and reimbursement structures 3. Scope of practice 4. Clinical logistics Scheduling, access to EMR 5. Establish outcome and productivity measures 6. System of review and continuous QA Engage quality manager Query EMR Review Ryan White Service Act reporting Do an adherence pilot study Look at drug utilization or 340B cost reports Hold focus groups with staff Contract with larger pharmacy/pharmacy department Partnering with University/School of Pharmacy Ryan White/Other grants Fee for Service? Internal pharmacy Employee Most expensive; most dedicated time Embedded model Academic medical center Affiliation with school of pharmacy Regional Model Centralized pharmacist covers multiple clinics Contracted model Least commitment Requires affiliation agreements and advanced HIT HIV New/switch HAART therapy Side effect management Comorbid condition Patient selection Large number of medications Multiple chronic disease Poly provider/poly pharmacy Frequency of care transition Hildegreade et al. J Am Pharm Assoc. 2012;52: Tseng et al. CJHP. 2012;65(2): Traditional Drug interaction review Adherence monitoring and counseling Medication information Drug procurement Medication therapy management Adverse event management Advanced Primary care management via CPA BP,Lipids, diabetes, INR HCV coinfection monitoring and management PrEP management Research Transitional care collaboration 5

6 An agreement between a qualified pharmacist and one or more physician(s) wherein the pharmacists is granted the authority to initiate, modify, or continue drug therapy in accordance with preapproved, written protocols Collaborative drug therapy management CDTM Must consult your state practice laws for scope and structure of CPAs Why Enter Into a CPA? Improved access to quality care Decrease delays in modifying regimens, ED visits or unplanned MD office visits Elevate the level of pharmacy practice Continues expansion of our role beyond dispensing Cost effective for the organization Potential decreased medical costs More opportunities for pharmacist compensation Increased patient adherence and understanding of disease state/pharmacotherapy accessed July 2013 Establish legality, authority and responsibility Establish outcome measurements and goals Establish mechanism of continuous quality review Defines referral process for patients 1. Patient interview 2. Lab and diagnostic tests 3. Select and/or administer pharmaceutical therapy to patients according to written protocols 4. Monitor and assess the outcomes of pharmacotherapy 5. Document activities and observations 6. Communicate regularly with the other provider(s) involved in the patient s care See CPA example Considerations in drafting CPA Professional judgment vs. prescriptive Training restrictive vs. all inclusive Disclaimer: Please consult with your state pharmacy boards, professional associations and institutional policies regarding all legal aspects of CPAs How a pharmacist bills for services depends on: 1. Practice setting 2. Geographic location 3. Payer mix 4 of the most common methods: MTM CPT codes Incident-to billing Facility fee billing Patient self-pay/ 340B Ryan White Part B/ Part C 6

7 Hospital campus or hospital-based clinic Most flexible Facility fee billing most common Independent clinic Incident-to billing (99211) MTM CPT codes (99605,06,07) Self-pay FQHC Medicare Fiscal intermediary Interpretation Other Related geographic issues: Available Medicaid MTM programs State provider status laws Available private insurance MTM programs : accessed July 7 th, 2013 Can be used in independent clinics (i.e. those not financially tied to a hospital) Pharmacist provides services incident to physician services Specific requirements for use Billed using the evaluation/management (E/M) codes used by physicians for an established patient (nurse visit) (problem focused) (expanded Problem focused) History none Brief 1-3 elements Expanded + ROS Physical Exam none Assess 1-5 elements Medical decision making none Simple Triage Low Assess 1-11 elements To Bill - Must complete 2 of 3 elements - Most fiscal intermediaries will not allow a charge > w/o the patient seeing the provider - Provider must be on-site - Pharmacist must be contracted or employed with clinic Hospital-based (provider-based) clinics Hospital Outpatient Prospective Payment System Generally only available for Medicare Requires provider supervision Can bill only as much resource is use Medicare does not provide much guidance Most Hospitals employ a point -based tool. 7

8 Diabetes Self-Management Education codes- G0108 and G0109 Used by ADA or AADE-recognized programs CLIA-waived tests (such as INR) Vaccinations Administration and product Medical Home Coordination fee Per patient per month Medicare Meaningful Use criteria Obesity Counseling (mandated by ACA)* ($21-$135) Tobacco cessation counseling ($8-$15) and ($ ) *Legislation introduced to add pharmacist to list of providers for obesity counseling Hildegreade et al. J Am Pharm Assoc. 2012;52: Primary care ambulatory clinic in N.C Evaluated pharmacist generated charges over a 4 year period billable encounters for 0.7 FTE pharmacist Majority of claims were billing Mean charge = $41 Mean Collection= $19 (47%) Scott M et al. Billing for pharmacists cognitive services in physicians offices: Multiple methods of reimbursement. J Am Pharm Assoc. 2012;52: Code Charge ($)* Time (minutes) Patients needed Notes: 1. Assumptions based on $100,000 plus $20,000 fringe benefits 2. Calculated based on being able to bill for multiple codes Conclusions: 1. Current reimbursement models are not sustainable 2. Pharmacist are integral to achieving positive health outcomes. Scott M et al. Billing for pharmacists cognitive services in physicians offices: Multiple methods of reimbursement. J Am Pharm Assoc. 2012;52: Currently pharmacists are not recognized as an incremental, payer specific medical provider under the Social Security Act Would require an act of Congress to change American College of Clinical Pharmacy proposal A valid drug therapy monitoring agreement Advanced training in patient care delivery Credentialing and/or certification in specific disease fields Recognizes the contributions of pharmacist interventions to positive patient outcomes Expands access of quality healthcare to patients Leads way for other 3 rd parties recognition of pharmacist provider status Allows independent medical centers, safety-net clinics, and small medical practices access to pharmacist services Creates a revenue stream congruent to time, effort, and outcomes of MTM services Not intended for every practicing pharmacist Would not make pharmacist independent prescribers Would not make competition for other midlevel practitioners NPs, PAs etc. Would not diminish physician revenue Would not remove pharmacist from dispensing role 8

9 Major position papers have written ASHP- Status.aspx AMCP- APhA- ACCPhttp:// PCPCCwww.accp.com/docs/positions/misc/CMM%20Resource%20Guide.pdf Petition filed at whitehouse.org Many individual state actions HIV medications AIDS Drug Assistance programs 340B programs Industry co-payment cards Primary care medications Patient assistance programs Hepatitis medications Copayment assistance foundations Patient Advocate Network Chronic disease funds Specialty pharmacies Familiarity with prior authorization processes Ask for peer to peer reviews Be sure to cite DHHS HIV guidelines Chronic disease repository programs Sampling programs Maintain relationships with Pharma Pharmacists are an underutilized healthcare provider in HIV and primary care settings Pharmacists training and professional development provide them with appropriate tools to increase patient outcomes in clinic settings Progress needs to be made in pharmacist service provision reimbursement structures Pharmacist play important roles in drug access Tseng A, Foisy M, Hughes C et al. Role of the Pharmacist in caring for patients with HIV/AIDS: Clinical practice Guidelines. CJHP. 2012;65(2): The Patient Centered Medical Home: Integrating comprehensive medication management to optimize patient outcome. PCPCC Foundation 2012 Scott M, Hitch W, Wilson C, Lugo A. Billing for pharmacists cognitive services in physicians offices: Multiple methods of reimbursement. JAPhA. 2012;52(2): Berdine H, Skomo M. Development and intergration of pharmacist clinical services into patient-centered medical home. J Am Pharm Assoc. 2012;52(5): True or False: The aspects of medication therapy management and patient-centered medical home practice models don t overlap much and therefore would be hard to integrate together in a clinic setting FALSE 9

10 All of the following are examples of demonstrated medical outcome improvements achieved through pharmacist driven programs except: a. Decrease in systolic blood pressure b. Improved HIV medication adherence rates c. Increased time spent at goal INR d. Improved LDL levels e. None of the above Which of the following is a mechanism that a pharmacist CANNOT currently use to submit for reimbursement a. Incident-to CPT code (99211) b. MTM CPT Codes (99605,06,07) c. Provider CPT Code (99212,13,14,15) d. Facility Fee Laura Traynor PharmD, BCPS Megan Grischeau, PharmD, BCACP Nicole Lentz PharmD, AAHIVP Steve Scholzen Doctor of Pharmacy Candidate 10