10/10/2017. Mythbusters: Primary Care Edition (Expanding Opportunities) Amina Abubakar, PharmD, AAHIVP Olivia bentley, PharmD, CFts, AAHIVP
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1 Mythbusters: Primary Care Edition (Expanding Opportunities) Amina Abubakar, PharmD, AAHIVP Olivia bentley, PharmD, CFts, AAHIVP 1
2 Disclosures Amina Abubakar, PharmD, AAHIVP, RX Clinic Pharmacy and Olivia Bentley, RX Clinic Pharmacy declare no conflicts of interest or financial interest in any product or service mentioned in this program, including grants, employment, gifts, stock holdings, and honoraria. Learning Objectives Discuss prescriber quality programs and how to have a conversation with prescribers that speaks to their pressure points Described workflow and billing in a prescriber s office Quantify community pharmacy revenue opportunities in primary care and how to negotiate financial agreements Illustrate the path for community pharmacy s role in primary care 2
3 Navigating Through Industry Challenges 3
4 Rethink Pharmacy s Role Allow Medical Providers to provide Episodic Care Focused on treatment, treatment, treatment Pharmacists to provide Preventative Care Comprehensive evaluation Development of Care Plans Implementation and coaching of Care Plans Remote Progress Check ins and Accountability Evaluation and Coordination of Care Update Care Plans Practice Sites: Rx Clinic Pharmacy #1 Independent Community Pharmacy Medication Synchronization 100% Community Pharmacy Enhanced Services Network (CPESN) Pharmacy MTM Program Pharmacogenetic Personalized Medication Review Program AADE Accredited Diabetes Education Program URAC Accredited Specialty Pharmacy Point of Care Testing Rapid Flu BHRT Saliva Testing Diabetes Screening Cardiovascular Risk Screening Blood Pressure Cholesterol HIV HepC 4
5 Practice Sites: Rx Clinic Pharmacy #2 Independent Medical Practice Within House Pharmacy Clinical Pharmacist Embedded in a Medical Practice Collaborative Practice Agreement Annual Wellness Visits Chronic Care Management Intensive Behavioral Therapy for Obesity BHRT HIV Specialty Pharmacist Pharmacist led Acute/Urgent Care Clinic Travel Health & Immunizations Clinic Yellow Fever Certified Pharmacogenetic Personalized Medication Reviews Allergy Testing Other Practice Sites Primary Care Medical Practices Similar Pharmacist led Clinical Services Pharmacist spends part time at different medical practices Assisted Living Facilities Federally Qualified Health Centers (FQHC) Training and Education Platforms Pharmacogenetics Community Pharmacy Implementation Hospital System Implementation Pharmacist led Clinical Services in Ambulatory Care Practices Community Pharmacy and ACO Integration 5
6 Pharmacy Redefined Management Service Organization Prescriber Quality Programs Join the health care team as a high level clinician bringing quality patient care and value to the medical practice 6
7 Important Terms from the CMS Quality Payment Program for Providers Old Terminology Meaningful Use (MU) EHR Incentive Program Physician Quality Reporting System (PQRS) incentive program for reporting quality measures (CQM) Clinical Quality Measures (CQM) tools that measure the quality of health care services 2017 Terminology MACRA name of the law that established a new way to pay providers MIPS Merit based Incentive Payment System Quality measures EHR related measures APM Advanced Payment Models e.g. ACOs CMS Quality Payment Program for Providers MACRA passed in 2015 Medicare Access and CHIP Reauthorization Act Created MIPS and APM By 2019 PQRS, MU and CQMs will collapse into MIPS Fee for service will be fixed Physicians accepting Medicare must either do MIPS program, value based (pay for performance) or ACO Value based contract for all providers by
8 CMS Quality Payment Program for Providers Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Who is in the Quality Payment Program (QPP) in 2017? Providers in an Advanced APM or Providers that bill Medicare more than $30K per year AND Provider care for more than 100 Medicare patients per year For MIPS, you must also be one of the following: Physician, PA, NP Clinical nurse specialist Certified registered nurse anesthetist *Must submit data on at least 50% of applicable Medicare and non Medicare patients on at least 6 quality measures 8
9 MIPS Performance Payment Adjustment Timeframe How Will MIPS Impact Medicare Payments? 9
10 Advanced APM Payment Adjustment Timeline and Impact What are Alternative Payment Models (APM) and Advanced APM? Incentive payments for high quality care and cost efficient care May apply to specific condition, care episode, or population Advanced APM Higher risk with potentially higher reward 5% incentive payment 2017 Example Advanced APMs Comprehensive Primary Care Plus (CPC+) Next Generation ACO Model Shared Saving Program Track 2 Shared Saving Program Track 3 10
11 How Are Pharmacist led Clinical Services Making an Impact for Medicare Providers? Quality = PQRS Most: up to 6 quality measures for a minimum of 90 days Group: 15 quality measure for a full year APMs: report through APM and do not need anything else for MIPS quality ACI = Meaningful Use Report through certified EHR Improvement of Activities Most: Attest to 4 for minimum of 90 days Groups <15: attest 2 for minimum of 90 days PCMH: automatically earn credit APMs: automatically earn credit through APM How Are Pharmacist led Clinical Services Making an Impact for Medicare Providers? 271 Quality Measures Most: 6 Group: 15 Medicare Annual Wellness Visit 30 measures addressed Chronic Care Management At least 7 linked to appropriate medication therapy management Transition of Care Management Medication reconciliation postdischarge Examples: Adults MDD: Suicide Risk Assessment Colonoscopy Screening Breast Cancer Screening Medication management STD Screening Cognitive Assessment Fall Risk Assessment Tobacco Cessation Counseling Osteoporosis Screening Urinary Incontinence Screening 11
12 Example MIPS Quality Measure Benchmarks Measures which give 10 points with performance <100% Point System within a single quality measure HepC screening >=20.02% Colonoscopy >=80.33% Breast Cancer screen Colorectal Cancer screen Pneumonia Vacc >90% Controlled BP >=91.07% Influenza >=91.84% CAD: DM or LVEF<40% + ACE/ARB >=96% BMI screen + f/u plan >97.34% Post MI or LVEF<40% + BB therapy >=97.92% Breast Cancer Screening 3 points 12 24% 4 points 24 25% 5 points 35 46% 6 points 46 55% 7 points 55 63% 8 points 63 74% 9 points 74 87% 10 points % PCMH Incentive Example from Commercial Payer Increased reimbursement in all codes by 5% Assigned NC AHEC Quality Improvement practice coach PCMH recognition is a mandatory component of the BQPP (double digit increase to fee schedules) 12
13 Pharmacist s Role in PCMH Assist in developing Care Plans Following up with patient s care plans counseling, coaching, monitoring and adjusting Meeting quality metrics submitted to NCQA Coordinating care amongst the healthcare team Monitoring quality measures and using care plan interaction to meet those measures HEDIS Measures for Commercial and State Payer Programs National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data & Info Set (HEDIS) 81 measures 5 domains Medicaid Core Set of Adult Health Care Quality Measures 2017 Primary Care Access and Preventative Care Maternal and Perinatal Health Care of Acute and Chronic Conditions Behavioral Health Care Experience of Care 13
14 14
15 Why Should Pharmacists Care About the Quality Measures for Medical Providers? Medical Providers do not have the time Medical Providers still do not understand what they are supposed to do Medical Providers are in denial that this is happening 15
16 16
17 Having Transplant Conversations with Medical Providers Showing a pharmacist s value in solving problems and pressure points. 17
18 Potential Revenue Opportunities Once they see the value in pharmacist led services, how can they afford to have you? Negotiating Financial Agreements Select the model that satisfies both the practice and pharmacy needs 18
19 Negotiating Financial Agreements Productivity Based Fixed Rate Incentive Based Workflow and Billing in a Medical Practice Understanding where a pharmacist fits in a new environment 19
20 The Path for Community Pharmacist s Role in Primary Care Using your strengths, abilities and pharmacy resources to impact quality patient care for medical providers 20
21 Choose Your Path Amina Abubakar PharmD, AAHIVP Olivia Bentley PharmD, AAHIVP, CFts Rx Clinic Pharmacy 21
22 22
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