A Roadmap to Working with Prescribers: Making Theory Into Practice. Amina Abubakar, PharmD, AAHIVP Olivia Bentley, PharmD, CFts, AAHIVP

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1 A Roadmap to Working with Prescribers: Making Theory Into Practice Amina Abubakar, PharmD, AAHIVP Olivia Bentley, PharmD, CFts, AAHIVP

2 Disclosures Amina Abubakar, PharmD, AAHIVP, RxClinic Pharmay 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.

3 Learning Objectives Describe the workflow for enhanced services, focusing on the role of pharmacy technicians and clerical staff in enhanced services Devise a plan to increase revenue by turning your medication sync program into a chronic care management program Establish a pharmacist-led clinic for acute care, annual wellness visits and other preventative care services inside a medical practice

4 Enhancing The Roles of Community Pharmacists Shift the mindset from being paid for dispensing a product to being paid for cognitive services Moving the pharmacists to the 90% pie of the Health Care spending

5 Enhanced Services within a Community Pharmacy Clinical Med Sync Vs Med Sync Clinical Pharmacists and Clinical Techs Adding your MTM s, CMR s,cipa s E-Care Plans All staff trained to capture and task opportunities Used for Specialty Medication monitoring

6 Other Clinical Services in the Community Pharmacy Accredited Diabetes Self-Management Training (DSMT) Program Point-of-Care Testing Program Pharmacogenetics Routine Immunizations Travel Health Clinic & Immunizations Diabetic Shoes & Compression Durable Medical Equipment

7 From Enhanced Services to Chronic Care Management (CCM) E-Care Plans Comprehensive Review of Patient s Medications and counseling on chronic disease state management Same requirements and components as Chronic Care Management Care Plans

8 A Collaboration Based on Quality & Value

9 Choose Your Path

10 Inside the Medical Practice No time to get to inboxes Refill requests from many pharmacies Prior Authorizations MTM recommendations pile up Lab results to counsel Patients are overbooked In Other Words Quality measures overlooked It s a MAD HOUSE Third party rejections for inappropriate note documentation New Pt visit = 30 mins / Follow up visit = 15 mins Just enough time to address 1 problem = the main problem Front desk Check-in/out Answer non-stop phone calls from pharmacies, patients checking on status of refills/pa, cancel or change appointments, fax requests, receive and transfer of medical records

11 Understanding Chronic Care Management (CCM)

12 Overview of CCM and Complex CCM Chronic Care Management (CCM) is a service performed by a physician or a non-physician practitioner and their clinical staff every month for patients with 2 or more chronic conditions. Chronic Conditions expected to last 12 months or until death Comprehensive care plan established, implemented, revised, or monitored Patient eligibility Medicare beneficiary 2 Chronic Conditions Patient does not have same day visit as CCM Patient is not in a Home Health System Must have had an evaluation by the provider before billing for CCM

13 CCM Services Include 5 Core Activities 1. Recording structured data in the patient s health record 2. Maintaining a comprehensive care plan for each patient 3. Providing 24/7 access to care 4. Comprehensive care management 5. Transitional care management

14 Types of Practitioner Supervision Direct Supervision - physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. Does NOT mean the physician must be present in the room. General Supervision - procedure is furnished under the physician s overall direction and control, but the physician s presence is not required

15 Supervising Medical Providers CCM may only be billed by Qualified Health Professionals Pharmacist Supervision may be under the following: MD PA NP Note: PA/NP only receives 85% of the MD s reimbursement

16 CMS uses the term auxiliary personnel instead of clinical staff Clinical Staff Terminology used by CPT Licensed practitioner who can assist in the delivery of services, in this case CCM, under the general supervision by a QHP Auxiliary Personnel Terminology used by CMS Individuals working under physician or other QHP supervision in an incident arrangement and whose services are billed by the QHP

17 CCM Billing Codes CCM BILLING CODES

18 Chronic Care Management Settings

19 Utilizing Medication Synchronization and CCM

20 Initial Set Up for CCM in a Community Pharmacy Run a report of Medicare patients that are eligible for CCM Approach the providers with majority mutual patients Explain to the provider your med sync program and how it can help them more if you did their CCM Get your CPA Get access to their EHR to document

21 Enrolling Patients in CCM Goal is to have all your patients synchronized for medication refills This allows for a controlled workflow During these monthly phone calls, a list is created of Medicare patients to ask patients if they are interested in monthly CCM phone calls This fulfills the verbal consent If practice doesn t currently have med synchronization, utilize interns to help make phone calls to sign patients up for service

22 Developing the Care Plan Initial patient workup must be completed by pharmacist to create care plan follow-up can be done by technician Review patient s most recent visit note To get an idea of what the patient has been recently told by the Physician/Pharmacist/Nurse Review patients Medications Review patient s Problems list Make sure everything on the Medications and Problems list correlate Checking DDIs, medications are appropriate, missing regimens Review Diet/Exercise regimen

23 Initiating CCM Make the phone call and start using the care plan CCM does not require the patient phone call all the time At least 20 mins of time documented from nurse/doctor/pharmacist communication e.g. prior authorizations, resolved a medication issue e.g. pharmacist performs work up on patient and makes recommendations to the provider

24 Valuable CCM s Yield More You show your value = provider wants to add more patients to your list that do not use your pharmacy Changes in your infrastructure i.e. Patients calling practice vs pharmacy to ask why someone is calling them Consider a call center mentality i.e. MTM pharmacists

25 Making Sure Your CCM is Profitable Use Med sync calls made by the Pharmacy Technicians to follow up on th e care p lan obje ctive s Havin g th e e n tire te am u tilize te ch n ology like th e MTM action s in Pioneer to capture any time spent resolving DTP s, PA, im m u n iza tion s etc OR Create internal communication paper that everyone can write in and submit to the med sync tech to document accordingly

26 From CCM to AWV (Annual Wellness Visits) Valuable CCM s assures medical providers they can trust you to do AWV s under their supervision in their practice Ex: Medicare Pt with uncontrolled diabetes, HBP, that your pharmacy follows up on CCM with great monthly follow up and interventions from the care plan. This makes it easy for the pharmacist to get the medical provider to delegate an AWV!

27 Pharmacist-led Clinical Services within a Medical Practice

28 Understanding Medicare Annual Wellness Visits The ABCs of the AWV

29 Annual Wellness Visits A visit to develop or update a personalized preventative care plan for Medicare Part B beneficiaries (>12 months coverage) Personalized Preventative Care Plan includes: Gather vitals: height, weight, BP, and other routine measurements Update a list of current providers and prescriptions Review and update medical and family history Create a checklist of risk factors, treatment options, and personalized health advice Create a screening schedule for appropriate preventative services e.g. mammogram, prostate exam, colonoscopy Assess for cognitive function and functional ability Depression screening

30 Annual Wellness Visit (AWV) Two Types of AWV 1.Initial AWV (after 12 months of Medicare coverage) 2.Subsequent AWV (one year after the initial AWV billed) Performed under Direct Supervision Reimbursements may differ based on your supervising provider s status (MD vs. PA or under penalty) Billing other codes on the same day separately identifiable E/M and medically necessary Modifier 25 Codes Description Physician Based Facility Based G0438 AWV; includes personalized prevention plan (PPPS), initial visit $170 $180 G0439 AWV; includes PPPS, subsequent visit $115 $125

31 Annual Wellness Visit (AWV) Resources Medicare Interactive provides general information about Medicare covered services Medicare Learning Network (MLN) contains detailed information on components, billing, requirements, etc for Medicare covered services Learning-Network- MLN/MLNProducts/downloads/AWV_chart_ICN pdf

32 Annual Wellness Visits (AWV) What do you need? Access to EMR Staff to book appointments Exam Room or private area for consultation Workstation Other considerations depending on clinic s workflow

33 Annual Wellness Visits (AWV) What s the different between IPPE and AWV? Preventative care visits are NOT used for an annual physical exam Initial Preventative Physical Exam (IPPE) aka. the Welcome to Medicare Visit Once in a lifetime Only billed within the first 12-months of initial Medicare Part B coverage Only furnished by PCP Annual Wellness Visit (AWV) Initial and Subsequent AWV AFTER first 12 months of coverage, perform initial Pharmacist may perform incident-to

34 Annual Wellness Visits (AWV) Practical Implementation Considerations Time burden Improves with efficiency Gets easier with subsequent visits Recruitment of patients Patient no shows Eligibility New patients may have already been billed by previous PCP EHR may be able to check eligibility Understanding clinic workflow E.g. referrals for mammograms, PAPs, colonoscopy, etc FQHC issues

35 *Appropriate documentation, ICD-10 codes, and modifiers are essential to success* Services improve quality patient care AND provide additional revenue to the program Additional Billing Services to AWV Description of Service Code Description of Service Code Initiation of CCM G0506 Tobacco Cessation 99406, Alcohol counseling G0443 STI prevention counseling G0445 IBT Cardiovascular Disease G0446 Diabetic Foot Exam G0245 Advance Care Planning CKD Education G0420 Cognitive Testing 96103, IBT Obesity G0447, G04473* Depression Screen* G0444 FOBT (CLIA waived test) G0328 QW

36 Other Physician Billed and Pharmacist Performed Services Transitions of Care Management (TCM) Outpatient/Community Setting Requires medication reconciliation within 2 business days postdischarge IBT Obesity Weekly 15 minute visits for the first month BMI >30 Incident-to Visits to Must follow appropriate billing rules

37 Pharmacist-led Acute Care Clinic Providing a solution to improve patient s access to care

38 Emerging Roles for Pharmacists in Urgent, Acute, and Emergency Care Pharmaceutical Journal - Feb 2017 New models of care and care delivery need to be developed in order to maintain and enhance standards of safe and accessible patient care Departure from traditional (doctor-led) approaches to workforce planning is necessary to develop a sustainable, multi-skilled workforce across primary,community and secondary care Emergency Departments have clinical pharmacists successful in delivering and supporting the advanced clinical role of pharmacists Clinical Example Primary Care practice No room for same day appointments PCMH metric not fulfilled AND patients did not have access to care SOLUTION: Pharmacist-led acute care visits

39 Pharmacist-led Acute Care Clinic URI Influenza Sinusitis Strep Otitis Media Uncomplicated UTI General

40 Pharmacist-led Acute Care Clinic: Standing Order Protocols

41 The Clinical Impact of Pharmacist-led Preventative Care Services

42 The Indirect Impact of Pharmacist-led Clinical Services

43 Sample Patient Case From Clinical Impact to Profitability

44 ML 68 yoa caucasian female Medicare Beneficiary with Medicaid secondary Presents for AWV with the clinical pharmacist PMH: HTN, T2DM, Dyslipidemia, CAD SH: former smoker for 10 years Allergies: NKA Hospitalizations: recurrent UTI Vitals: BP145/90, Ht 5 2, Wt 174 lbs, BMI 31.8 Labs: A1C 9.2% TC 289, LDL 95, HDL 15, TG 315 CMP: WNL except glucose 215 Medications: Metformin 1000mg BID Lisinopril 10mg QDay Simvastatin 20mg Qday Canagliflozin 100mg Qday Immunizations: none on file

45 Potential Codes, Procedures and Opportunities Description of Service Code Reimbursement Annual Wellness Visit Initial G0438 $ Initiation of CCM G0506 $65.00 Advance Care Planning $83.00 Diabetic Foot Exam G0246 $38.00 CVD Behavioral Therapy G0446 $25.00 SubTotal $ CCM non-complex 20 mins $ CCM complex 60 mins $97.00 Final Total for Physician Billable Services $779.00

46 Potential Codes, Procedures and Opportunities Upsolutions Pharmacy Billed Code/Units Gross Profit Potential Opportunity in 1 Year for Case Patient Physician Billed = $ Pharmacy Billed = $2, Total = $3, Individual DSMT G0108 (2 units) Group DSMT G0109 (18 units) $ $ Diabetic Shoes 1 pair set $75.00 Diabetic Compression Stockings 4 pairs $40.00 Immunizations (P13, P23, Shingles)* $60.00* Omega-3 prescription** 12 fills $1, Topical Pain Cream Cash** 4 fills $ Total $2,449.00

47 Potential Codes, Procedures and Opportunities If an independent practice = 450 Medicare Patients If third of those are diabetic = 150 eligible patients for services in case scenario If half of those patients meet case criteria = 75 patients 75 patients x $3, $242,100.00

48 Team Based Care

49 Start Your Journey Now