Bob Davis, PharmD, FAPhA Professor and Chair, KPIC davisb@kennedycenter.sc.edusc edu South Carolina Primary Health Care Association September 19, 2015 Myrtle Beach, SC Disclosures Robert E. Davis declare(s) no conflicts of interest, real or apparent, and no financial interests in any company, product, or service mentioned in this program, including grants, employment, gifts, stock holdings, and honoraria. The American Pharmacists Association is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. 1
Kennedy Pharmacy Innovation Center Foundation established at the University of South Carolina in 2010 through alumni gift Fosters creativity it and innovation by connecting passionate, forward-thinking, entrepreneurial pharmacy students, educators, and practitioners Develops and supports entrepreneurial programs, and exploration of new sustainable business models Transforms pharmacy practice into viable, effective patient-centered care model by providing tools, resources, and relationships 2
Evolving Care Models Decentralization of simple care process closer to patient More interdependent, collaborative, structured care Facilitated with new technology enablers Embracing a care system where clinician's skill and location is matched to the difficulty of the problem Innovation Creating Change Patient Centered Medical Home (PCMH) 1967: The American Academy of Pediatrics introduces the term medical home 2005: Dr. Barbara Starfield, primary care champion, publishes cornerstone concepts of PCMH greater patient access better quality of care greater focus on prevention early management of health problems role of primary care in reducing unnecessary or harmful specialty/inpatient services 2010: The Patient Protection and Affordable Care Act (ACA) also referred to as Obamacare 3
Patient Centered Medical Home Key Attributes PCMH Recognition SC FQHC: 16 of 20 organizations have PCMH Recognition 66 total sites statewide HRSA: Strongly encourages FQHCs to be recognized Awarded grants to assist with the process Provided base grant adjustments for recognized sites 4
PCMH Quality Assurance Standards Developed by National Committee for Quality Assurance (NCQA) Assurance (NCQA) 1. Enhances access continuity 2. Identify and manage patient populations 3. Plan and manage care 4. Provide self-care support and community support 5. Track and coordinate care 6. Measure and improve performance Accountable Care Organization (ACO) The term "Accountable Care Organization" was first used by Elliott Fisher Director of the Center for Health Policy Research at Dartmouth Medical School Included in the federal Patient Protection and Affordable Care Act (ACA) Medicare announced approval of 32 ACOs in pilot projects 7 5
Accountable Care Organization (ACO) Provide evidence-based care in a collaborative and coordinated open network model. 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) 6
Exploring Pharmacists Role in a Changing Healthcare Environment 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 ACOs (PCMH/CHC) may look to integrate pharmacistprovided medication management to improve medication adherence and clinical outcomes while Avalere Health LLC, 2014 Traditional role Pharmacist Roles Medication distribution Contraindications and drug drug interactions Physician s resource for medication information Patient education about medications Emerging Role Collaborative Medication Management Chronic Care Management Annual Wellness Visits Transitional Care Management 7
Ambulatory Roles Pharmaceutical Care Clinical Pharmacy Services Comprehensive Medication Management Medication Therapy Management Collaborative Drug Therapy Management Integrated Medication Management 8
Why Medication Management >75% of medical expenses are for chronic care 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: Dosage titration Add new drug Medication outcomes monitoring Adverse event >32% of adverse events leading to hospital admissions are related to medication Pharmaceutical Care Responsible provision of drug therapy for the purpose of achieving outcomes that improve a patients quality of life. Clinical pharmacy of the 70 s still focused on products and services rather than on the patient. Increased reliance on managing drug therapies adverse effects ( drug misadventures ) Conceptualized by Doug Hepler and Linda Strand It s a philosophy of practice not a list of rules M b f d t Ph C Ph i t C 9
Medicare Prescription Drug Improvement and Modernization Act of 2003, Part-D Built upon pharmaceutical care concepts Emphasizes the importance of medications in public health and safety Recognizes collaborative nature of pharmacists with other health care professionals to achieve outcomes Mandated payment for MTM services Clearer models for implementation and services than pharmaceutical care model APhA MTM Definition Medication therapy management is a partnership of the pharmacist, the patient or their caregiver, and other health professionals that promotes the safe and effective use of medications and helps patients achieve the targeted outcomes from medication therapy. Reference: www.pharmacist.com 10
Medication Therapy Management Core Elements Medication therapy review Personal medication record Medication related action plan Intervention/referral Documentation Monitoring and follow up Achieves quality outcomes Comprehensive Medication Management ensures that each patient's medication are individually assessed to determine appropriateness for the patient, effective for the medical condition, safe with other comorbidities and medications, and able to be taken by the patient as intended. What s different? 1. Includes individual comprehensive care plan, not single MRP 2. Patient activated and engaged in care plan implementation 3. Delivered face to face to patient 4. Works within a collaborative team of medical providers 5. Integrated documentation 6. Includes an assessment of the patient s medication 11
Comprehensive Medication Management Pharmacist Patient Care Services Obtain and evaluate patient history as it impacts medication management and patient care outcomes. Assess and manage medication therapeutic regimens of chronic conditions within written treatment guidelines. Provide patient counseling on medications, nutrition, lifestyle, and medication self-management Conduct limited physical assessments per guidelines for managing medication therapeutic regimens. Order diagnostic tests and medical devices to support medication management of chronic conditions Pharmacist Value Improve patient quality outcomes Develop new revenue streams Improve physician productivity Lower healthcare cost Reduce cost of medication Reduce hospitalizations and ER visits Eliminate duplicate services and procedures Enhance patient and provider satisfaction 12
Medication Management Barriers to Success 1. Drug focus: preoccupation with dispensing. 2. Location: services provided distant from the patient and without regard to outcome. 3. Design: pharmacies not designed to do private consultations 4. Other health care professionals: infringement on others turf ; politics. 5. Ignorance: I ve seen the enemy and it is us. 6. Laws/Regulations: lack of provider status 7. Payment/Lack of incentives: compensation based on dispensing productivity rather than patient care. Payment Landscape for Pharmacists In response to a January 22, 2014 inquiry from the AAFP, Marilyn Tavenner, CMS Administrator, responded on March 25, 2014 stating: In your letter, you ask that 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. We agree. On July 3, 2014, Marc Hartstein, Director, Hospital and Ambulatory Policy Group, CMS wrote a reconfirming letter to UNC Health Care: a physician may bill for the services of a pharmacist under their supervision with which they have a relationship that meets the requirements of 42 CFR 210.26,, if the services being provided are consistent with state law and meet all other requirements of the incident to rules. 13
South Carolina Practice Acts Impact March 18, 2014, Board of Pharmacy Statement Regarding Scope of Pharmacy Practice: The South Carolina Board of Pharmacy confirms that the scope of pharmacy practice as defined in the South Carolina Pharmacy Practice Act permits a South Carolina licensed pharmacist, in collaboration with a South Carolina licensed physician, to obtain a patient medical history, evaluate laboratory results, conduct limited examinations, and make medical decisions pursuant to a medical order. Medical Practice Act "Delegated medical acts" means additional acts delegated by a physician or dentist to a 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. must be performed under the supervision of a physician or dentist who must be readily or immediately available for consultation Billing Requirements for Pharmacists Collaborative practice-physician supervision Billing through recognized provider incident to or auxillary personnel Employment relationship (contract or employee) Pharmacist's Scope of Practice includes authority to: Take patient history Perform limited examination Make medical decisions 14
Payment Models Fee for Service: Payment for professional services in which the practitioner is paid for the specific service rendered. Pay for Performance: Financial incentives to clinicians for achieving patient-focused high value health outcomes based upon evidenced-based defined measures. Shared Savings: Financial incentives for clinicians to reduce health care spending for a defined patient population by offering them a percentage of net savings. Bundled Payments: Single payment to providers for all services to treat a given condition or provide a given treatment. FQHC Provider Recognition/Payment Face to face encounter between patient and: Physician Clinical Psychologist Physician Assistant Certified Social Worker Nurse Practitioner Certified Diabetes Certified Nurse Midwife Provider Encounter Payment Methods: FCHC qualifies for specific reimbursement under Medicare and Medicaid. All-inclusive rate (AIR) Per visit rate for all primary and preventive health care services as specific facility costs. Prospective Payment System (PPS) Per visit rate for all primary and preventive health care services, adjusted to geographic region and costs. 15
How Can Pharmacist Participate in FQHCs Current 340B Drug Program Existing FQHC Payment Models Diabetes Self Management Training (DSMT) Emerging Transitional Care Management (TCM) Accountable Care Organizations (ACO) Population Health Management Chronic Care Management (CCM) Annual Wellness Visit (AWV) Diabetes Self Management Training CMS recognizes pharmacist as provider if certified through ADA or AADE g Cannot be billed on same day as medical visit or in group visit Must be face to face encounter with pharmacist Billed as G0108/G0109 16
Metrics Performance Resource Requirements erials porting Mate ing Sup Marketi Collaboration Referr rals & Sche duling Environmental Scan Agreements Billing Leadership Documentation Targeted Conditions 17
Approaching the Decision Maker Assess Develop Present Leadership Demographics Needs Resources Funding Outcomes Compensation Customer Value Proposition Key Activities Cost Structure Key Resources Revenue Streams Key Partners Financial Model Assessment Value Message Business Case Proposal Business Case: Develop Customer Segments (Who we help) Patient, Physician, Payer Value Proposition (How we help) ROI, Revenue, Quality Cost Avoidance, Satisfaction Provider Productivity Key Activities (What we do) Medication management, education, standardization Key Resources (What we have) Knowledge, treatment pathways, operating system Adapted from Business Model You by Clark, Osterwalder, and Pigneur, publisher Wiley & Sons. 18
Decision Maker Attention Grabbers Pharmacist inclusion in the care team will enhance: Quality Physician Productivity Practice Revenue Patient Satisfaction Business case integrating a pharmacist into the overall care process will create a significant ROI. Leadership Who will serve as the physician and administrative champion(s)? Describe the commitment to collaborative practice environment. Environmental Scan Needs Assessment Asses s What would improve the quality of our patient s care? What would improve the productivity of our physicians What would improve the satisfaction of our patients? Performance Measures What measures are used for performance evaluation and/or payment for the practice? Current results? 19
Resources What clinical facility space will be available to pharmacist to provide patient care? Asses s Comprehensive Medication Management (CMM) Identify chronic conditions for pharmacist collaborative management Develop Comprehensive Medication Management Protocols Referrals and Scheduling Define criteria/process for pharmacist referrals and appointments Documentation and Billing Identify billable MTM, E&M and CPT codes Define documentation, billing processes Building Collaborative Relationships Integrating Care Coordination Internal/External Communication & Marketing Agreements & Contacts Collaborative Practice Agreement Medication Treatment Algorithms Employment or Consultant Agreement Asses s 20
Collaborative Practice Agreements Document establishing the contractual delegation of patient care authority between providers Defines pharmacist as a mid-level provider Creates environment for: Improved patient access and quality Comprehensive Medication Management (CMM) Components include: Scope of Practice (delegation of authority) Job Description (qualifications) Medication Management Pathways (algorithms) 18 Medication Management Pathways optimal sequencing and timing of interventions by health care professionals for a particular diagnosis or procedure, designed to minimize delays and resource utilization and maximize the quality of care Critical pathways represent evidence-based comprehensive plans that aim to optimize and streamline patient care. Objectives include: Continuous quality improvement Increase continuity of care Optimize cost Guide patient and family through expected treatment Increase patient and provider satisfaction 21
Medication Management Pathways 28 Early Challenges Referrals, appointments, and warm handoffs All provider buy in Medical Record documentation & templates Billing for pharmacist s CMM services Cash flow 30 22
Quality-A1c Improvement Patients with A1c >10.0 Patients with A1c >7.0 Mean A1c Improvement Mean A1c Improvement 14 20.8% 9 11.2% 12 9.3 8 12.1 8.2 10 8 6 4 2 9.6 0 0 10 7 6 5 4 3 2 1 84.0% Patients Improved 77.2% Patients Improved 202 Patient retrospective chart reviews Evaluation period November 2013-October 2014 Minimum 2 pharmacist visits and pre/post A1c 23