New Opportunities for Pharmacy Part 1: Central Fill Pharmacy - A Consolidated Services Center Part 2: A Review of CMS Initiatives That Involve Drug Therapy Presenters: Bonnie Kirschenbaum, MS, FASHP, FCSHP Free-lance consultant, columnist Boulder/Breckenridge, CO Bonniekirschenbaum@gmail.com Rita K. Jew, Pharm.D., MBA, FASHP Director of Pharmacy, Mission Bay Campus UCSF Health
FACULTY DISCLOSURE The faculty reported the following financial relationships or relationships to products or devices they or their spouse/life partner have with commercial interests related to the content of this CE activity: - Rita K. Jew Nothing to report - Bonnie Kirschenbaum -- Nothing to report
Learning Objectives Explain the dynamics of Consolidated Services Centers in the Hospital Pharmacy setting. Describe new opportunities for billing for pharmacy services. Identify methods for improvement in hospital pharmacy management strategies.
Why Central Fill Pharmacy US health care cost approaching 20% GDP #1 in health expenditure per capita #31 in life expectancy, #36 in infant mortality Pressure to decrease cost while improving quality and improve access Payment model change: buddle payment, pay for performance, ACO Bottom line: Do more with less!!
UCSF Health 3 campuses with a total of 701 inpatient beds Parnassus 412 beds with 77 ICU beds Mission Bay 183 pediatric beds with 90 ICU beds 36 OB beds 70 adult beds with 14 ICU beds Mount Zion Outpatient surgical center
UCSF Health - Pharmaceutical Services 254 FTEs 3 main pharmacies, 4 pharmacy satellites, 4 infusion center pharmacies, central fill pharmacy 185 clinics Clinical services in all patient care units Investigational drug services 340B program Dispenses >5 million doses a year >80% of doses dispensed via automation/technology
Why Central Fill Pharmacy at UCSF Lack of space on campus prompted the move of sterile compounding off site Medication errors prompted investment in automation Automation on campus vs off site $24 million vs $15 million
UCSF Central Fill Pharmacy IV bags batches twice daily IV syringe batch once daily Oral syringe batch once daily Cartfill (Swisslog) twice daily CRRT fluids Code medication trays refill Oral non-patient specific unit-dose IV non-patient specific bags and syringes TPN order entry & review
UCSF Central Fill Pharmacy 43.5 FTEs (17% of total) 5 administrative & management 14.5 pharmacists 24 technicians 24/7 operation Dispenses >90% of total doses for entire health system >90% doses dispensed are automated
10 Robots R Us...
Advantage of Central Fill Pharmacy Consolidated dispensing allow for use of automation Reduce need for technicians & pharmacists for dispensing & redeploy for clinical & other services Reduction of FTEs due to consolidation & automation 7 to 2.4 FTEs for cartfill 17% of total FTEs to support entire health system Enable insourcing of outsourced sterile compounds >$300,000 savings in 6 months
Disadvantage of Central Fill Pharmacy Need for duplication of inventory For 1 st doses & downtime Limit ability to have just-in-time production Batch production lead to waste 20-25% Increase lead time 5.5-8 hrs Transportation waste
Transport 4 miles 13
Batch Frequency Study Schedule 1 3 batches/day Average waste: 11 doses/day Average % waste: 9% (1 in every 11 doses) Schedule 2 6 batches/day Average waste: 6.5 doses/day Average percent waste: 5.3% (1 in every 19 doses) 14
Cost analysis Batch Frequency Study Delivery/Transportation: $126 round trip Schedule Cost of Drug Waste Cost of Add l Deliveries Total Cost Current $1,504 -- $1,504 Schedule 1 $478 $450 $928 Schedule 2 $250 $937 $1,187 15
Central fill pharmacy: Conclusions Allows for automation and reduced labor due to consolidation Reduces the need and expense for outsourcing May not decrease total inventory May not be best used for patient specific batches 16
Population Health Population health refers to the health of a population as measured by health status indicators and as influenced by social, economic and physical environments, personal health practices, individual capacity and coping skills, human biology, early childhood development, and health services. It s a unifying force for the entire spectrum of health system interventions -- from prevention and promotion to health protection, diagnosis, treatment and care -- and integrates and balances action between them.
Part A (IPPS) Hospitalization Medicare The single largest payor Part B Outpatient (OPPS) & MD Office (PFS) Drugs covered as incident to in both OPPS & PFS Part D Prescription Drug Coverage for Home/Ambulatory use MTM applies 18
Clinical Services Focusing on the Outpatient With the focus on population health and the prevalence of medication use in key disease states, pharmacy's participation in this growing field of ambulatory care is essential. A multitude of initiatives under CMS involving drug therapy cover pharmacy services as part of diabetes management services, chronic care management, transitions of care medication therapy management annual wellness visits
Pharmacy Billing for E&M codes in Part B "incident to" codes used to help support pharmacist services fall under E&M services codes Understanding E&M services and billing codes under CMS rules for documentation is essential when "incident to" billing codes are used to support pharmacist services https://www.cms.gov/outreach-and-education/medicarelearning-network-mln/mlnedwebguide/emdoc.html work with pharmacy staff to ensure they know how to proceed with getting paid for these services
Payment for pharmacy services in any of these areas? Ambulatory Care Patient Sleeps @ home Part D Meds MD office visit: PFS Yes under MTM and PFS & Transitions of Care & CMS chronic care rules when coordinated with the physician Outpatient Sleeps @ home except* OPPS, Part B Drugs Clinic visit, ER visit Ambulatory Surgery Observation Patient* Procedural Areas Yes under MTM and PFS & CMS chronic care rules when coordinated with the physician Inpatient Sleeps @ hospital 21 IPPS Not currently
Medication Therapy Management: a federally mandated component of services that must be provided to Targeted Medicare beneficiaries under Part D Multiple Diseases Multiple Drugs Annual $ exceed a cost threshold Target Patient >$4000 22
Medicare Part D payers are required to cover MTM services for eligible patients After identifying and contracting with Medicare Part D plans, consult with each payer to determine how MTM services should be billed. most common scenarios for provision of Medicare Part D MTM services are: The payer (Medicare Part D plan) uses its own employee pharmacists to provide MTM and does not contract for the services. The payer contracts with pharmacies or individual pharmacists to provide the services. Note that some Medicare Part D plans require a pharmacy to have a contract for the prescription drug benefit in order to qualify for MTM service contracts
CPT Codes for Billing MTM Services CPT Code AMA determined Code definition 99605 Initial 15 minute encounter, new patient 99606 Initial 15 minute encounter for new problem, established patient 99607 Each additional 15 min, used as add-on to 99605 or 99606 as required Have you got an NPI #??
Medicare Diabetes Prevention Program Model Expectations of this CMS program interventions carried out through the program will lower the incidence of type 2 diabetes and is likely to reduce Medicare expenditures FAQ s effective Jan 1, 2018 requires all Medicare health plans cover services for eligible Medicare beneficiaries under the Medicare Diabetes Prevention Program (MDPP) model finalized as part of the 2017 Physician Fee Schedule rule. The MDPP expands both the length and scope of the Diabetes Prevention Program model test authorized under Section 1115A(c) of the Social Security Act. The MDPP benefit will be covered at zero cost-sharing. Details at http://tinyurl.com/jdhf8t2
Transitions of Care Why get involved? communication breaks down somewhere between hospital discharge and outpatient follow-up. Much of it has to do with medications What s at the core of the program? Collaboration between care providers What can it accomplish? reduce readmissions improve outcomes keep your patients in your healthsystem
Transitional Care Management Services One of the opportunities available for seeking payment for pharmacy clinical services. Use the recently updated and published CMS Fact Sheet that provides valuable information on health care professionals furnishing these services supervision services settings, components, and billing FAQs on billing describe scenarios that may mimic those that you encounter and will help you prepare for smooth implementation. https://www.cms.gov/outreach-and-education/medicare- Learning-Network-MLN/MLNProducts/Downloads/Transitional- Care-Management-Services-Fact-Sheet-ICN908628.pdf
Outpatient Chronic Care Management (CCM) CY 2015: CMS adopts separate payment codes for CCM services nonface-to-face care management services for Medicare patients with multiple (2 or more) significant, chronic conditions Could include regular development and maintenance of a plan of care communication with other treating health professionals medication management Hospitals requested clarification of their role in furnishing CCM services and in defining the scope of service elements for the hospital outpatient setting that are analogous to the scope of service elements finalized as requirements to bill for CCM services in the CY 2015 Medicare Physician Fee Schedule final rule with comment period (see page 39290)
CCM by Pharmacy in hospital based OP Clinics OPPS 2015: CCM Payment begins, includes pharmacists OPPS 2016: additional requirements Federal Register link http://www.gpo.gov/fdsys/pkg/fr-2015-07- 08/pdf/2015-16577.pdf pg 39289 CMS FAQ link https://www.cms.gov/medicare/medicare-fee-for- Service-Payment/HospitalOutpatientPPS/Downloads/Payment- Chronic-Care-Management-Services-FAQs.pdf Work with Pharmacy staff to ensure they understand requirements for this payment Payment is inclusive of all providers (physician, pharmacist, etc) Who s coordinating this at your facility??
MLN Connects for Thursday, March 23, 2017 View this edition as a PDF News & Announcements Connected Care: New Educational Initiative to Raise Awareness of Chronic Care Management Quality Payment Program: New Materials IRF and LTCH Compare Quarterly Refresh Provider Compliance Preventive Services CMS Provider Minute Video Upcoming Events
New Educational Initiative to Raise Awareness of Chronic Care Management 3.15.2017: CMS Office of Minority Health and the Federal Office of Rural Health Policy at HRSA introduced Connected Care, an educational initiative to raise awareness of the benefits of Chronic Care Management (CCM) services for Medicare beneficiaries with multiple chronic conditions and to provide health care professionals with support to implement CCM programs.
Connected Care Nationwide effort within fee-for-service Medicare that includes a focus on racial and ethnic minorities + rural populations, who tend to have higher rates of chronic disease. Offers new resources to help educate patients and provide information for health care professionals, including: Toolkit for health care professionals with detailed information about CCM and resources to help providers implement CCM Partner toolkit with downloadable resources and suggested activities to get involved in the Connected Care initiative (Patient education resources, with a poster + postcard for use in clinical or community settings https://www.cms.gov/about-cms/agency-information/omh/equityinitiatives/chronic-care- management.html
Chronic Care Management Payment Correction for RHCs and FQHCs : Payment Update Effective 1.1.2016, Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) received payment for Chronic Care Management (CCM) services based on the Medicare Physician Fee Schedule national average nonfacility payment rate. However, for claims with dates of service on or after 1.1.2017, RHCs and FQHCs have been receiving a locality adjusted payment rate for these services. Your Medicare Administrative Contractor will adjust any claim processed incorrectly. No provider action is required.
Key Takeways Want to participate in CCM + Complex CCM? Use these CMS resources Why should you do it? It s an opportunity for sustainable revenue for typical services provided in medication management How does it fit into payment? Under the fee-for-service model, where clinical staff including pharmacists can participate in collaboration with Medicare Part B providers Can I do this alone? No. This is an opportunity for pharmacists to work with their providers in this space
Annual Wellness Visits: Coding, Diagnosis & Billing https://www.cms.gov/outreach-and-education/medicare-learning-network- MLN/MLNProducts/downloads/AWV_chart_ICN905706.pdf Diagnosis CMS doesn t require a specific diagnosis code for the AWV, you may choose any appropriate diagnosis code but you must report a diagnosis code. Billing Medicare Part B covers AWV if performed by a: Physician (a doctor of medicine or osteopathy); Qualified non-physician practitioner (a physician assistant, nurse practitioner, or certified clinical nurse specialist); or Medical professional (including a health educator, registered dietitian, nutrition professional, or other licensed practitioner), or a team of such medical professionals who are working under the direct supervision of a physician (doctor of medicine or osteopathy) AWV HCPCS Codes G0438 G0439 Billing Code Descriptors Annual wellness visit; includes a personalized prevention plan of service (PPPS), initial visit Annual wellness visit, includes a personalized prevention plan of service (PPPS), subsequent visit
AWV: Preparing Eligible Medicare Beneficiaries Providers can help eligible Medicare beneficiaries get ready for their AWV by encouraging them to come prepared with the following information Medical records, including immunization records; Family health history, in as much detail as possible A full list of medications and supplements, including calcium and vitamins how often and how much of each is taken A full list of current providers and suppliers involved in providing care
Putting $ into Perspective Rituximab billing error HCPCS code: J9310 Billing unit 100mg July 2016 ASP $791.40 Case Description Billing unit 10 fold error Each 1000mg dose billed as 1 billing unit instead of 10 billing units Got $791.40 but lost $7122.60 for each pt Assume 1000 patients/yr Lost revenue = $7,122,600 Chronic Care Management Opportunity Available $ $60/month/eligible patient for 20 minutes documented service Would need to manage 9892 patients for 20 minutes each month for 1 year to earn $7,122,600 37 BonnieKirschenbaum 4.2016
Codeable documentation Payor info shared Document PA in EHR Payment + collection can no longer be confined to the financial silo. Clinical input is critical! Bundled items billed Zeropriced drug billing Living up to your reimbursement potential Focus Areas Identified LCD/NCD requirements met Accurate CDM Waste billing Document + Bill IV drug admin CDM PDM 38 match
Think you can bill for clinical services if you don t understand how the reimbursement system works? A quick review of charging ICD10 codes used by hospitals to designate disease types CPT codes (determined by the AMA) used by physicians, providers to describe procedures they do may include payment for all products used during the procedure HCPCS codes are for products and may or may not be reimbursed DRGs apply to Medicare inpatients APCs apply to Medicare outpatients SI (status indicators) indicate reimbursement status DRG and APC methodology is often used as a template for other insurance reimbursement Part B covers drugs administered in an outpatient setting Part D covers drugs that are considered self-administered (several oral cancer drugs)
Everyone has a fiduciary responsibility!! IT The P&T Committee The MD writing orders Social Services Patient Navigator The patient taking responsibility Pharmacy working across all care sites Nursing Revenue Cycle: the Billing Dept 40
Who s your competition? Physician offices Retail pharmacy PBMs Nursing Social Workers Dieticians Patient Navigators Patient Advocates Hospital pharmacy
Key Takeaways Key Takeaway #1 Move out of your silo, Recognize implications of your decisions & actions and remember, it s not about you, it s about the patient!! Key Takeaway #2 The 3 Elements to Leadership are vision, understanding the situation and having the courage to act while remembering that It s not a popularity contest!! Key Takeaway #3 Pharmacy is part of the healthcare ecosystem, every part of which has to step up their efforts to contribute to affordability. What are you going to start doing? Stop doing? Keep Doing?