primary care edition (expanding opportunities) · mythbusters: primary care ... • diabetes...
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Mythbusters: Primary Care Edition (Expanding Opportunities)
Amina Abubakar, PharmD, AAHIVPOlivia bentley, PharmD, CFts, AAHIVP
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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
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Navigating Through Industry Challenges
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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 #1Independent 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
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Practice Sites: Rx Clinic Pharmacy #2Independent 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
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Pharmacy RedefinedManagement 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
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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 2018
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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
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MIPS Performance Payment Adjustment Timeframe
How Will MIPS Impact Medicare Payments?
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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
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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 post‐discharge
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
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Example MIPS Quality Measure Benchmarks
Measures which give 10 points with performance <100%
•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%
Point System within a single quality measure
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 87‐100%
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)
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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
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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
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Having Transplant Conversations with Medical ProvidersShowing a pharmacist’s value in solving problems and pressure
points.
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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
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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
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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
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Choose Your Path
Amina Abubakar PharmD, AAHIVPOlivia Bentley PharmD, AAHIVP, CFts
Rx Clinic Pharmacy
[email protected]@rxclinicpharmacy.com
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