Pharmacist Compensation for Cognitive Services: Focus on the Physician Office and Community Pharmacy

Return-On-Investment for Billable Pharmacist-Provided Services in the Primary Care Setting

BACKGROUND

Pharmacists are increasingly fulfilling roles on primary care teams, yet business models for pharmacist services in these settings have not been optimized. This study describes how an ambulatory care pharmacy department implemented various billing methods to generate revenue for pharmacist services.

OBJECTIVES

(1) Describe pharmacist-delivered billable and non-billable services; and (2) Assess the impact of various billing methods on the return-on-investment (ROI) for billable services.

METHODS

This study was conducted from September 2016 to August 2017 in Virginia. Pharmacist time spent performing billable encounters using current procedural technology (CPT) codes (e.g., incident-to a physician, annual wellness visits) was calculated. Encounters eligible for the hospital-based facility (G0463) and chronic care management (CCM) codes were considered to be potentially billable services. The ROI was calculated for billable and potentially billable services.

RESULTS

A total of 948.3 hours (0.46 full-time equivalents (FTE)), 17% of all clinical services, were billed using CPT codes. This resulted in a total revenue of $173,638.66. Missed revenue from not billing for the G0463 and CCM codes was $68,268.37. The cost of pharmacist services for 0.46 FTE was $78,613.08, resulting in a ROI for billed pharmacist services of 1.2:1. The ROI increased to 1.6:1 when considering potentially billable services.

CONCLUSION

It is feasible to have a positive ROI for billable pharmacist services. To achieve a sustainable business model, there must be a high volume of billable services. G0463 and CCM codes are often underutilized, yet represent significant opportunities in revenue for pharmacist services and should be pursued.

Third-party Reimbursement of Pharmacist-Led Cardiovascular and Diabetes Preventive Health Services for Workplace Health Initiatives: A Narrative Systematic Review

Objective:

To summarize available literature describing third-party payer reimbursement models for pharmacist-led preventive health services as part of workplace health initiatives.

Methods:

A combination of search terms related to pharmacists, preventive health, and third-party reimbursement were searched in MEDLINE, EMBASE, and PubMed. Included studies described community pharmacist-led cardiovascular and diabetes preventive health service to employees older than 18 years of age as part of a workplace health program with corresponding third-party reimbursement models. Programs that were reimbursed by government resources or studies lacking reimbursement model details were excluded. One reviewer performed level 1 screening and three reviewers analyzed included studies.

Results:

The search criteria yielded 863 results. Sixteen articles were reviewed after level 1 screening and 13 were ineligible and excluded. Three studies with varying quality of reporting were included. Reimbursement models varied from $40 USD for a 20-minute visit to $391 to $552 USD total per patient with an average of 6 visits per patient.

Conclusion:

There is a lack of quality literature describing third-party reimbursement models for pharmacist-led preventive health services, which hinders the ability to implement a standardized model. High quality studies evaluating the cost of reimbursing pharmacist-led cardiovascular preventive health services compared to the savings to the third-party payer should be performed to inform the standardization of payment models.

Assessing the Acceptance of the Pay-For-Performance Model in a Segment of California Pharmacists

Background Pay-for-performance (P4P) is a payment system in which providers are rewarded financially for the outcome of patient care. This study surveyed pharmacists to gain an overall understanding of their knowledge, experience, and attitude toward P4P. We investigated if having prior experience with P4P influences one's attitude toward and acceptance of this payment model. Methods A cross-sectional study was performed where a survey was sent to pharmacists affiliated with the University of California, San Diego (UCSD) School of Pharmacy. Data was collected over a two-week period. Chi-square and odds-ratio (OR) tests were used to assess an association between payment preference and the following factors: management experience, experience with P4P, years of practice, and familiarity with P4P. Six benefits and six problems relating to P4P were evaluated. Results Eighty-seven pharmacists participated in our survey. Fifty preferred traditional pay, and thirty-seven preferred P4P. The OR analysis suggests: 1) Pharmacists with P4P experience are 50% more likely to prefer P4P, 2) Pharmacists with management experience are 39% more likely to prefer P4P, and 3) Pharmacists with less than five years of working experience are 12% more likely to prefer P4P. The top perceived benefit of P4P was increased collaboration among healthcare providers. The main perceived challenge was cumbersome billing processes. Conclusion Pharmacists with P4P experience held more positive views of the payment system. Pharmacists without experience in the program were less supportive. The positive responses about P4P from those with P4P experience suggest that employers may receive more support for P4P from their staffs by educating them about the benefits of the model.

Point-of-care testing for infectious diseases: opportunities, barriers, and considerations in community pharmacy

OBJECTIVES To identify opportunities to perform point-of-care (POC) testing and/or screening for infectious diseases in community pharmacies, provide an overview of such tests and how they are used in current practice, discuss how the Clinical Laboratory Improvement Amendments of 1988 (CLIA) affect pharmacists performing POC testing, and identify and discuss barriers and provide recommendations for those wanting to establish POC testing for infectious diseases services in community pharmacies. DATA SOURCES PubMed and Google Scholar were searched from November 2012 through May 2013 and encompassed the years 2000 and beyond for the narrative review section of this article using the search terms rapid diagnostic tests, POC testing and infectious diseases, pharmacy services, CLIA waiver, and collaborative drug therapy management. All state boards of pharmacy in the United States were contacted and their regulatory and legislative websites accessed in 2012 and January 2013 to review relevant pharmacy practice laws. DATA SYNTHESIS POC testing for infectious diseases represents a significant opportunity to expand services in community pharmacies. Pharmacist education and training are addressing knowledge deficits in good laboratory practices and test performance and interpretation. Federal regulations do not define the qualifications for those who perform CLIA-waived tests, yet few pharmacists perform such services. Fewer than 20% of states address POC testing in their statutes and regulations governing pharmacy. CONCLUSION POC testing for infectious diseases could benefit patients and society and represents an opportunity to expand pharmacy services in community pharmacies. Existing barriers to the implementation of such services in community pharmacies, including deficits in pharmacist training and education along with state regulatory and legislative variance and vagueness in statutes governing pharmacy, are not insurmountable.

Perceived successes and challenges of clinical pharmacist practitioners in North Carolina

OBJECTIVES

To describe the successes and challenges reported by current (active) and formerly practicing (inactive) CPPs and to determine the reasons why inactive CPPs discontinued advanced practice.

METHODS

A sampling frame, consisting of all active and inactive CPPs, was obtained from the North Carolina Boards of Medicine and Pharmacy. An electronic survey was sent to 84 active and 32 inactive CPPs. Respondents were queried regarding qualifications, experience, and practice characteristics, perceived successes, and perceived challenges.

RESULTS

54 active and 22 inactive CPPs responded. Among active CPPs, 28 (51.9%) reported improved patient care outcomes and 27 (50.0%) reported an expanded scope of practice. Regarding challenges, 30 (55.6%) identified billing for services and 19 (35.2%) noted reimbursement through third parties. Among inactive CPPs, 14 (63.6%) experienced improved patient care outcomes and 11 (50.0%) said their licensure created a practice model for learners. Billing (54.5%) and reimbursement (31.8%) were the top challenges experienced by inactive CPPs. A total of 12 inactive CPPs (54.5%) discontinued CPP licensure because it was not a requirement of their current position. Three (13.6%) discontinued because of insurmountable challenges that made it difficult to continue practice.

CONCLUSION

Although CPPs held a perception of improved patient care outcomes, billing for services and obtaining reimbursement were reported as the most prevalent challenges and may have played a major role in CPPs becoming inactive.

Current trends in outpatient pharmacy services and billing

OBJECTIVES

To provide a summary of community and ambulatory pharmacy practices and billing patterns for medication therapy management (MTM) services and to identify reasons pharmacists report not billing for direct patient care services.

DESIGN

Cross-sectional study.

SETTING

United States, February 2011.

PARTICIPANTS

Members of the American College of Clinical Pharmacy Ambulatory Care Practice and Research Network, American Society of Health-System Pharmacists Ambulatory and Chronic Care Practitioners, and American Pharmacists Association MTM e-community.

INTERVENTION

Online survey.

MAIN OUTCOME MEASURES

Practice setting, pharmacy services performed, billing technique, and payer, as well as reasons for not billing.

RESULTS

MTM services were provided by 287 pharmacists. The most common practice settings included physician office (23.6%), health-system outpatient facility (21.7%), and community pharmacy (20.2%). A total of 149 of 276 pharmacists (54.0%) reported billing for MTM services; 16 of 276 (5.8%) did not know if they were currently billing. Community pharmacists were more likely to bill than all other sites combined (80.5% vs. 53.1%, P < 0.001), and pharmacists with >75% of visits face-to-face were more likely to bill (66.2% vs. 46.6%, P < 0.002).

CONCLUSION

A variety of MTM services are provided in outpatient settings with inconsistent billing techniques and reimbursement. Pharmacists should continue to work toward consistent, sustainable reimbursement to expand MTM services.

Billing for pharmacists' cognitive services in physicians' offices: multiple methods of reimbursement

OBJECTIVES

To evaluate the charges and reimbursement for pharmacist services using multiple methods of billing and determine the number of patients that must be managed by a pharmacist to cover the cost of salary and fringe benefits.

SETTING

Large teaching ambulatory clinic in North Carolina.

MAIN OUTCOME MEASURES

Annual charges and reimbursement, patient no-show rate, clinic capacity, number of patients seen monthly and annually, and number of patients that must be seen to pay for a pharmacist's salary and benefits.

RESULTS

A total of 6,930 patient encounters were documented during the study period. Four different clinics were managed by the pharmacists, including anticoagulation, pharmacotherapy, osteoporosis, and wellness clinics. "Incident to" level 1 billing was used for the anticoagulation and pharmacotherapy clinics, whereas level 4 codes were used for the osteoporosis clinic. The wellness clinic utilized a negotiated fee-for-service model. Mean annual charges were $65,022, and the mean reimbursement rate was 47%. The mean charge and collection per encounter were $41 and $19, respectively. Eleven encounters per day were necessary to generate enough charges to pay for the cost of the pharmacist. Considering actual reimbursement rates, the number of patient encounters necessary increased to 24 per day. "What if" sensitivity analysis indicated that billing at the level of service provided instead of level 1 decreased the number of patients needed to be seen daily. Billing a level 4 visit necessitated that five patients would need to be seen daily to generate adequate charges. Taking into account the 47% reimbursement rate, 10 level 4 encounters per day were necessary to generate appropriate reimbursement to pay for the pharmacist.

CONCLUSION

Unique opportunities for pharmacists to provide direct patient care in the ambulatory setting continue to develop. Use of a combination of billing methods resulted in sustainable reimbursement. The ability to bill at the level of service provided instead of a level 1 visit would decrease the number of patients needed to pay for a pharmacist.

Pharmacy Medication Therapy Management Services and Reimbursement Options

The Director's Forum series is written and edited by Robert Weber and Scott Mark and is designed to guide pharmacy leaders in establishing patient-centered services in hospitals and health systems. As more pharmacy boards are approving and endorsing medication therapy, management directors of pharmacy will need to understand mechanisms for payment for these services. This article provides some initial information for pharmacy directors in developing a strategy for financial support of pharmacy cognitive services.

Cognitive pharmaceutical services and the community pharmacist: are South African patients receiving them and are they willing to pay?

Objective

The objectives of this study were to ascertain the opinions of randomly selected South African medical aid members regarding the provision by community pharmacists of patient counselling and information; member satisfaction with pharmacist services; their rating of pharmacist accessibility; and if pharmacists should be reimbursed for providing cognitive pharmaceutical services.

Setting

A South African private healthcare insurance company.

Method

A 39-item web-based survey instrument was used to telephonically interrogate randomly selected insured participants to determine their use of prescription medicines, if they received medication counselling and disease-related information, their satisfaction with the advice provided, how they rated their relationships with pharmacists, if they believed that pharmacists should be reimbursed for providing professional services and their rating of pharmacist accessibility. A total of 628 randomly selected insured patients were telephonically surveyed and their responses included.

Key findings

Of the 507 participants, 60% received prescription medicine for their own use from pharmacists at least once during the six-month period under review, 26% from dispensing doctors and 14% from both pharmacists and doctors. Seventy-nine per cent reported receiving medication counselling and 77% received health-related information from pharmacists. This contrasted with those participants who received medicines from doctors where 98% reported being counselled on medicine use and 99% received health-related information. Almost 90% of those who consulted pharmacists believed that they were provided with good advice. Just over two-thirds of participants (68%) rated their relationships with pharmacists as good, 62% considered doctors more accessible than pharmacists and 46% said that they were willing to pay pharmacists for providing professional cognitive services.

Conclusion

Although pharmacists were significantly more likely to provide participants with their prescription medicines, they compared unfavourably with doctors in terms of healthcare provider accessibility and in providing patients with health-related information and medication counselling. While the majority of participants surveyed classified their relationships with their pharmacists as good, just under half were willing to pay pharmacists for providing professional pharmacy services.

PharmacistCARE: description of a pharmacist care service and lessons learned along the way

OBJECTIVE

To describe the PharmacistCARE program, an innovative pharmacy practice model implemented within a self-insured employer and to describe lessons learned by the authors in implementing and maintaining the program.

SETTING

University of Kentucky (UK), March 2003 to present.

PRACTICE DESCRIPTION

A free-standing pharmacist clinic located within an ambulatory care facility owned by UK HealthCare.

PRACTICE INNOVATION

PharmacistCARE, a pharmacist-provided patient care service for UK Health Plan members that includes comprehensive disease and medication therapy management.

MAIN OUTCOME MEASURES

Various lessons learned by the authors during development, implementation, and maintenance of the program.

RESULTS

The program has been recognized by the university as a positive contribution to health plan service enhancement and cost savings and has documented enhanced patient care outcomes.

CONCLUSION

The PharmacistCARE program is a unique pharmacist-provided service delivered in a free-standing pharmacist clinic that enhances health outcomes for adult members in a self-insured employer group.

Designing pharmacy services based on grocery store patron preferences

OBJECTIVE

To assess preferences of grocery store patrons concerning pharmacy services and identify study participant characteristics that may predict the success of pharmacy services in the community setting.

DESIGN

Self-administered survey.

SETTING

Central Ohio from December 16, 2005, to January 12, 2006.

PARTICIPANTS

163 grocery store patrons.

INTERVENTIONS

Eight grocery store survey events.

MAIN OUTCOME MEASURES

Responses to survey items about (1) perceived importance of 28 pharmacy services, (2) identification of the 3 most important services, (3) frequency of grocery store and pharmacy use, (4) preferred methods of advertising pharmacy services, and (5) socioeconomic demographics. Preferred services delineated by various demographics also were analyzed.

RESULTS

A total of 163 surveys were returned from study participants. Nine services appeared in both the top 12 overall preferred services and the 12 highest-ranked services. Statistically significant differences were observed among services ranked as important or very important by age, race, employment, income, caregiver status, and prescription drug coverage status. The three advertising tools selected most frequently included: weekly grocery store ads (68.6%), in-store signs (51.0%), and flyers attached to prescription bags (36.0%).

CONCLUSION

Grocery store patrons would like a wide range of nontraditional pharmacy services that could be implemented into community pharmacies. Pharmacies in grocery stores need to provide both traditional and expanded pharmacy services to meet the desires and expectations of current and potential patients, and expanded marketing methods should be considered.

Medication therapy management: Its relationship to patient counseling, disease management, and pharmaceutical care

OBJECTIVE

To delineate the relationship, including similarities and differences, between medication therapy management (MTM) and contemporary pharmacist-provided services, including patient counseling, disease management, and pharmaceutical care, to facilitate the continued evolution of commonly used language and a standard of practice across geographic areas and practice environments.

SUMMARY

Incorporation of MTM services into the array of Medicare-funded services affords an opportunity for pharmacists to develop direct patient care services in the community. Defining the role of MTM within the scope of pharmacist-provided patient care activities, including patient counseling, disease management, and all currently provided pharmacy services is essential to the delineation of a viable and sustainable practice model for pharmacists. The definitions of each of these services are offered, as well as comparisons and contrasts of the individual services. In addition to Medicare-eligible patients, MTM services are appropriate for anyone with medication-related needs. MTM is offered as an all-encompassing model that incorporates the philosophy of pharmaceutical care, techniques of patient counseling, and disease management in an environment that facilitates the direct collaboration of patients, pharmacists, and other health professionals.

CONCLUSION

Defining the role of MTM within the current patient care models, including patient counseling, disease management, and all who provide pharmacy services, is essential in delineating a viable and sustainable practice model for pharmacists.

Community and ambulatory pharmacy: evaluation of patient care services and billing patterns before implementation of Medicare part D

OBJECTIVE

To provide a summary of community and ambulatory pharmacy practice and billing patterns for medication therapy management services before implementation of Medicare Prescription Drug Improvement and Modernization Act of 2003 (MMA).

DESIGN

Cross-sectional survey.

SETTING

Ambulatory care and community pharmacy practice settings in the United States in January 2004.

PARTICIPANTS

Members of the American College of Clinical Pharmacy Ambulatory Practice and Research Network, preceptors of the American Pharmacists Association (APhA) Community Pharmacy Residency Programs, and participants in the APhA Immunizing Pharmacist listserv.

INTERVENTIONS

E-mail invitations to participate in a Web-based survey.

MAIN OUTCOME MEASURES

Practice setting; pharmacy services performed; whether pharmacists were billing for pharmacy services; if billing, the billing technique used; if not billing, the reason for not billing.

RESULTS

Of 349 respondents, 127 (36.4%) were practicing within a physician office, while 121 (34.7%) were practicing in community pharmacies. Diabetes, anticoagulation, dyslipidemia, hypertension, and smoking cessation management services were performed significantly more often in physician offices. Immunization delivery and diabetes, dyslipidemia, and osteoporosis screenings were performed significantly more often in community settings. A total of 190 (54.5%) pharmacists stated that they were billing for pharmacy services. More community pharmacists were billing for services compared with other combined practice settings (69.2% versus 46.7%, P < .001). Top reasons identified for not billing for services were salaried position, indigent population, and discomfort with the billing process.

CONCLUSION

Valuable baseline data are provided regarding pharmacy services that have been successfully implemented in ambulatory and community practice settings and which billing techniques were used to receive reimbursement before the implementation of MMA.

Need for community pharmacist-provided food-allergy education and auto-injectable epinephrine training

OBJECTIVE

To determine whether community pharmacist-provided food-allergy education and auto-injectable epinephrine training is needed.

DESIGN

Cross-sectional assessment.

SETTING

United States.

PARTICIPANTS

1,887 recently joined members of the Food Allergy & Anaphylaxis Network.

INTERVENTION

Electronic survey.

MAIN OUTCOME MEASURES

35 items covering past education and training associated with food allergy and use of auto-injectable epinephrine, demographics, attitudes toward pharmacist-provided education about food allergy, training in the use of auto-injectable epinephrine, confidence in managing food allergies on a daily basis and in emergency situations, and the necessity for pharmacists to provide education and training about food allergy and auto-injectable epinephrine use.

RESULTS

Prescriber-provided food-allergy education and auto-injectable epinephrine training is incomplete (60.7%) or absent (16.3%) at the time auto-injectable epinephrine is first prescribed. These initial prescriptions are being dispensed from community pharmacies (94%), and written information is commonly provided with the medication (73.6%); however, oral counseling is largely absent (86.6%), and training in administration of auto-injectable epinephrine occurs infrequently (13.3%). Food-allergic patients and their care-givers are receptive to the idea of pharmacist-provided education and training. The majority (63.6% or more) feel confident about managing their food allergies. They are not requesting counseling when refill prescriptions are dispensed (81.4%); however, they would like to see routine review at refill time of the signs of allergic reaction (54.5%) and use of the epinephrine auto-injector (79.3%).

CONCLUSION

Community pharmacists have an opportunity to assist newly diagnosed food-allergic patients by working collaboratively with their pediatricians and allergists. Community pharmacists can provide ongoing assistance at refill time by retraining patients in the use of the epinephrine auto-injector and reviewing the signs of allergic reaction.

The Pharmacist as Physician Extender in Family Medicine Office Practice

OBJECTIVE

To describe the role of the pharmacist as a salaried physician extender in a private practice diabetes management clinic.

SETTING

Columbus, Ohio.

PRACTICE DESCRIPTION

Private suburban family medicine office practice.

PRACTICE INNOVATION

Clinical pharmacy physician-extender practice in a private medical office and direct compensation to pharmacist.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Financial reimbursement for providing pharmaceutical care; improvement in disease outcomes; pharmacist and student pharmacist satisfaction.

RESULTS

Family medicine physicians hired a pharmacist to extend their diabetes care for complex metabolic syndrome patients and other patients with diabetes who had therapy management problems. The pharmacist, working with student pharmacists, develops treatment plans for drug therapy, nutrition, exercise, and foot care that are reviewed and approved by the managing physician and implemented by the pharmacist and other office staff. More than 260 patients have been referred and managed by the practice with favorable results. The pharmacist is reimbursed as an employee and the practice receives revenue for the pharmacist's practice.

CONCLUSION

Working in a private physician office practice provides a unique means of providing pharmaceutical care with reimbursement for the pharmacist.