Consultant Pharmacist Impact on Physician Quality Measures and Reimbursement


Physicians and pharmacists face similar reimbursement issues.

As my business leads me further down the rabbit hole of outcomes-based reimbursements, I’ve learned that physicians and pharmacists face similar reimbursement issues.

Instead of the Medicare Star Ratings System, physician practices are measured by the Physician Quality Reporting System (PQRS), and instead of direct and indirect remuneration (DIR) fees, they’re subject to the Merit-Based Incentive Payment System (MIPS).

At the same time I started discovering this hidden world, hundreds of pharmacists and students were reaching out to share their struggles with finding meaningful and fulfilling work. They’re looking for work that allows them to practice at the pinnacle of their ability and provides them the autonomy that’s virtually unobtainable outside of a university or federal health care setting.

While I’ve always been impressed by the advancement of pharmacy made possible by those institutions, I confess I never thought their programs would be applicable to real-life situations. However, when I began learning about the issues physicians face with new performance-based payment incentives and penalties, I saw opportunity. If their practices would spend tens of thousands of dollars on some software in hopes of improving patient outcomes and gaining incentives, why wouldn’t they hire a consultant pharmacist for a better return on investment?

Consultant pharmacists can not only save time for physicians and improve their patients’ outcomes, but also impact PQRS measures by selectively targeting certain patient populations for medication therapy management (MTM) interventions.

The first performance year for MIPS will begin in 2017, making 2019 the first year any adjustments in payments will be made. The Centers for Medicare and Medicaid Services (CMS) will define the performance years for MIPS in a final rule anticipated to be published at the end of 2016. This means that practices don’t have much time to figure it out, but that’s where a consultant pharmacist can intervene.

Imagine there are 2 types of practices: proactive and reactive. When the initial 2018-2019 adjustment in payment comes to fruition, reactive practices will look for quick fixes to increase payment and already be behind the curve, but proactive practices will know what’s expected. They may want an MTM consultant pharmacist on board to handle their new clinical programs, put new procedures in place, train staff members, track outcomes, and enroll their patients in CMS’s new programs.

Proactive practices see the value, understand the changes in payment adjustment, and are willing to invest in a consultant pharmacist now. Reactive practices may or may not understand what’s coming and prefer to wait and see what damages may occur in the future.

The consultant pharmacist’s target market is proactive practices, but physicians aren’t the only MIPS-eligible providers. Physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists are also eligible.

CMS may further expand the types of MIPS-eligible providers to other Medicare Part B-eligible providers within the next 3 years. With any luck, pharmacists will be recognized with provider status under Medicare Part B and included in the interim.

Quality of care impacts about 50% of the MIPS weighting scale, while clinical improvement activity affects about 15% of it. Pharmacists can impact both through diabetic education, polypharmaceutical reviews, hospital admission reduction, tobacco counseling, and much more.

Depending on the 9 PQRS measures chosen or attributed by CMS, pharmacists can help eligible physicians avoid penalties and earn incentive payments by improving the most appropriate measures. In my research, I came across chronic care management (CCM) as a way to target the most appropriate patients and focus on those measures.

CCM is a mix of formalized services with certain compliance standards required by Medicare. It involves a monthly 20-minute non-face-to-face interaction between a patient and a “qualified health care provider” under the general supervision of the physician. Its intent is to provide support, accessibility, coordination of care, and transitional care processes to the high-risk patients who need them.

There are many other aspects of CCM to consider, including transitional care management services, a comprehensive and coordinated care plan, different disciplines and settings of care to coordinate, and putting together a plan that can be accessed by the patient, caregivers, and other providers at any given time. Pharmacists are already skilled in these types of patient interactions and multidisciplinary coordination, so they can help practices implement these new services.

A consultant pharmacist can impact PQRS measures for a group practice in the following ways:

  • Managing diabetic education and patient outcomes in a target group in order to impact the specific diabetes management-related G-codes
  • Managing refill authorizations for these targeted patients and work with their pharmacy to develop a medication synchronization plan
  • Developing a comprehensive care plan for a targeted list of CCM patients with diabetes
  • Identifying transitional care needs and opportunities for billing during the monthly call
  • Coordinating transitional care management for the clinic

For detailed information about these services, and to learn how you can build a pharmacy consulting business of your own, consider signing up for the Pharmapreneur Academy. Through its online membership site, I’ve helped dozens of other pharmacists learn the ins and outs of consulting.

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