Understanding CMS Value-Based Payment Models to Advance Pharmacy Services


The outcomes-based reimbursement law passed in 2016, but providers are still struggling to understand what it means for the bottom line.

The Centers for Medicare and Medicaid Services' (CMS) newest piece of outcomes-based reimbursement legislation passed in 2016, but pharmacists, physicians, and other providers across the country are still struggling to make sense of what it means for the bottom line.

The legislation has been referred to as both "pay-for-performance" and "value-based payment reform," but not many understand the full repercussions of the legislation.

A Bit of Background

On October 14, 2016, CMS released this final rule of the Medicare Access in Children's Health Insurance Program, the CHIP Reauthorization Act of 2015, which is referred to as MACRA.

MACRA created 2 separate reimbursement models called quality payment programs (QPP). These reimbursement models shift from a volume-based fee-for-service system to what we have now, the value-based payment system. This rule dramatically changes how physicians are compensated for their services under Medicare.

The Financial Impact

Beginning in 2019, payments will be decreased or increased by up to 4%, based on the data submitted during the 2017 reporting year, and this will rise to about a 9% adjustment in 2022.

For the first year of merit-based incentive payment system (MIPS) reporting, the providers, which include anesthetists, certified registered nurses, chiropractors, clinical nurse specialists, dentists, nurse practitioners, optometrists, physician assistants, physicians, and podiatrists, can choose the amount of 2017 data to submit to MIPS for the 2019 payment adjustment.

These payment adjustments could be in the hundreds of thousands of dollars, and they could be positive or negative reimbursements for a practice. This could equal hundreds of thousands of dollars in difference between the reimbursement that they may have already received and may have to pay back or that they could be receiving as a bonus incentive.

Opportunities for Pharmacists

Understanding the impact of quality-based payment structures can be an opportunity for building advanced pharmacy services that align with these goals.

It is important to be familiar with these quality-based payment models so that pharmacists can tailor their enhanced services to meet or exceed these measures.

Additionally, many of the measures that providers are now required to report on can be affected by things that pharmacists are already doing, such as medication synchronization and medication therapy management programs.

Pharmacists can demonstrate to providers how enhanced pharmacy services can affect patients’ therapeutic outcomes and quality.

The Details

MACRA legislation created 2 value-based payment tracks in the QPP. These are advanced alternative payment models (APMs) and MIPS. A QPP equals APMs, plus MIPS.

Of the 2 tracks of MACRA, MIPS will have the largest impact on independent physicians’ offices. So, let's look at how pharmacists can help providers enhance their performance in these quality metrics.

4 Weighted MIPS Categories

First is quality, 60% for 2017; then advancing care information, 25%; and improvement activities, 15%. These will balance out in subsequent years, but for 2018, they expect to use these same percentages proposed for the year. The cost resource use is 0% for 2017 and 2018. However, it is expected to increase in subsequent years.

Pharmacists, as the most accessible health care providers, can focus on increasing patients’ access to care, decreasing the overall number of hospitalization and re-admissions, and reducing the total net health care spend.

That makes pharmacists perfectly poised to offer assistance to providers as quality coordinators.

1. Quality

In 2017, the quality measure category is going to hold the most weight in MIPS, at 60%. It will gradually lose weight as the other categories increase over time, but this quality category is a holdover from the Physician Quality Reporting System, in which the providers used to choose 9 measures on which to report.

The change requires providers to choose 6 quality measures from a list of more than 271 subcategories. These 6 measures can be any metric they choose.

However, there are a few requirements. They must have 2 high-priority measures, which would be an outcome measurement; 1 cross-cutting measure, which would be applicable to all provider specialties; and then the 4 others can be a mixture between the 2.

Because of its weight, providers’ focus will likely weigh heavily on the quality measure category for the MIPS reporting.

2. Advancing Care Information

This category makes up about 25% of MIPS and expands on the meaningful-use program.

Pharmacists can leverage the physicians’ need to meet these measures in this category and request access to the providers’ electronic health records (EHRs).

This will significantly improve patient care and quality. Pharmacists with access to EHRs either directly or through the sharing of electronic care plans can help save the health care system and patients money.

Increasingly, we are able to submit e-Care Plans ourselves through some new technology.

Also, the expanding of meaningful-use category means the inclusion of the ability for providers to send electronic prescriptions, to allow the patients access to their electronic medical records, to help them protect their electronic health information, and also share information with others involved in patient care.

This is a great opportunity for pharmacists to leverage the technology and the EHR side of meeting those measures and collaborating with physicians through the advancing care information category.

3. Cost/Resource Use

This category, which is at 0% for 2017 and 2018, does not require active reporting by physicians. Instead, it is pulled from Medicare claims data that are submitted throughout the year. Part of the goal of this measure is to encourage health care professionals to help beneficiaries understand their benefits and make medical decisions accordingly.

4. Improvement Activities

There are more than 90 improvement activities defined for the MIPS.

Some major subcategories of improvement activities are expanding practice access, care coordination, beneficiary engagement, patient safety and practice assessment, and emergency response and preparedness.

Here are the 3 improvement activities on which pharmacists should focus:

A. Implement medication management practice improvements.

The focus of this activity would be integrating pharmacists into care teams and designating clinic times for these pharmacists.

The pharmacist's role would be to conduct periodic structured medication reviews, reconcile and coordinate medications across transitions of care, identify and resolve drug use issues, adjust strength dosage form, or suggest therapeutic substitutions, as needed.

In an e-course at the Pharmapreneur Academy, I discuss the details of using certain billing codes, such as incident-to billing codes or annual wellness visit billing codes, to see patients under the direct supervision of the provider in their clinic.

B. Proactively manage chronic and preventative care for patients.

The focus here is to use evidence-based protocols to guide treatment for chronic conditions and provide chronic care management services.

The pharmacists’ role would be to individualize care plans for patients and educate them about their medication use. Pharmacists could also help enroll them in medication synchronization programs, screen them for additional comorbid conditions, and perform routine medication reconciliations.

To bill for these services, a consultant pharmacist under a collaborative practice agreement acting as an auxiliary staff member can work under the general supervision of a physician. This means a pharmacist could work in an offsite role as a consultant pharmacist and bill for chronic care management codes (CCMs) under a physician's National Provider Identifier.

Learn more about CCM codes and building a collaborative practice agreement with a collaborative physician in lessons 7 and 8 of the e-course at PharmapreneurAcademy.

C. Focus on communication and care coordination.

The pharmacist would address the sharing of information and coordination of clinical and preventative services among caregivers, multiple health care professionals, and patients.

The role of the consultant pharmacist is to identify and document patient care activities using the chronic care management or transitional care management codes, document clinical and preventative services, such as immunizations, and notify the prescriber so that the patient's record is up to date.

To bill for these services, a pharmacist could use annual wellness visit codes, incident-to billing codes, chronic care management codes, or even transitional care management codes. A pharmacist can offer the initial contact of the 2-part transitional care management code service under a physician's collaborative practice agreement without being under the direct supervision of the physician.

Study the MACRA legislation, and become knowledgeable about value-based payment reform. Then use that knowledge to reach out to local high-volume prescribers and request appointments to discuss these changes and their challenges.

In addition, share the pharmacy's commitment to supporting them in this new performance-based reimbursement landscape.

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