Loren Bonner
As physician practices try to meet outcomes required by new value-based payment models, pharmacists are being brought in to help them meet certain quality metrics.
Results of these arrangements appear to be positive, according to a new study published March 1, 2023, in the American Journal of Health-System Pharmacy.
Pharmacists in these arrangements are mostly spending their time performing chronic care management services (CCM) and transitional care management, which are generally non–face-to-face visits reimbursed by Medicare. Pharmacists can also see patients in person for evaluation and management (E/M) services and annual wellness visits (AWV), also reimbursed by Medicare.
Researchers of the new study found that pharmacist provision of AWVs and CCM in a privately owned family medicine clinic grew the number of patients who received these services while also increasing reimbursement for the clinic.
“This information provides additional evidence that pharmacists can positively contribute to clinical practice, by improving both revenue and quality of care via AWVs and CCM,” said study author Keri Mack, PharmD, from Palm Beach Atlantic University Lloyd L. Gregory School of Pharmacy in Florida.
While the total number of AWVs completed remained about the same, Mack said the reimbursement from those visits increased. The boosted revenue was likely driven by improvements in advanced care planning, annual depression and alcohol misuse screenings, and counseling for CVD and obesity. Several of these counseling codes and screenings are also tied to current Merit-based Incentive Payment System (MIPS) quality measures, she noted.
“AWVs represent an important opportunity for preventative care and to ensure clinicians are meeting and reporting quality metrics, which are now tied to reimbursement,” said Mack.
Increases
The research team only examined reimbursement for CCMs and AWVs. They reviewed claims data for Current Procedural Termi-nology codes and reimbursement applicable to AWVs and CCM and found that reimbursement from AWVs increased by $25,807.21 in 2018 and $26,410.01 in 2019 compared to 2017 for the small family practice where the study took place. Additionally, reimbursement from CCM increased by $16,664.29 in 2018 and $5,698.85 in 2019.
Researchers also found that with pharmacists’ services in place, the number of CCM encounters increased to 362 in 2018 and 152 in 2019 and the number of AWVs totaled 236 and 267, respectively.
Completed Healthcare Effectiveness Data and Information Set (HEDIS) measures and star ratings also increased during the study period.
“The major strength of this study was that improvements in both quality metrics and reimbursement were shown even with a single pharmacist in a small private practice,” said Mack.
However, in 2019, there were issues with the third-party billing vendor for the practice. Delayed billing of office visits led to many claims being denied as a penalty for untimeliness, according to Mack. Reimbursement for pharmacist-led AWVs and CCM may not be representative of the true reimbursement potential had these billing issues not been present, Mack added.
Additionally, since this practice was not required to report MIPS measures until 2020, those measures could not be analyzed during the timeframe of the study.
“The published evidence on reimbursement for pharmacist-led AWVs and CCM is relatively limited, but our study adds to that body of literature without contradicting results of other publications on this topic,” Mack said.
Getting started
Mack believes that data on this topic not only allow the profession of pharmacy to move forward, but help fill an important need in primary care.
“In the world of primary care, we not only have a shortage of physicians, but increased demands on those remaining physicians,” Mack said. “Our payment systems are shifting from a fee-for-service to a quality-based payment system. Reporting these quality metrics for a practice, or even for individual providers can be hefty, which further increases demands on those providers and allows less time for patient care.”
However, using pharmacists in this capacity remains slow to catch on, particularly in certain regions of the United States.
“If pharmacists are looking to embed themselves within a clinic, choosing a progressive physician who is pro-pharmacy is a great place to start,” said Mack.
“As word gets around as to the value of this pharmacist in one clinic, more physicians may be ready to embed a pharmacist within their own practice,” she said. “If pharmacists are already within a clinic and experiencing barriers, starting with a simpler clinical service, such as AWVs, can be beneficial to build trust prior to expanding to other services, like diabetes management via a collaborative practice agreement.” ■
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