On The Cover

Loren Bonner

For years, some pharmacists have been working in collaboration with health care providers in models that generate revenue through the delivery of various Medicare services. The most common example of this is pharmacists who deliver chronic care management (CCM) services to patients who meet the qualifications. This includes CCM, which are non–face-to-face visits, as well as in person transitional care management services and annual wellness visits, all reimbursed by Medicare. Pharmacists working in these ways are usually directly employed by a physician practice as a full-time employee and often share in the revenue created from these services.

But this delivery model may just be a taste of what could be possible when pharmacists and health care providers collaborate. Three pharmacists profiled in this story are working collaboratively with providers—but in new ways. Their stories are a testament to what pharmacists are capable of and what they should be paid for.

Jaron Stout, PharmD

Jaron Stout, PharmD, is shaking up the model of consultant pharmacy in nursing homes.

“It has to change,” said Stout, who has worked as a consultant pharmacist in Utah for over 12 years.

CMS regulations from 2018 state that 66% of medication-related adverse events in nursing homes are preventable. Two of the most common medication-related adverse events are related to anticoagulation and diabetes—the “bread and butter for consultants,” according to Stout.

“Consultant pharmacists are missing the mark because that is unacceptable,” said Stout.

CMS regulations require that every skilled nursing facility employs a consultant pharmacist to review residents’ medication every month. But, Stout said, consultant pharmacists should be doing more than checking a box to say they looked at a patient’s medications. “It’s unfortunately a lot of compliance checks to make sure the [facility] is in line with regulations instead of ‘here are things we can address with your medications,’” he said.

Stout is working to deliver better care to nursing home patients through collaborative practice agreements (CPAs).

“When I came across collaborative practice agreements, that’s when things changed for me,” said Stout. “I met with an attorney, wrote a CPA, and started my own company.”

Stout currently has CPAs with roughly eight different physicians or medical groups.

“The benefit of a CPA is that instead of me leaving [the facility] a stack of paperwork to take care of, it’s me giving them the stack and saying here’s the stuff that’s been discussed with your physician and preapproved,” said Stout. “Eventually, and ideally, it will turn into a report saying here’s the stuff I did fix while I was here, and it’s all done for you.”

CPAs have different requirements depending on the state. In a nursing facility or a skilled nursing facility, they are under federal regulations and are thus limited. Current federal regulations specify who can write an order, and pharmacists are not included in that language. However, physicians may delegate writing orders to a therapist for therapy and to a dietitian for diet. Currently, those are the only two situations that can be delegated.

“We need to add pharmacists operating under a collaborative practice agreement to the list of professionals who can be delegated the task of writing orders,” said Stout. He’s created a coalition to get CMS to recognize pharmacists under CPAs to write orders in nursing homes.

Regulations also specify that signing orders, which is different from writing orders, can be handled according to state laws and regulations. “I’ve discussed the difference between writing and signing orders with my health care attorney. We both concluded that signing orders is likely for routine day-to-day orders, but writing orders will be generating an entirely new order from scratch,” said Stout.

Stout also performs CCM services through incident-to billing and has recently started doing behavioral health integration, which functions like CCM but is centered around behavioral health. He plans to do annual wellness visits in the near future. Stout can perform and get paid for these services as an employee (i.e., with a W-2 or 1099) of a medical group—essentially services performed under a business agreement, which is different from a CPA.

“Pharmacists have two problems. We can’t write orders, and we cannot bill for our time,” said Stout. “Physicians can delegate to us their ability to write orders through a collaborative practice agreement. They can also delegate their ability to bill for their time through a business agreement.”

The long-term goal and vision for consultant pharmacists, in Stout’s view, is to be a service provided by the medical director. This means, consultant pharmacists work under CPAs and are able to perform billable services. It also means that instead of one consultant pharmacist overseeing 12 to 15 homes, they go to 3 to 5 homes and have a greater impact with a smaller patient load.

“Pharmacists want provider status, but rather sit and wait for it to happen, I think we should use the tools and resources that CMS has given us to prove ourselves,” Stout said. “There are tons of opportunities in long-term care that we can use as stepping stones to provider status.”

Stout even noted that CMS has asked the attorney of his coalition why they haven’t used any of these opportunities before.

Ana Simonyan, PharmD

Most pharmacists will independently manage a patient’s chronic disease state when working collaboratively in primary care or other settings. But in integrated health-system specialty pharmacy, pharmacists work as part of the team on a patient’s care plan.

“The integrated specialty pharmacy model is unique in that pharmacists are present in the clinic space to see patients, to interface with providers, to provide counseling, but also to have access on the back end to the pharmacy dispensing software, to the prior authorization and appeals information,” said Ana Simonyan, PharmD, a clinical pharmacy specialist in Vanderbilt’s infectious diseases clinic as well as a clinical team lead for Vanderbilt Specialty Pharmacy.

Simonyan has a CPA in place with prescribers in her clinic. “We are perfectly positioned to not only have an idea of what the provider wants, but also what the payer wants,” said Simonyan.

In general, most specialty medications require prior authorization or some additional step needed for approval. Simonyan assists with that—usually with the help of a pharmacy technician—and navigates all financial aspects for the patient.

More than 40 pharmacists span 20 different specialized clinics within Vanderbilt. For Vanderbilt’s infectious disease clinic, Simonyan is the only pharmacist dedicated to the space, along with a technician. Floaters also come through.

On a typical day in the clinic, Simonyan will see a patient alongside the provider, either before or after the provider has seen the patient. During a warm handoff, Simonyan will talk to the patient and caregiver about what to expect after the visit. This can include everything from labs to the process for getting the patient’s medication approved.

Once all the relevant clinical information is received, Simonyan and the provider discuss the patient’s prescriptions.

“Through a CPA, I can order the prescription, order any ancillary drugs, order refills, and order labs,” said Simonyan. “It really helps smooth the process and helps the patient have a point of contact for their treatment.”

When people think of specialty pharmacy, they usually don’t think about a clinical side, said Simonyan. “It leads to the question of how we are using a collaborative practice agreement,” she said. “I’m very fortunate in that the physicians I work with heavily involve me in the treatment and decision-making process with the patient.”

Working in an integrated health-system helps, too. Simonyan is able to mitigate issues when they happen because she can fill medications for patients, and she can pull up relevant information when it’s needed.

Simonyan’s role is hybrid. On days she works remotely, she is following up with patients via phone or telehealth meetings, managing other pharmacists on her team, and participating in the outcomes research projects within Vanderbilt Specialty Pharmacy.

A Vanderbilt team presented research at ASHP’s 2023 summer meeting on implementing collaborative pharmacy practice within an integrated health-system specialty pharmacy, using their model to show how quality and efficiency of patient care improves and is favorably accepted by clinic staff. There is limited research that exists currently on collaborative pharmacy practice agreements within integrated health-system specialty pharmacy, even though a growing number of health systems are developing integrated specialty pharmacies that provide comprehensive specialty medication management.

“As more specialty drugs come out, there’s more clinics touching and handling these drugs that really require a high-touch model,” said Simonyan.

Jena Quinn, PharmD

“There’s this very hidden thing in the United States that no one is talking about that is called polypharmacy in pediatrics,” said Jena Quinn, PharmD, owner of Perfecting Peds. Her team—all board-certified, residency-trained pediatric pharmacists—serve pediatric patients in long-term care, medical daycare, or home health.

“There are long-term care facilities all over the United States with kids getting subpar care,” said Quinn. “This is the first time in U.S. history that a pediatric-trained pharmacist has come in and is doing medication reviews via a CPA.”

Her team performs medication reviews, comprehensive clinical services, pharmacogenomics testing, and more.

Quinn wants to improve the quality of life for the children she’s working with, many who are terminally ill, and subsequently better the lives of their caregivers. Her patients have not had comprehensive medication management done previously. Quinn said this should be the standard of care.

“These kids are at that threshold of five or more medications, and they almost always have medications errors or a lot of room for med optimization,” said Quinn. “Many are on multiple meds, or are not on the right medication; they are mismanaged and experiencing lots of adverse effects,” she said.

Quinn has been practicing in New Jersey under CPAs, and since starting Perfecting Peds, she’s contracted with several New Jersey facilities. But Quinn knew that in order to grow her business and for anyone to take her seriously, she needed proof of concept with data.

In roughly 9 months of working under CPAs in these New Jersey facilities, Quinn and her team were able to build a cohort of 102 medically complex pediatric patients. With a total of 1,355 interventions, Quinn found a 44% reduction in hospital admissions or readmissions, 28 emergency department admissions or readmissions avoided as well as 61 clinic and urgent care visits, and an average reduction of 15% fewer medications per child.

For cost savings, they were able to save about $400 per month per child—$489,120 total annually.

The research is forthcoming in the Journal of Pediatric Pharmacology and Therapeutics.

Managed care organizations are taking note, too. According to Quinn, these are data she can take not only to insurance companies, but home care companies and other facilities.

Quinn has to be paid through the providers she’s in contract with because the state of New Jersey does not recognize pharmacists as providers. But Quinn and her team recently became licensed in Minnesota, where they are recognized as providers and are credentialed with Minnesota Medicaid. They see patients via telehealth. Quinn has trained about 10 other pediatric pharmacists to work with her on her team.

“We got a headquarters in Minnesota with the Minnesota Epilepsy Group and are directly billing Medicaid patients,” said Quinn. “As you can imagine, this patient population needs the most help, and we are finding so many opportunities there for med management.” ■