Reimbursing Pharmacists for Patient Care Service: An Idea Whose Time is Overdue

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By Tony Schueth

Pharmacists are increasingly called on to work with other healthcare professionals to increase their participation in care services. Studies and experience have shown that pharmacists add value to patient care—whether, for example, it is through counseling in the pharmacy, conducting medication reconciliation, assisting in disease management or working as part of a patient care team in a patient-centered medical home or accountable care organization. There is an ever-expanding list of services and venues in which pharmacists’ participation can be a definite value-add in terms of decreasing medication errors, reducing overall healthcare costs and improving the quality of patient care.

So what’s not to like? The answer is that payers have been reluctant to reimburse pharmacists for such services.  Medicare—the 800 lb. gorilla in the policy room—has so far been the biggest holdout. And as we all know, private payers tend to follow Medicare’s reimbursement lead.

That could be changing soon.  A coalition of pharmacy stakeholders–the Patient Access to Pharmacists Care Coalition (PAPCC)—has garnered Congressional support to introduce legislation that will enable patient access to, and payment for, Medicare Part B services by state-licensed pharmacists in medically underserved communities. Details are in HR 4190, and PAPCC hopes a Senate bipartisan introduction can be carried out in the near future.

We at Point-of-Care-Partners believe this certainly is a step in the right direction. It is evidence that the healthcare system is beginning to officially recognize the value of pharmacists in patient care, acknowledge the expansion of their roles in an evolving healthcare system and pay them their due. 

We also applaud PAPCC for creating Congressional traction on this important issue.

Such efforts will help the profession become even more relevant as value-based payment and integrated delivery models take hold. It also can be an effective strategy to nibble away at reimbursement policy.  Policymakers often find it easier to digest small Medicare reimbursement changes than try and create a force-feeding of sweeping reimbursement policies.

While we’re at it, we’d like to give POCP’s own Jeanette Nelson a pat on the back for her participation as an APhA Provider Status volunteer in support of PAPCC. We hope to see more results from the group and we’ll keep you posted.

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MU3 and WIIFM – Have we missed the boat?

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By Michael Burger, Senior Consultant

On March 11, the Health IT Policy Committee endorsed the Meaningful Use Workgroup’s recommendations for Meaningful Use Stage 3.  The Workgroup’s initial proposal was scaled back by 30%, eliminating 8 of the 26 initial measures.  The Policy Committee’s recommendations now go to the Centers for Medicare and Medicaid Services (CMS), which will develop a proposed rule later in 2014, with a final rule expected during the first half of 2015.

Reports are that the March 11 meeting was contentious, with many participants dismayed at the outcome – but for different reasons.  Some expressed concern that decisions were being made without applying feedback from Stage 2, now just getting underway.  Others stressed that with Stage 2 and ICD-10 looming, providers and EHR vendors are overwhelmed – and that the requirements should be reduced even further.

Forceful and eloquent arguments could be (and have been!) made about the merits and demerits of Meaningful Use.   The intent of MU remains pure – investing in the technology infrastructure with which to put public health policy into action.

The challenge, as with all things public policy, is that the intent is often obscured by the reality of the real world.  Given that there has never been widespread organic demand for EHRs, it shouldn’t be a surprise that use of EHRs that have been adopted as a result of incentives is faltering. Nor is it surprising that providers are opting to not continue with the MU program in year two.  The intent – putting public health policy into action – is obscured by the reality:  Using an EHR requires commitment, change management and a big picture view.  Physicians aren’t seeing the good that could come from EHRs because they’re bogged down going through the motions to pass the MU test.

Why Not Medication Adherence?

From that perspective, it’s interesting to look at what’s “in” and what’s “out” for Stage 3.  While I was not a participant in either the Meaningful Use Workgroup or at the HIT Policy Committee, I will say some of the choices do not make sense.  One troubling choice was the decision to remove a requirement related to Medication Adherence.

Medication Adherence (or compliance) refers to a patient’s conformity to a physician’s recommendations about medication therapy treatment with respect to timing, dosage, and frequency.  Med Adherence is a valuable EHR feature because it has the potential to have an immediate and measurable effect on public health.  Monitoring and taking proactive steps to remind and encourage patients to stick to their medication care plan will result in an enormous improvement in public health, in addition to sizable reduction in spending.  For diabetes alone, it has been estimated that increases in medication adherence of only 20% could reduce total health care spending by $1,074 annually for every person with diabetes.[i]

Compare that to the proposed requirement requiring providers to record electronic progress notes which are text-searchable.  Electronic progress notes refer to visit documentation that is recorded either as text (i.e. word processing) or as individual fields of data (i.e. as a template); versus handwritten dictated, or scanned documents.

For electronic progress notes, the intent is that one phase builds upon another until the goal is reached. Text-searchable notes lead to codified notes, which lead to interoperability and data mining of notes, which leads to population-wide progress note analytics.  The intent makes sense – in the big picture.    The reality is that in the physicians’ view, electronic progress noting increases the amount of time a physician spends to document a visit, reducing productivity (and revenue) and does little to improve population health in the short term.

Perhaps it’s time for CMS to consider the time tested acronym– WIIFM – What’s in it for me?  If all a physician sees is a bunch if “must do” MU requirements and doesn’t see WIIFM, they’re not going to stick with the program long enough for the intent of MU to be recognized.  Requirements like Medication Adherence monitoring have a pretty clear WIIFM factor.

[i] Sokol MC, McGuigan KA, Verbrugge RR, Epstein RS. Impact of medication adherence on hospitalization risk and healthcare cost. Med Care. 2005;43(6):521–530.

 

 

 

 

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Stopping Physician Overprescribing

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By Maria Friedman, Senior Consultant

The war on drug abuse is taking a turn with the growing spotlight on physician overprescribing. More fuel has been thrown on the fire with new studies showing that it’s overprescribing physicians who are putting patients at risk, not just the friendly neighborhood drug dealers.

According one study, nearly one in three Medicare beneficiaries who get prescriptions for painkillers can get them from multiple doctors and, not surprisingly, they have higher hospitalization rates. What’s worse, the physician prescribing them is unaware that they are already receiving prescriptions from another doctor. Possible results are easy to predict: further drug abuse, inadvertent drug-drug interactions, avoidable hospitalizations and premature deaths. Although nobody has quantified these impacts on the Medicare budget, a back-of-the-envelope computation leads to big costs very quickly.

Another study focused on the drug abuse problem in Tennessee.  One of every three Tennesseans fills a prescription for narcotic painkillers at least once a year. Nearly 5.2 million Tennessee residents received painkillers — 37 million total prescriptions — between 2007 and 2011.  This adds up to about 1.4 prescriptions per resident. Among patients who received narcotic pain killers in 2011, 7.6 percent got prescriptions from more than four doctors and 2.5 percent went to more than four pharmacies to get their medication. Topping the list in 2011, 32,000 Tennesseans received 25 or more prescriptions for opiates, and 5,500 got prescriptions from 10 or more doctors. The researchers and law enforcement think this kind of scenario is not necessarily limited to Tennessee, and is found nationwide to one degree or another.

Opioid Abuse Linked to Heroin Use

Prescription drug abuse—especially for opioids–is at epidemic proportions.The Centers for Disease Control and Prevention (CDC) has characterized prescription drug abuse and overdose as 2014’s second highest health threat. Deaths from overdoses of opioids have risen to more than 16,600 in 2010. Moreover, experts believe opioid abuse has led to the recent spike in heroin use, as well as heroin overdose deaths. The reason is that many patients often abuse painkillers before switching to heroin. Attorney General Holder has announced law enforcement’s commitment to address the problem.

Stopping doctor overprescribing is complicated. There is no question that opioids are a front line of defense against pain and suffering. But then there is the overprescribing aspect. First, there are the doctors who unknowingly overprescribe—either because they lack the knowledge about what medications their patients are taking across the board or because they are not well educated about addiction. Then there are the rogue physicians who are in it mostly for the money. And it’s good money. Take, for example, Anand Persaud. This Long Island, N.Y., internist, wrote more than $1 million in prescriptions for painkillers for 5,800 patients. He accepted only cash from his patients, many of whom subsequently were reimbursed by Medicaid. (Such fraudulent activity is rampant elsewhere. Pro Publica published an interesting article on the extent of fraud in Medicare Part D, if you’re interested.)

Health IT Solutions and Policy Levers Key

However, law enforcement, state governments, pharmacies and others are developing solutions.  Electronic prescribing (ePrescribing) is among the first lines of defense. New York will require that all prescriptions—including those for controlled substances—be ePrescribed by March 27, 2015. Efforts to make medication histories more complete will help, especially if we can figure out how to fold in drugs that are paid for by cash. Nearly all states have Prescription Drug Monitoring Programs (PDMPs), which are in the process of being beefed up both in terms of content and technology. Some states are moving to require real-time access to data; others are requiring at the PDMP data base be checked and annotated when a prescription is written or dispensed.  Pharmacies, including CVS-Caremark and Walgreens, are on the case as well.  CVS-Caremark is using data analytics to identify potential problem prescribers. Walgreens has a “Good Faith Dispensing” policy, which requires pharmacists to use a checklist before dispensing controlled substances. Medicare is beginning to get on board by starting to use data analytics to identify problem prescribers. Medicare also is exploring policy levers for better oversight, such as requiring all Part D prescribers to becoming Medicare participating physicians. The American College of Physicians is concerned about the problem enough to issue a white paper about it.

It’s disheartening to learn that physicians are a bigger part of the Nation’s drug abuse problem than we might have suspected. On the other hand, it’s heartening to see that stakeholders are recognizing the problem and are stepping up.  But it’s only a beginning. We all can, and should, do more.  

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