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Implementing Direct Payment for Clinical Pharmacy Services
Dr. Allen Nichol, PharmD COO/VP Clinical Operations, CeutiCare Inc.
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Discuss the steps involved in implementing a pilot program and the barriers encountered during the process Provide an expected timeline for implementing a pilot program Go over components of a successful program Answer questions Objectives
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Barriers Encountered During Implementation
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Legal Challenges Establishment of collaborative practice agreements
Ability for the pharmacist to order medication changes (modify strength, dosage, type of medication) within their agreed upon chronic disease(s) base upon their clinical judgement Ability for the pharmacist to order appropriate lab work to assess disease status and monitor patient response to drug therapy
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Transitioning Role of the Pharmacist
Pharmacist must be positioned in a medical practice site and seeing chronic disease patients on a monthly or quarterly basis Pharmacist should be proficient in patient interviewing and clinical decision making Pharmacist should be current in the clinical literature in their chronic disease areas of interest i.e. diabetes, lipids, hypertension etc.
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Insurance Buy-In Consider approaching a large insurance carrier that has experience with pharmacist pilot projects Develop a program that utilizes pharmacist provided clinical services to improve chronic disease outcomes Identify measurable outcomes for the pharmacist to report to the insurance company to justify the clinical services Best to reach out to the regional chief medical officer (CMO) to initiate contact
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Physician Recruitment
Target independent physician practice sites of family or internal medicine Can try smaller health systems or physician networks, but like larger health systems they tend to only engage in internal programs Physicians that you will work with will expect payment for each patient that is seen, as part of a cost share for the pharmacist that is providing clinical services
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Billing & Compensation
Use CPT coding for evaluation and management (E & M) services, not MTM codes Pharmacy group must be able to bill electronically for services-different than the systems used for billing prescription claims Compensation needs to be at the exact (100%) rate that physicians receive and collected (including co-payments)
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Billing & Compensation
Funds are then distributed among three groups: Pharmacist: The pharmacists directly providing the services must be compensated. Compensation should take into account pharmacist will most likely be responsible for their own insurance, IRA, 401k ,etc. Physician Office: Physician site will demand compensation for the use of the facility, use of ancillary staff, and to cover a percentage of overhead costs (utilities, insurance, etc.) Pharmacist Group: Pharmacist group must have funds because they are responsible for billing, engaging pharmacists to provide the services for the patient, negotiating with the insurance carrier and the physician group, and tracking outcomes
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Data Analysis & Outcomes Reporting
Documenting patient clinical outcomes is necessary in order to report those outcomes and justify costs to the insurance carrier Insurance carriers will demand de-identified lab data from the pharmacy group to prove improvement in clinical outcomes Data analysis and outcomes reporting is also critical for potential outcome-based payments. The STAR ratings of the practice are directly tied to the management of chronic care gaps and clinical outcomes Improvement in clinical outcomes and STAR ratings can lead to greater reimbursement rates and potential bonuses
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Technological Challenges
Essential that all pharmacist have an NPI number or they cannot bill and participate The insurance carrier will need to import the pharmacist NPI numbers into their database There are several other databases that the pharmacist’s information must be entered into. This will allow not only for payment for services rendered, but also allow pharmacists to be listed as providers and eligible to order prescription medications and labs Pharmacist should also become a provider with the major clinical laboratories (i.e. Quest, LabCorp etc.) so that the labs ordered are listed under their names and are directly sent to them for review
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Contracting Contracts should be drawn between the pharmacist group and the insurance carrier as well as between the pharmacist group and the medical practice site The contract between the pharmacist group and the insurance carrier should include everything discussed on previous slides Contract between the pharmacist group and the medical practice site should include financial arrangements, space and staffing allocation, as well as, a separate collaborative practice agreement Collaborative practice agreements should define which disease states are to be managed and treated by the pharmacist and what authority is the physician delegating to the pharmacist to achieve best clinical outcomes
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Expected Timeframe for Implementation of Pilot Program
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Timeframe for Implementation
*Does not include time frame allocated to changing state collaborative practice agreement laws to allow pharmacists to both prescribe and order clinical labs Lobbying the insurance company, arranging for meetings with the CMO, coming to a satisfactory conclusion on the merits of such a pilot project: 1 full year
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Timeframe for Implementation
At least 1 more year for achieving concurrence on the project from the insurance carrier and participating physicians including: Negotiation of an acceptable financial arrangement Ensuring the necessary software changes by the insurance carrier to allow for billing, prescribing, and claims adjudication Integrating pharmacists into the clinic and developing a work flow pattern at the medical practice site *Allow an additional 90 days for either of the non-pharmacist groups changing their minds on any number of issues.
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Timeframe for Implementation
Patient recruitment: 2-3 Months Done by the physicians based upon a targeted list of patients that do not meet clinical outcomes measurements in the targeted disease states (chronic care gaps) This list of identified patients is typically provided by the insurance carrier Look to schedule about patients per day
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Timeframe for Implementation
Recruitment of additional insurance companies Allow competing insurance carriers to know that a contract is in place with outcomes being tracked. They will probably take a wait and see approach to see how the pilot progresses and if there is any clinical and economic data reported to support the program Expect a shorter timeframe when implementing the pilot program with additional insurance carriers since you will most likely be working with the same physician groups Software updates to include pharmacists into the databases will probably take the same 12 months
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Key Components for Success
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Data Analysis & Outcomes Reporting
Outcomes reporting and data analysis can be utilized as an additional source of revenue for the pharmacist group Essential to the growth of additional pilot projects throughout the US and can potentially reduce marketing costs
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Marketing Marketing of this process is yet to be perfected, but is important in establishing and expanding a pilot program Developing a client base and continuously updating the clinical and business software requires substantial funding that may not be afforded from clinical services revenue alone Revenue from data collection and analysis services provided by the pharmacist group can be used as a funding source for marketing and clinical expansion opportunities
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Clinical Advisory Panel
Software must be continuously updated and the clinical content needs an advisory panel to evaluate new treatments for chronic diseases Once the FDA allows a drug to come to market, it still needs to be evaluated for clinical success over a 6-month period, which includes reading peer reviewed articles and attending lectures
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Management Team A business plan and management team needs to be in place to continually evaluate the chance for success and to drive this concept forward The management team should be comprised of members from multiple disciplines and consist of individuals with business, clinical, and administrative backgrounds Quarterly meetings of both the clinical advisory panel and management team are essential for identifying new business opportunities and for continuous quality improvement of the software to meet expanding business needs
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Questions?
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Implementing Direct Payment for Clinical Pharmacy Services
Dr. Allen Nichol, PharmD COO/VP Clinical Operations, CeutiCare Inc.
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