News Continued from page 772
ASHP urged FDA to update and make better use of the agency’s DailyMed drug labeling database and use that as the central portal for all labeling-related
information instead of creating a new database system for CBE-0 supplements. ASHP was also 1 of 21 signatories on a March 6 letter to FDA Commissioner Margaret Hamburg expressing concerns about potential adverse economic and
Hospital earns financial rewards for inpatient MTM services
A
n Oregon hospital may have cracked the code for private-payer reimbursement of inpatient medication therapy management (MTM) services provided by pharmacists. Deborah Sanchez, director of pharmacy practice and residency at 380-bed Asante Rogue Regional Medical Center in Medford, said the hospital last year billed private and public insurers for about 5000 MTM encounters. None of the expenses were reimbursed by Medicare or Medicaid. But Sanchez estimates that the MTM services continue to bring in about $50,000 per month from one private insurer with whom the hospital has negotiated rates for the services. “It’s money. It’s not nothing,” Sanchez said. “You bill a lot more than you receive, but the hospital bills a lot more than it receives overall, as well.” Sanchez said the hospital first examined the possibility of billing for inpatient MTM services about five or six years ago. She said the pharmacy and finance directors “discussed the services we were providing and if there was an opportunity to do billing for them.” Ultimately, she said, “the facility determined that the types of services that we provide in the hospital as pharmacists” fall under evaluation and management (EM) inpatient procedural codes. EM codes capture three key elements of patient care encounters—patient historytaking, physical examination, and medical decision-making—and categorize the services on the basis of complexity. 774
Sanchez said her hospital uses the SOAP (subjective data, objective data, assessment, plan) documentation style to meet state requirements for documenting pharmacists’ MTM services. Oregon state law permits pharmacists to provide MTM services and to establish collaborative practice agreements with physicians. Both of these activities require adequate documentation of the pharmacist’s encounter with the patient, and Sanchez said the SOAP process satisfies the state’s requirements. She said some of the hospital’s pharmacists weren’t familiar with SOAP charting and “needed a little bit of training” in the method and how to work it into their daily practice. “They were already doing [patient] education, so it wasn’t a huge deal” to document what they were doing, Sanchez said. Sanchez said the hospital established five billing levels for MTM services. Because the services are provided to inpatients, all encounters are face-to-face. At the low-complexity end of the spectrum are level 1 MTM services such as simple fall consultations, medication reviews, and medication reconciliation for patients who require little or no follow-up and no change to the medication regimen. Level 2 services are brief but more complex than level 1 services and are problem focused. Examples may include a fall consultation that results in a medication change, a renal function evaluation with no change to therapy, the ordering of laboratory tests, or a switch between oral and i.v. therapy.
Am J Health-Syst Pharm—Vol 71 May 15, 2014
patient safety effects of adopting the proposed rule. —Kate Traynor DOI 10.2146/news140035
Sanchez said pharmacokinetic or renal function monitoring with subsequent dosage adjustments may represent moderatecomplexity (i.e., level 3) services, and initiating warfarin therapy or evaluating a drug-induced disease may be considered level 4 services by the hospital. Level 5 services require a complete physical exam and involve extremely complex medical decision-making in patients who are critically ill. Examples may include services for intensive care unit patients with multiple medication problems or services focused on the prevention of serious adverse drug events. “It’s broken down by category, by complexity,” Sanchez said. “These all go through the biller, and the biller codes them. And they do the same thing for other nonphysician provider practitioners.” She said hospital administrators have emphasized the importance of submitting bills for services even when there is no expectation of reimbursement, because the data help establish the value of pharmacists’ clinical work. And billing the Medicare program ensures that the agency has this data available when it sets payment rates. Sanchez said other pharmacists have contacted her about billing for inpatient MTM services, but she doesn’t know if other hospitals have implemented a process like that used at her facility. She said the success depends on the willingness of insurers to reimburse for inpatient MTM services and the existence of a billing system that allows the codes to be processed for payment. She speculated that “flat-rate” or bundledpayment systems may not permit the Continued on page 776
News Continued from page 774
type of billing that her hospital has successfully used. Sanchez said allowing pharmacists to provide billable MTM services has had a “community impact or cultural impact” at the hospital by promoting and codifying pharmacists’ routine interactions with patients at the bedside. “When you . . . become that practitioner who is face-to-face and interact-
ing with the patients and caring for them, you change the dynamics of your role, becoming much more visible,” she said. “We’ve gotten some phone feedback and some letters, and [patients] really appreciate some of the care they’ve gotten.” She said pharmacy students who come to the nonprofit community hospital during experiential rotations are enthusiastic about using the SOAP documentation format.
Direct engagement as part of collaborative practice improves diabetes care
P
harmacists’ direct engagement with patients whose diabetes mellitus had not been under control has helped a health care organization better serve this population and save money, metrics suggest. The direct engagement is part of the Lindsey Valenzuela collaborative practice protocol between the medical group and pharmacists at Desert Oasis Healthcare for the management of patients with Teresa L. Hodgkins diabetes, said Lindsey Valenzuela and Teresa L. Hodgkins. Valenzuela is the director of medication management services at the health care organization, based in Palm Springs, California. Hodgkins until recently was the services’ administrator. She is now the health care organization’s associate vice president for clinical performance and outcomes. Better outcomes, lower costs. The year before the health care organization created the protocol-based program, Hodgkins said, 24% of seniors with diabetes in the Medicare Advantage plan had a glycosylated hemoglobin (HbA1c) level greater than 9%. 776
But then, with the program in operation, the prevalence of poorly controlled disease dropped by at least half. Hodgkins said less than 12% of those seniors had an HbA1c level greater than 9% in 2012 and 2013. “That’s in the five-star cut point,” she said, referring to the top grouping in the Centers for Medicare and Medicaid Services’ quality-rating system for Medicare Advantage, or Part C, plans. Hospitalizations also decreased. In 2010, before implementation of the protocol-based program, patients with diabetes accounted for 40% of the bed days in acute care hospitals for the Medicare Advantage plan, Hodgkins said. That percentage has dropped as well, she said. Through the program, which starts with a physician’s referral, Hodgkins said, the pharmacists at any particular time manage 120–150 of the health care organization’s 5000-some patients with diabetes. These 120–150 collaboratively managed patients primarily are enrollees in the organization’s capitated health care plans: the Medicare Advantage plan and the commercial health maintenance organization. “How we can improve the outcomes and ultimately reduce costs is how they
Am J Health-Syst Pharm—Vol 71 May 15, 2014
“In this kind of setting—which is the majority of [U.S.] hospitals anyway—a lot of times the pharmacists aren’t actually seeing the patients very much. So when [students] come to us, they realize that here they get to go and see the patients,” Sanchez said. “They feel like they are doing patient care. I hear a lot about that.” —Kate Traynor DOI 10.2146/news140036
justify having the program,” Hodgkins said of her health care organization. The organization has reported a return on investment for the program of approximately 5:1. Reasons for success. Valenzuela said the requirement for a physician’s referral works in the pharmacists’ favor. By virtue of the referral, she said, “the physician has vetted that the program is positive.” The result is that even patients who were initially reluctant to be treated by a pharmacist are likely to follow the pharmacist’s instructions. Hodgkins said her health care organization embarked on the diabetes care program hoping to decrease hospital utilization, prevent preventable admissions, and perform better on the diabetesrelated Medicare Part C and Healthcare Effectiveness Data and Information Set quality measures. In 2013, the California Association of Physician Groups recognized Desert Oasis Healthcare’s “Pharmacist-Enabled Diabetes Care Management” program as a case study in excellence. Hodgkins and Valenzuela ascribed the success of their program to some features the two considered unusual. Under the protocol-based program, they said, the pharmacists • Can make the changes described in the collaborative practice agreement Continued on page 778
Copyright of American Journal of Health-System Pharmacy is the property of American Society of Health System Pharmacists and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
ASHP urged FDA to update and make better use of the agency’s DailyMed drug labeling database and use that as the central portal for all labeling-related
information instead of creating a new database system for CBE-0 supplements. ASHP was also 1 of 21 signatories on a March 6 letter to FDA Commissioner Margaret Hamburg expressing concerns about potential adverse economic and
Hospital earns financial rewards for inpatient MTM services
A
n Oregon hospital may have cracked the code for private-payer reimbursement of inpatient medication therapy management (MTM) services provided by pharmacists. Deborah Sanchez, director of pharmacy practice and residency at 380-bed Asante Rogue Regional Medical Center in Medford, said the hospital last year billed private and public insurers for about 5000 MTM encounters. None of the expenses were reimbursed by Medicare or Medicaid. But Sanchez estimates that the MTM services continue to bring in about $50,000 per month from one private insurer with whom the hospital has negotiated rates for the services. “It’s money. It’s not nothing,” Sanchez said. “You bill a lot more than you receive, but the hospital bills a lot more than it receives overall, as well.” Sanchez said the hospital first examined the possibility of billing for inpatient MTM services about five or six years ago. She said the pharmacy and finance directors “discussed the services we were providing and if there was an opportunity to do billing for them.” Ultimately, she said, “the facility determined that the types of services that we provide in the hospital as pharmacists” fall under evaluation and management (EM) inpatient procedural codes. EM codes capture three key elements of patient care encounters—patient historytaking, physical examination, and medical decision-making—and categorize the services on the basis of complexity. 774
Sanchez said her hospital uses the SOAP (subjective data, objective data, assessment, plan) documentation style to meet state requirements for documenting pharmacists’ MTM services. Oregon state law permits pharmacists to provide MTM services and to establish collaborative practice agreements with physicians. Both of these activities require adequate documentation of the pharmacist’s encounter with the patient, and Sanchez said the SOAP process satisfies the state’s requirements. She said some of the hospital’s pharmacists weren’t familiar with SOAP charting and “needed a little bit of training” in the method and how to work it into their daily practice. “They were already doing [patient] education, so it wasn’t a huge deal” to document what they were doing, Sanchez said. Sanchez said the hospital established five billing levels for MTM services. Because the services are provided to inpatients, all encounters are face-to-face. At the low-complexity end of the spectrum are level 1 MTM services such as simple fall consultations, medication reviews, and medication reconciliation for patients who require little or no follow-up and no change to the medication regimen. Level 2 services are brief but more complex than level 1 services and are problem focused. Examples may include a fall consultation that results in a medication change, a renal function evaluation with no change to therapy, the ordering of laboratory tests, or a switch between oral and i.v. therapy.
Am J Health-Syst Pharm—Vol 71 May 15, 2014
patient safety effects of adopting the proposed rule. —Kate Traynor DOI 10.2146/news140035
Sanchez said pharmacokinetic or renal function monitoring with subsequent dosage adjustments may represent moderatecomplexity (i.e., level 3) services, and initiating warfarin therapy or evaluating a drug-induced disease may be considered level 4 services by the hospital. Level 5 services require a complete physical exam and involve extremely complex medical decision-making in patients who are critically ill. Examples may include services for intensive care unit patients with multiple medication problems or services focused on the prevention of serious adverse drug events. “It’s broken down by category, by complexity,” Sanchez said. “These all go through the biller, and the biller codes them. And they do the same thing for other nonphysician provider practitioners.” She said hospital administrators have emphasized the importance of submitting bills for services even when there is no expectation of reimbursement, because the data help establish the value of pharmacists’ clinical work. And billing the Medicare program ensures that the agency has this data available when it sets payment rates. Sanchez said other pharmacists have contacted her about billing for inpatient MTM services, but she doesn’t know if other hospitals have implemented a process like that used at her facility. She said the success depends on the willingness of insurers to reimburse for inpatient MTM services and the existence of a billing system that allows the codes to be processed for payment. She speculated that “flat-rate” or bundledpayment systems may not permit the Continued on page 776
News Continued from page 774
type of billing that her hospital has successfully used. Sanchez said allowing pharmacists to provide billable MTM services has had a “community impact or cultural impact” at the hospital by promoting and codifying pharmacists’ routine interactions with patients at the bedside. “When you . . . become that practitioner who is face-to-face and interact-
ing with the patients and caring for them, you change the dynamics of your role, becoming much more visible,” she said. “We’ve gotten some phone feedback and some letters, and [patients] really appreciate some of the care they’ve gotten.” She said pharmacy students who come to the nonprofit community hospital during experiential rotations are enthusiastic about using the SOAP documentation format.
Direct engagement as part of collaborative practice improves diabetes care
P
harmacists’ direct engagement with patients whose diabetes mellitus had not been under control has helped a health care organization better serve this population and save money, metrics suggest. The direct engagement is part of the Lindsey Valenzuela collaborative practice protocol between the medical group and pharmacists at Desert Oasis Healthcare for the management of patients with Teresa L. Hodgkins diabetes, said Lindsey Valenzuela and Teresa L. Hodgkins. Valenzuela is the director of medication management services at the health care organization, based in Palm Springs, California. Hodgkins until recently was the services’ administrator. She is now the health care organization’s associate vice president for clinical performance and outcomes. Better outcomes, lower costs. The year before the health care organization created the protocol-based program, Hodgkins said, 24% of seniors with diabetes in the Medicare Advantage plan had a glycosylated hemoglobin (HbA1c) level greater than 9%. 776
But then, with the program in operation, the prevalence of poorly controlled disease dropped by at least half. Hodgkins said less than 12% of those seniors had an HbA1c level greater than 9% in 2012 and 2013. “That’s in the five-star cut point,” she said, referring to the top grouping in the Centers for Medicare and Medicaid Services’ quality-rating system for Medicare Advantage, or Part C, plans. Hospitalizations also decreased. In 2010, before implementation of the protocol-based program, patients with diabetes accounted for 40% of the bed days in acute care hospitals for the Medicare Advantage plan, Hodgkins said. That percentage has dropped as well, she said. Through the program, which starts with a physician’s referral, Hodgkins said, the pharmacists at any particular time manage 120–150 of the health care organization’s 5000-some patients with diabetes. These 120–150 collaboratively managed patients primarily are enrollees in the organization’s capitated health care plans: the Medicare Advantage plan and the commercial health maintenance organization. “How we can improve the outcomes and ultimately reduce costs is how they
Am J Health-Syst Pharm—Vol 71 May 15, 2014
“In this kind of setting—which is the majority of [U.S.] hospitals anyway—a lot of times the pharmacists aren’t actually seeing the patients very much. So when [students] come to us, they realize that here they get to go and see the patients,” Sanchez said. “They feel like they are doing patient care. I hear a lot about that.” —Kate Traynor DOI 10.2146/news140036
justify having the program,” Hodgkins said of her health care organization. The organization has reported a return on investment for the program of approximately 5:1. Reasons for success. Valenzuela said the requirement for a physician’s referral works in the pharmacists’ favor. By virtue of the referral, she said, “the physician has vetted that the program is positive.” The result is that even patients who were initially reluctant to be treated by a pharmacist are likely to follow the pharmacist’s instructions. Hodgkins said her health care organization embarked on the diabetes care program hoping to decrease hospital utilization, prevent preventable admissions, and perform better on the diabetesrelated Medicare Part C and Healthcare Effectiveness Data and Information Set quality measures. In 2013, the California Association of Physician Groups recognized Desert Oasis Healthcare’s “Pharmacist-Enabled Diabetes Care Management” program as a case study in excellence. Hodgkins and Valenzuela ascribed the success of their program to some features the two considered unusual. Under the protocol-based program, they said, the pharmacists • Can make the changes described in the collaborative practice agreement Continued on page 778
Copyright of American Journal of Health-System Pharmacy is the property of American Society of Health System Pharmacists and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
