Pressures such as increased competition and inadequate prescription reimbursements from pharmacy benefit managers (PBMs) are causing independent community pharmacies to look for other ways to increase margins and provide added value to patients.
Fortunately, Medicare is starting to recognize the valuable role pharmacists can play in patient care. More opportunities are arising for pharmacists to expand their scope of practice and actually get paid for the services they provide.
By partnering with physicians in their communities, independent community pharmacists can be reimbursed by Medicare for services that meet certain requirements.
And, it’s a win-win. Physicians benefit from these partnerships as well. Collaborating with pharmacists allows them to provide better care and achieve improved patient outcomes, which is becoming increasingly important due to new value-based payment models implemented by the Centers for Medicare & Medicaid Services (CMS).
Opportunities for pharmacists
Medicare services that pharmacists and physicians can bill for include chronic care management (CCM), transitional care management (TCM) and annual wellness visits (AWV).
There are multiple models pharmacists can use to work with physicians on providing these services. For example, a pharmacist could be directly employed with a physician practice and share in the practice’s revenue. Or, a pharmacist could provide the services at clinics and be paid by the hour, per service, or as a percentage of what the clinic is reimbursed.
But to use the billable codes associated with these Medicare services, providers must meet certain requirements. Here’s a breakdown of each service.
Chronic care management
CCM services are non-face-to-face care management or coordination services provided to Medicare beneficiaries with multiple chronic conditions. They offer a way to improve health outcomes and the care provided to individuals with chronic conditions. They can also help reduce overall health care costs.
These services usually involve pharmacists calling patients to follow up with them about their chronic diseases and to provide medication management. The physician practice or clinic can then bill Medicare for the pharmacist’s non-face-to-face-time using CCM codes.
Additionally, by providing CCM services, pharmacists can identify gaps in care patients are experiencing and use that information to help physicians improve their patients’ overall health outcomes. For example, a pharmacist may notice that a patient is not up-to-date on his immunizations.
The flexibility of non-face-to-face CCM services present a great opportunity for independent community pharmacists. Pharmacists don’t have to be directly supervised in order to meet the CCM code requirements, meaning they don’t have to be physically located within the practice to provide the services.
By collaborating with a physician practice on CCM services, independent pharmacists can help bring in added revenue for the practice and themselves while achieving better patient outcomes.
Transitional care management
TCM services ensure patients with a chronic or acute illness experience a smooth transition from an inpatient hospital setting to a community setting.
Typically, the services are delivered over a 30-day period post-discharge from the inpatient setting, and include three primary components:
- Initial contact with patient within two days of discharge
- Non-face-to-face services
- Face-to-face visit within a required time frame
In order to meet TCM codes, the pharmacist must conduct the face-to-face visit under direct supervision, and the patient has to have contact with the physician at some point during the visit. Non-face-to-face services during the 30 days may be conducted under general supervision.
Having pharmacists available to assist with TCM services, especially the non-face-to-face component, is crucial to improving outcomes. As the medication experts, they’re more equipped to handle medication management and ensure patients are properly adhering to their regimens.
Though more collaboration is necessary as both pharmacists and physicians must be present for part of the TCM services, both parties can benefit from the additional revenue and reduced hospital readmissions.
Annual wellness visit
An AWV is a yearly appointment to discuss a patient’s plan of preventive care for the next year. AWVs can also help providers identify potential patients in need of CCM services.
For Medicare to reimburse the service, the AWV must be conducted under direct supervision in the physician’s office.
When pharmacists are involved in AWVs, they can help the physician meet quality measures by reviewing medication-related problems, identifying gaps in care and creating a more effective prevention plan.
And, once physicians understand the added value pharmacists bring to AWVs, it can open the doors the other opportunities, such as CCM and TCM services.
Looking to the future
With more changes to CCM codes this year, it may be even easier for independent community pharmacists to further expand their scope of practice by implementing these services.
Key improvements for CCM in 2017 include:
- Increased payments and additional codes
- Reduced requirements associated with initiating care and increased payments when extensive initiation work is necessary
- Significantly reduced administrative burden
- General supervision in Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs)
Learn more about these changes here.
Independent community pharmacists can take advantage of these improvements by reaching out to the physicians in their communities who they’ve established good relationships with.
With more pharmacist/physician collaboration and the implementation of Medicare services, pharmacists may finally start to see an increase in margins for their businesses while improving patient outcomes and meeting quality measures.
Learn how to improve your relationships with physicians—and boost star ratings.
