A practical billing and payment plan for cognitive services

Documentation of Pharmaceutical Care Activities in Community Pharmacies by Doctor of Pharmacy Students

The practice of pharmacy is evolving from a product-related focus to one that is more patient-oriented and outcome-directed. This new focus can reduce the cost and/or improve the quality of care. Pharmacists often detect and resolve medication-related problems, though few reimbursement incentives exist for the amount of time and effort it takes. With statutory restrictions on the total use of pharmacy technicians and state-mandated OBRA patient counseling and prospective drug utilization review, community pharmacists are pressed for time more than their hospital colleagues to document their daily interventions for improving drug therapy for their patients. PharmD students can assist the community pharmacist in documenting these medication-related problems. Documentation of these "cognitive" or "value-added services," including their outcome on cost and care, is critically necessary for future reimbursement consideration by third-party payers. Copyright © 1995 by W.B. Saunders Company

A pharmacy management intervention for optimizing drug therapy for nursing home patients

BACKGROUND

A drug therapy management service was designed to reduce polypharmacy among Medicaid recipients. This service selectively focused on patients who were high users of prescription drugs and had potential drug therapy problems (PDTPs).

OBJECTIVES

This article reports the results of the first phase of the North Carolina Polypharmacy Initiative. The goals of this study were to determine: (1) the frequency with which recommendations were made by pharmacists in response to targeted profile alerts aimed at high-risk patients, (2) the frequency and type of drug therapy changes, and (3) the impact on drug-related quality and costs.

METHODS

A before-after design was used. Nursing home patient profiles with PDTP alerts for specific drugs and drug categories were provided to consultant pharmacists. Targeted patients had received 218 prescription fills within 90 days. Pharmacists were compensated for performing and documenting targeted drug regimen reviews. Interventions of pharmacists and results after physician consultation are described, and cost impacts of changes in drug therapy are reported. Monetary results are shown in year-2002 U.S. dollars.

RESULTS

Prescription profiles were generated from Medicaid claims data and sent to consultant pharmacists for 9208 patients in 253 nursing homes. Pharmacists returned 7548 (82%) of all profiles sent to them. After excluding 1204 patients (13%) who were discharged or deceased, 6344 patients (69%) remained for analysis. At baseline, patients used a mean (SD) of 9.52 prescriptions per month, costing the North Carolina Medicaid program a mean (SD) of 502.96 dollars (309.70). A mean of 1.58 recommendations were offered to prescribers. After physician consultation, > or =1 recommendation was implemented for 72% of patients with a change recommendation, 68% of whom experienced a switch to a lower-cost drug. Drug cost savings were a mean of 30.33 dollars/patient per month. Cost savings from 1 month alone covered the compensation paid to pharmacists for consultation efforts.

CONCLUSIONS

This supplemental program of medication reviews for targeted nursing home patients resulted in a reduction of polypharmacy and was beneficial based solely on drug cost savings.

Provision of pharmaceutical care services in North Carolina: a 1999 survey

OBJECTIVE

To describe the extent of and factors associated with the provision of pharmaceutical care services (PCS) and value-added pharmaceutical services (PS) by pharmacists in North Carolina, the physical changes made in pharmacies to accommodate these services, the nature and extent of prior consent or collaborative practice arrangements between North Carolina pharmacists and prescribers, and the frequency of reimbursement for PCS.

DESIGN

Descriptive study based on a mail survey.

PARTICIPANTS

Pharmacist-managers at each of the 2,048 licensed pharmacy sites in North Carolina; a list of licensed pharmacies provided by the North Carolina Board of Pharmacy was used as the sampling frame.

MAIN OUTCOME MEASURES

Pharmacists' reports of PCS and pharmacy demographics.

RESULTS

Response rate was 40%. More than 30% of respondents provided PCS at their site, although only 20% met our more stringent definition of PCS (i.e., ensuring appropriate pharmacotherapy, ensuring patient understanding and adherence, and monitoring and reporting patient outcomes). Services were more frequently offered by university-affiliated (35%) or independent (32%) pharmacies. The median number of patients receiving PCS across all sites was 10 per week. Diabetes was the most common health problem for which PCS were offered. Three variables-weekly prescription volume (positive correlation); number of staff pharmacists with advanced training, specifically fellowship training; and medical clinic/health maintenance organization setting-were significant predictors of the numbers of patients provided PCS. Independent community pharmacies were most likely to have private counseling areas and to bill for and receive payment for PCS.

CONCLUSION

In North Carolina, a substantial number of pharmacists provided PCS in 1999 or planned to do so in the near future. However, the number of patients receiving PCS was relatively low. Practice setting, pharmacist education level, and prescription volume were weakly predictive of the number of patients receiving PCS. Pharmacists commonly used prior consent arrangements with physicians in their practices, but primarily to facilitate generic substitution. Relatively few pharmacists billed for PS or PCS.

Hypothetical versus real willingness to pay in the health care sector: results from a field experiment

We conducted a field experiment comparing hypothetical and real purchase decisions for a pharmacist provided asthma management program among 172 subjects with asthma. Subjects received either a dichotomous choice contingent valuation question or were given the opportunity to actually enroll in the program. Three different prices were used: US$ 15, 40, and 80. In the hypothetical group, 38% of subjects said that they would purchase the good at the stated price, but only 12% of subjects in the real group purchased the good (p = 0.000). We cannot, however, reject the null hypothesis that "definitely sure" hypothetical yes responses, as identified in a follow-up question, correspond to real yes responses. We conclude that the dichotomous choice contingent valuation method overestimates willingness to pay, but that it may be possible to correct for this overestimation by sorting out "definitely sure" yes responses.

Frequency and characteristics of cognitive services provided in response to a financial incentive

OBJECTIVE

To determine the effects of a financial incentive on the number and types of cognitive services (CS) provided by community pharmacies to Medicaid recipients in the State of Washington.

DESIGN

Prospective randomized trial. CS were reported using a problem-intervention-result coding system over a 20-month period.

SETTING AND SUBJECTS

Pharmacists practicing in 110 study (financial incentive) and 90 control community pharmacies.

RESULTS

Study pharmacists documented an average of 1.59 CS interventions per 100 prescriptions over a 20-month period, significantly more than controls, who documented an average of 0.67 interventions (P < .05) per 100 prescriptions. One-half (48.4%) of all CS were for patient-related problems, 32.6% were for drug-related problems, 17.6% were for prescription-related problems, and 1.4% were for other problems that did not involve drug therapy. A change in drug therapy occurred as a result of 28% of all CS documented in this demonstration. Changes were rarely (2.4%) due to generic or therapeutic substitution and almost always (90%) followed communication with the prescriber. The average self-reported time to perform CS was 7.5 minutes; 75% of interventions were < or = 6 minutes. Considerable differences existed between study and control groups in the types of problems identified, intervention activities performed, and results of interventions.

CONCLUSION

A financial incentive was associated with significantly more, and different types of, CS performed by pharmacists.

Influence of a financial incentive on cognitive services: CARE project design/implementation

OBJECTIVE

To describe the design and methods of the Washington State Cognitive Activities and Reimbursement Effectiveness (CARE) Project, a demonstration project in which community pharmacies were paid for cognitive services (CS) provided to Medicaid patients, its evaluation objectives, and the extent to which implementation objectives were achieved.

DESIGN

Prospective randomized trial. Community pharmacies were allocated to a documentation-and-payment group, documentation-only group, and "silent" control group. CS were reported using a problem-intervention-result classification system embedded within a pseudo-National Drug Code format. Management strategies included use of area coordinators.

SETTING

Pharmacies serving ambulatory Medicaid patients in the state of Washington, excluding staff-model health maintenance organization pharmacies and pharmacies predominantly serving long-term-care residents.

PARTICIPANTS

200 community pharmacies (110 treatment; 90 control), with another 100 randomly selected pharmacies as a silent control group.

INTERVENTIONS

A modest monthly stipend. The treatment group billed Medicaid for each documented CS associated with a drug therapy-related problem. All participants received training in documentation methods. A unique coding scheme allowed documentation of CS within the constraints of the Medicaid program. Data edit checks and feedback were used to ensure data quality and completeness. Area coordinators were used to facilitate training, compliance with study procedures, and participation.

MAIN OUTCOME MEASURES

Participation rates, documentation rates, coding scheme revision, data quality and completeness rates, and effectiveness of area coordinators.

RESULTS

Pharmacists documented more than 20,240 CS records. Approximately 89% of records passed edit checks, and 94% did so after modification. Nearly 83% could be linked to a paid drug or CS claim. The coding system was sufficient, with minor modifications, to account for all interventions documented. Area coordinators did not function as expected.

CONCLUSION

A system for documentation and payment of pharmacists' CS to Medicaid recipients was implemented successfully and relatively easily in community pharmacies.

Characteristics of pharmacies and pharmacists associated with the provision of cognitive services in the community setting

OBJECTIVE

To determine the influence of payment, pharmacy setting characteristics, pharmacist demographics, practice setting, and attitudinal characteristics on whether cognitive services (CS) were performed by pharmacists, and the volume of CS performed.

DESIGN

Prospective randomized trial. Community pharmacies were randomized to a documentation-and-payment group (study group) and a documentation-only group (control). Participating pharmacies and pharmacists were surveyed by mail, and responses were linked to a documented CS database.

SETTING

Community pharmacies serving ambulatory Medicaid patients in the state of Washington, excluding health maintenance organization pharmacies and pharmacies predominantly serving long-term care residents.

PARTICIPANTS

200 community pharmacies and their pharmacists (110 study, 90 control) participating in the Washington State Cognitive Activities and Reimbursement Effectiveness (CARE) Project.

INTERVENTION

Payment for CS. All participants documented CS. Study group pharmacies billed Medicaid for services performed in identifying and resolving drug therapy-related problems.

MAIN OUTCOME MEASURE

Documentation of CS.

RESULTS

Documentation of CS was more likely if the pharmacist was an owner or manager, if documentation was not perceived as burdensome, and if the pharmacy had a low ratio of prescription to total sales. Higher documentation rates were associated with study group status, lower pharmacy prescription volume as a percentage of total sales, and a higher percentage of prescriptions billed to Medicaid. Among pharmacists, two setting variables--medical center location and rural location--were associated with higher documentation rates.

CONCLUSION

Performance of CS was strongly affected by payment and other situational factors, including practice setting and volume of prescriptions dispensed. Pharmacies and pharmacists were also more likely to perform CS if the target patient population represented a relatively large percentage of that pharmacy's patient clientele.

Pharmacists as agents of change for rational drug therapy

We analyze what is known and unknown about the contribution of the pharmacist as patient educator, physician consultant, and agent to affect patient outcomes in ambulatory settings. The need for pharmacist services is discussed, as are the theoretical underpinnings and quality of the scientific evidence to support their efficacy. The analysis is conducted in the context of a shift in pharmacists' roles from product to patient orientation as well as recent U.S. legislation mandating enhanced pharmacists' roles via drug utilization review for all Medicaid patients. We conclude with a research and action agenda, calling for stronger research designs in evaluating pharmacists' interventions. The shifting paradigm in the pharmacy profession, coupled with the implementation of the Omnibus Budget Reconciliation Act of 1990, provide unique opportunities for rigorous evaluations of pharmacists as agents of change for rational drug therapy.