Current trends in outpatient pharmacy services and billing

Assessing Pharmacists' Views and Barriers to Providing and Billing for Pharmacist-Provided Health Care Services

Background: The role of Idaho and Alaska pharmacists in providing health care services has steadily broadened over recent years. With many new pharmacist-provided health care service possibilities, this study assessed the impact of these advancements on community pharmacies. Objective: The objective of this study was to identify current pharmacist-provided health care services and pharmacist-perceived barriers to providing and billing for these services in Idaho and Alaska community pharmacies. Methods: A questionnaire was developed focusing on 2 areas: providing services and billing for services. Pharmacy students on experiential rotations administered the questionnaires to pharmacists at their rotation sites. Pharmacists at community pharmacy practice sites in Idaho and Alaska completed the questionnaire in an interview format conducted by students. Likert-type scale data were analyzed using descriptive statistics. Because the study did not include a comparator group, no power calculation was conducted. All open-response answers were analyzed independently by 2 researchers and discrepancies in coding open-ended questions were resolved by discussion with a group of 4 researchers. Results: Most pharmacists reported that they already provide non-dispensing services, desired to implement new services, and had confidence in their team's ability to handle new services. Time and resources were the most cited barriers to providing new services; compensation, company support, and education were the most cited barriers to billing for services. Conclusions: Community pharmacists already provide non-dispensing services and many are looking to provide more services, but barriers of time, resources, compensation, company support, and education will need to be overcome to move forward.

Opioid use disorder: Calling pharmacists to action for better preconception and pregnancy care

Opioid use disorder (OUD) in women of child-bearing potential is problematic in the United States. This has resulted in increasing risk for adverse maternal outcomes, neonatal abstinence syndrome, fetal and neonatal harm, prolonged hospitalizations, and increased health care costs. Pharmacists in all practice settings have opportunities to provide preconception and pregnancy care to prevent and manage OUD. Given pharmacists' scope of practice and expertise, key roles include assessing patients for OUD; mitigating exposure; educating patients regarding potential infant effects; recommending contraceptive methods and counseling on proper use; ensuring safe breastfeeding with concurrent medications; and linking patients to needed services. Through patient counseling, medication management, and harm reduction interventions, pharmacists can work to combat this public health crisis. To encourage increased uptake of pharmacists into these roles, more needs to be done to reimburse pharmacists for these important services and quantify their impact on patient and population health outcomes.

Standardized documentation workflow within an electronic health record to track pharmacists' interventions in pediatric ambulatory care clinics

OBJECTIVES

To describe the implementation of a standardized documentation workflow within an electronic health record (EHR) and to track pharmacists' interventions in pediatric ambulatory care clinics.

SETTING

Ambulatory care clinics and a transitions-of-care (TOC) service within a pediatric health care system in central Ohio.

PRACTICE DESCRIPTION

Ambulatory clinical pharmacists work as integrated members of the health care team in 7 pediatric ambulatory care clinics and a TOC service to achieve the best medication-related outcomes for patients.

PRACTICE INNOVATION

A standardized documentation workflow was established among ambulatory clinical pharmacists to document the interventions made in their practice settings with the use of a tool in the EHR. A weekly report from the EHR was run by a technician to gather intervention data, identify reimbursable opportunities, and document and bill via a separate Internet-based medication therapy management platform.

EVALUATION

The success of the new documentation workflow was evaluated, and continuous feedback was gathered from the pharmacists and the billing technician. Updates were provided to the ambulatory clinical pharmacist at monthly staff meetings and workflow changes implemented as needed.

RESULTS

A total of 5210 interventions were documented by the pharmacists in various intervention categories. The 3 most common intervention categories included patient and medication education (1765), medication reconciliations (1170), and compliance assessments (795).

CONCLUSION

A standardized documentation workflow allowed for consistent tracking of interventions across ambulatory care clinics and a TOC service. Key elements to the successful implementation of this new documentation workflow included proper training and continuous feedback to the ambulatory clinical pharmacists, assistance from a billing technician, and consistent documentation by the ambulatory clinical pharmacists.

Impact of pharmacy collaborating services in an outpatient clinic on improving adverse drug reactions in outpatient cancer chemotherapy

BACKGROUND

Collaboration between pharmacists, doctors, and nurses in outpatient treatment is beneficial; however, such services are limited in Japan due to the lack of a healthcare reimbursement fee for outpatient pharmacy services at outpatient clinic.

OBJECTIVE

We evaluated the impact of a service in which clinical pharmacists collaborated with an oncologist at an outpatient clinic in the treatment of adverse drug reactions in outpatient cancer chemotherapy.

METHODS

We performed a retrospective cohort study using patients' medical records and treatment diaries. Subjects were patients who received outpatient chemotherapy via a clinical pharmacist collaboration service provided by six outpatient pharmacists and an oncologist at an outpatient clinic between June and August 2016.

RESULTS

During the study period, the total number of outpatient services was 2508, with 2055 (81%) related to chemotherapy. The six outpatient pharmacists provided interventions to 498 of the 2055 cases (24%). Of the 498 interventions, 103 (20%), in addition to oncologist's prescription, were suggested treatments for adverse drug reactions due to cancer chemotherapy. Oncologists approved a total of 82 prescription suggestions from pharmacists (79%) to 63 patients. Fifty-seven percent (n = 47) of the adverse drug reactions were improved following the pharmacists' suggested prescriptions.

CONCLUSIONS

This is the first study to clarify the benefits of outpatient pharmacy services in which pharmacists collaborate with oncologists at an outpatient clinic for the management of adverse drug reactions in cancer patients in Japan.

Patients' willingness to pay for cognitive pharmacist services in community pharmacies

AIM

To determine the general population willingness to pay for cognitive pharmacist service in community pharmacy, describe the behavior of participants regarding health care issues, and evaluate correlation between participants' sociodemographic characteristics or attitudes and their willingness to pay.

METHODS

A questionnaire-based survey was conducted among general population visiting community pharmacies. The participants were asked about receiving cognitive pharmacist services to identify and resolve potential medication therapy problems after the initiation of a new medicine to optimize health outcomes of the patients. A univariate and multivariate analysis were used to analyze associations between different variables and willingness to pay for pharmacy service.

RESULTS

Of 444 respondents, 167 (38%) reported that they were willing to pay for a medication management service provided in the community pharmacy. Univariate analysis showed significant association between the willingness to pay for pharmacist-provided service and respondents' socio-demographic factors, health-related characteristics, and behavior, dilemmas, or need for certain pharmacist-provided service. The logistic regression model was statistically significant (χ2=4.599, P<0.001).

CONCLUSIONS

The respondents expressed their willingness to pay for cognitive pharmacist services, which has not been fully recognized within the health care system. In future, pharmacists should focus on practical implementation of the service and models of funding.

Assessment of reimbursement in a community hospital-based pharmacist-managed outpatient transition clinic

PURPOSE

The assessment of reimbursement for and time spent on patient visits in a newly implemented, outpatient pharmacist-managed transition clinic (TC) was studied.

METHODS

A retrospective chart review was conducted on clinic visits that occurred during January 1 to December 31, 2015. Patients who had at least one TC visit during the study period were included. Any visit with no response from insurance by March 31, 2016, was excluded. Services provided by the TC were billed using a facility fee billing model. The following data were collected: number of visits, time length of individual visits, billed amount, level of service, type of insurance, and amount reimbursed (from primary insurance, secondary insurance, and total amount). Data were analyzed using descriptive statistics.

RESULTS

One hundred eight patients were eligible for inclusion in the study, with a total of 306 eligible visits. Each patient had a mean of 2.82 visits. The mean ± S.D. time spent per visit was 55 minutes. Visits were billed at level 2 (2%), level 3 (36%), and level 4 (62%). Two hundred seventy-two visits (89%) were partially or completely reimbursed by insurance, whereas 34 visits (11%) provided no reimbursement. The mean ± S.D. reimbursement was $99 ± $51.88 per visit.

CONCLUSION

A pharmacist-managed TC service based in a community hospital achieved a positive return on investment through insurer reimbursement over a 12-month period.

Development of Collaborative Drug Therapy Management and Clinical Pharmacy Services in an Outpatient Psychiatric Clinic

Collaborative drug therapy management (CDTM) is a written agreement that allows a pharmacist to initiate, modify, or continue pharmacotherapies under a physician's scope of practice. While available literature pertaining to cardiometabolic and respiratory CDTM services is growing, publications are sparse in psychiatry, particularly outside Veterans Health Administration medical centers. A descriptive study was undertaken to demonstrate how a board-certified psychiatric pharmacist would begin organizing a protocol for clinical pharmacy services at an outpatient, community treatment center for mental health and substance abuse disorders. The primary CDTM service proposed was metabolic monitoring for atypical antipsychotics, though profile reviews for medication reconciliation, drug level monitoring, and insurance coverage were also considered. Potential obstacles identified and worked through during the project included pharmacist-prescriber relationships, federal and state law requirements, pharmacy informatics development, and pharmacy services billing. Discussions with both administrative and medical stakeholders across the health system were essential in helping a pharmacist detail professional qualifications, justify positive impacts on patient outcomes, and navigate these legal and financial issues. The systematic approach arrived at through the study addresses current literature gaps concerning how pharmacists can evolve their practices from ancillary to collaborative design by nature within psychiatric settings.

Challenges to integrating pharmacogenetic testing into medication therapy management

Some have proposed the integration of pharmacogenetic (PGx) testing into medication therapy management (MTM) to enable further refinement of treatments to reduce risk of adverse responses and improve efficacy. PGx testing involves the analysis of genetic variants associated with therapeutic or adverse response and may be useful in enhancing the ability to identify ineffective and/or harmful drugs or drug combinations. This "enhanced" MTM might also reduce patient concerns about side effects and increase confidence that the medication is effective, addressing 2 key factors that impact patient adherence: concern and necessity. However, the feasibility and effectiveness of the integration of PGx testing into MTM in clinical practice has not yet been determined. In this commentary, we consider some of the challenges to the integration and delivery of PGx testing in MTM services.

Psychiatric Services

Deinstitutionalization in the 1960s shifted the care of the mentally ill from state-funded institutions to community settings. Unfortunately, funding to support the treatment needs of this population has continued to be minimized, and countless individuals have not received much needed care. This has resulted in a large increase in mentally ill patients surfacing in jails, homeless shelters, and emergency departments. Subsequently, the federal government has begun to prioritize funding to address the mental health needs of our communities. Pharmacists are in a unique position to influence treatment outcomes for patients with mental illnesses, and the current state of health reform provides avenues for the pharmacist to become an essential part of the health care delivery team in numerous ambulatory care clinical settings. The challenges with adherence, medical and psychiatric comorbidities, polypharmacy with psychotropics, potential for life-threatening adverse effects, and the ever-present need for patient education are but a few reasons why pharmacists can be utilized to provide Medication Therapy Management services for these patients.

Preparing to Provide MTM Services

Medication Therapy Management (MTM) has been a way for pharmacist to enhance their position as an integral member of the health care team as the need for improved clinical and economic outcomes in relation to the US health care system became apparent. MTM Certificate training programs are provided by numerous organizations. Collaboration Practice Agreements (CPA) are gaining significance as the role of the pharmacist is expanding in the care of patients as part of a multidisciplinary health care team. One major hurdle that many pharmacists are faced with is receiving reimbursement for the services provided. The Medicare Modernization Act of 2003 recognized that pharmacists play an important role in the management of patient care and that pharmacists bring an expertise and knowledge that will help to identify and resolve patient medication therapy problems.

Perceived successes and challenges of clinical pharmacist practitioners in North Carolina

OBJECTIVES

To describe the successes and challenges reported by current (active) and formerly practicing (inactive) CPPs and to determine the reasons why inactive CPPs discontinued advanced practice.

METHODS

A sampling frame, consisting of all active and inactive CPPs, was obtained from the North Carolina Boards of Medicine and Pharmacy. An electronic survey was sent to 84 active and 32 inactive CPPs. Respondents were queried regarding qualifications, experience, and practice characteristics, perceived successes, and perceived challenges.

RESULTS

54 active and 22 inactive CPPs responded. Among active CPPs, 28 (51.9%) reported improved patient care outcomes and 27 (50.0%) reported an expanded scope of practice. Regarding challenges, 30 (55.6%) identified billing for services and 19 (35.2%) noted reimbursement through third parties. Among inactive CPPs, 14 (63.6%) experienced improved patient care outcomes and 11 (50.0%) said their licensure created a practice model for learners. Billing (54.5%) and reimbursement (31.8%) were the top challenges experienced by inactive CPPs. A total of 12 inactive CPPs (54.5%) discontinued CPP licensure because it was not a requirement of their current position. Three (13.6%) discontinued because of insurmountable challenges that made it difficult to continue practice.

CONCLUSION

Although CPPs held a perception of improved patient care outcomes, billing for services and obtaining reimbursement were reported as the most prevalent challenges and may have played a major role in CPPs becoming inactive.

HIV medication therapy management services in community pharmacies

OBJECTIVES

To present a rationale and a proposed structure to support pharmacist-delivered medication therapy management (MTM) for human immunodeficiency virus (HIV ) disease and to outline challenges to implementing and sustaining the service.

DATA SOURCES

Professional literature.

SUMMARY

Historically, the effect of pharmacy services for HIV-infected persons has been demonstrated in inpatient and clinic-based settings. Developing similar programs adapted for community pharmacists could be a model of care to improve patient adherence to antiretroviral therapy and retention in care. Initiation of antiretroviral therapy and regular monitoring of CD4+ cell count, HIV RNA viral load, adverse drug events, and adherence form the backbone of successful medical management of HIV infection. Support for these services can be provided to HIV-infected patients through pharmacist-managed HIV MTM programs in community pharmacy settings in collaboration with primary providers and other health care professionals.

CONCLUSION

Community pharmacists can help meet the growing need for HIV care through provision of MTM services. Although resources have been developed, including the general MTM framework, challenges of adequate training, education, and support of community pharmacists need to be addressed in order for HIV MTM to be a successful model.