PHARMACIST AND FAMILY MEDICINE COLLABORATION FOR PRE-VISIT PLANNING FOR SHARED PATIENTS RECEIVING CHRONIC CARE MANAGEMENT SERVICES

AUTHORS

James D. Hoehns, PharmD, BCPS, FCCP1,2

Matthew Witry, PharmD, PhD1

Madison McDonald, PharmD3,4

Sarah Kadura, PharmD5,6

Emily O’Brien, PharmD, BCACP6,7

Robert Nichols, PharmD, BCPS4

Joe Greenwood, PharmD, MBA4

Jamie Snyder, LPN6,9

Raemi Chavez, PharmD, MPH1,8

Adam Froyum-Roise, MD, MPH, FAAFP6,9

The authors declare no potential conflicts of interest

1 University of Iowa College of Pharmacy, Iowa City, IA, USA

2 MercyOne Northeast Iowa Family Medicine Residency & Research, Waterloo, IA, USA

3 AdventHealth East Orlando, Orlando, FL, USA

4 Greenwood Pharmacy, Waterloo, IA, USA

5 University of Iowa Hospital & Clinics, Iowa City, IA, USA

6 Northeast Iowa Family Medicine Residency, Waterloo, IA, USA

7 UCHealth-Northern Colorado, Fort Collins, CO, USA

8 Hy-Vee Pharmacy (1825), Vinton, IA, USA

9 UnityPoint Central Iowa Residency Program-Waterloo Track, Prairie Parkway Residency Clinic, Cedar Falls, IA, USA

Abstract

Background: Pre-visit planning entails completing necessary tasks prior to clinic appointments. Community pharmacists (CPs) have unique knowledge about patients’ medication use but do not routinely provide drug therapy reviews before clinic visits. Objectives: (1) Create and implement a business partnership between a CP and family medicine clinic (FMC) for CP provision of pre-visit medication reviews, and (2) describe the billing experience for shared patients in the FMC chronic care management (CCM) program. Methods: A prospective 8-month study in one community pharmacy and FMC in Iowa. Eligible patients were enrolled in the clinic CCM program and received their prescriptions at the community pharmacy. CPs were granted access to the clinic electronic health record (EHR), performed medication reviews, and recorded drug therapy recommendations (DTRs) in the clinic EHR. FMC physicians reviewed CP DTRs before the patient encounter. Time tracking software in the EHR recorded CP and FMC time performing CCM services. CCM revenue was prorated between parties. FMC physicians completed a survey about their experience. Results: Overall, there were 129 CP reviews performed for 95 patients. These reviews resulted in 169 DTRs and 76% were accepted by the physician. There were 71 CCM claims billed and CCM revenue was $3596 ($1796 FMC, $1800 CP). More than 90% of physicians (N = 11) indicated they reviewed CP DTRs before the patient encounter and agreed they were helpful to their practice. Conclusion: CPs completed pre-visit medication reviews and made accepted medication therapy recommendations.

CCM billing provided a mechanism for CPs to receive revenue for their services.

Keywords pre-visit planning, chronic care management, patient-centered medical home, community pharmacy

Background

Medication optimization has been defined as “a patient-centered, collaborative approach to managing medication therapy that is applied consistently and holistically across care settings to improve patient care and reduce overall costs”.1 There are compelling financial and quality of care reasons for improving the use of medications. It has been estimated that the annual cost in the United States of drug-related morbidity and mortality resulting from nonoptimized medication therapy in 2016 exceeded $528 billion and resulted in 276,000 deaths.2 The patient-centered medical home (PCMH) model of primary care has significant potential to improve health care value and patient care. A core principle of the PCMH is a team-based approach to care.3,4 Pre-visit planning is a key component of PCMH guidelines.5

Pre-visit planning is a proactive approach to organizing care that shifts tasks like lab tests, identifying “care gaps” such as immunizations or prevention screenings, pre-visit checklists, and medication review before the appointment so the care team members can focus on patient needs and engaging in patient-centered decision-making during the appointment.6-8 With pre-visit planning, providers have the information they need at the time of the visit to provide evidence-based care.

Community pharmacists (CP) are well suited to complete pre-visit medication reviews for primary care-based teams. In addition to their professional drug therapy knowledge, they have familiarity with the patient, medication adherence, prescription costs and copays. However, there are several barriers to CP providing such services. These include a lack of structures to facilitate patient information sharing, inadequate access to patient electronic health records, and a lack of adequate compensation methods for care team members.9

Chronic care management (CCM) is a reimbursable service for Medicare beneficiaries in the community setting which includes comprehensive care management and other activities.10 While only Qualified Health Professionals (QHPs) (ie, physicians, nurse practitioners, physician assistants) are eligible to bill for CCM services, pharmacists can create business partnerships with QHPs to provide CCM services. We and others have reported on successful pharmacist provision of CCM care.11-13 Pre-visit planning activities can be billed as chronic care management within CCM arrangements.

There have been a small number of reports about pharmacists contrib- uting to pre-visit planning including prior to appointments for diabetes and hypertension management.14,15 More work is needed to describe financially sustainable solutions to integrating pharmacists, including those working in the community setting, into the pre-visit planning process. The objectives of this study were to describe the drug therapy recommendations (DTRs) and billing experience of a community pharmacist-provided pre-visit planning service for a shared cohort of patients enrolled in the clinic CCM program.

Methods

This was a single group prospective pilot intervention. Previsit medication reviews were performed by community pharmacists over 8 months from 8/1/2020 to 3/31/2021 at Greenwood Pharmacy. Greenwood Pharmacy is an independently owned community pharmacy in Waterloo, Iowa that serves 7100 patients. Northeast Iowa Family Practice Center (NEIFPC) is a family medicine clinic also located in Waterloo, Iowa. NEIFPC has 1332 Medicare patients enrolled in the CCM program; 153 of the 1332 patients have Greenwood Pharmacy as their primary pharmacy. This study was approved by the NEIFPC ethics committee as a quality improvement project in April 2020.

NEIFPC uses a web-based EHR for clinic documentation which also has supplemental software to aid in CCM provision and billing. This system has been utilized by the practice since 2017. NEIFPC granted EHR access to Greenwood Pharmacists and provided training. NEIFPC created an agreement with Greenwood Pharmacy to be an independent contractor to provide pre-visit medication reviews (a CCM-related service) for select NEIFPC patients. This allowed community pharmacists to review medical charts and document pre-visit drug therapy recommendations.

Patient Eligibility and Recruitment

To be eligible for the study, patients had to be enrolled in the CCM service at NEIFPC, received their maintenance prescriptions from Greenwood Pharmacy, and had Medicare as their primary insurance. The clinic provided a list of shared patients to Greenwood Pharmacy and eligible patients (N = 153) were informed by the clinic via a mailed letter that the community pharmacist would be providing the consented CCM service related to pre-visit medication reviews.

Pharmacist Intervention to Support Pre-Visit Planning

Each week, NEIFPC supplied Greenwood Pharmacy with a list (via the clinic EHR) of enrolled CCM patients who had a physician visit for chronic disease or adult health maintenance scheduled in clinic the following week. CPs reviewed pharmacy records and the clinic EHR for each patient. The CPs noted any discrepancies between the medication list in the clinic EHR and pharmacy dispensing records. CPs reviewed the pharmacy prescription profile for interactions, fill history, and adherence. Patients were contacted by telephone to resolve discrepancies; however, most reviews were conducted via record review. The CP would make edits in the clinic HER medication list as necessary.

Within 7 days before the patient’s scheduled clinic visit, the CPs were required to document their interventions in the clinic EHR with the use of a templated note for pre-visit planning. The template contained the following elements: a list of maintenance medications with “proportion of days covered” (PDC) < 80%, medication costs (total monthly co-pays for maintenance medications, total monthly adjudicated ingredient costs, and cost savings opportunities), pharmacist’s recommendations, drug therapy problem categories,16 and whether or not they agreed with each pharmacist recommendation. This templated pharmacist note was located in the “exam prep” section of the EHR; it was the first documentation the physician would view when they opened the patient encounter in the EHR. The CP also recorded the same information in the patient’s care plan in the community pharmacy’s electronic record system.

CCM Billing

All CCM service documentation, including for pre-visit planning was recorded to the second through the EHR supplemental software’s time tracking capabilities. This level of tracking allowed delineation of the exact time contributions from each site. NEIFPC was responsible for submitting CCM billing to Medicare. Centers for Medicare & Medicaid Services (CMS) pays for care coordination services to Medicare beneficiaries who reside in the community setting that meet the following requirements: two or more chronic conditions expected to be at least 12 months, chronic conditions placed the patient at significant risk of death, decompensation, or decline, and a comprehensive care plan is established, implemented, revised, or monitored. CMS regulations state that billing should be done if the eligible patient was provided at least 20 minutes of non-face-to-face CCM time within a calendar month. When patients exceed the 20-minute limit, where no complex medical decision was made or there is no change in the care plan, a 99 490 code is billed. If it exceeded 60 minutes where a moderate to high complexity medical decision shall be made regarding the patient’s care plan, a 99 487 code is billed. Finally, the 99 489 code is billed when a 30-minute time interval is added after the initial 60 minutes.17

Medicare reimbursed NEIFPC for the CCM services, and then the clinic paid the community pharmacy a prorated amount of the monthly CCM services provided by the community pharmacists. Prorated amounts for each party were determined according to the number of CCM billing minutes each party contributed for a subject each month. There was also a processing fee from the software vendor for each billing code claim processed. Key components of the pre-visit planning service are outlined in Figure 1.

Data Collection

Demographic information obtained from the clinic EHR for study participants included age, sex category, common chronic diseases (from the problem list in the EHR), smoking status, and insurance. From the EHR we collected patient attendance at the scheduled clinic visit, and pre-visit pharmacist recommendations. From the pharmacy records, we recorded chronic medications, monthly prescription copays, and adjudicated prescription ingredient costs.

For the study, the final, completed physician EHR encounter note with only the pharmacist recommendation was reviewed for analysis. Also, extracted was clinic physicians documentation of which of the CP recommendations they agreed with. These were verified by one of the study pharmacists (SK). Monthly data of CCM billing was extracted from the billing software linked to the clinic EHR.

Lastly, an anonymous 3-item electronic survey was sent to all 17 physicians and resident physicians involved with the pre-visit planning pilot. They were asked if they had seen a pharmacist-previsit planning note and responded with their 5-point agreement (strongly agree, agree, neutral, disagree, strongly disagree) to whether they had enough time to read the notes, and how helpful the notes were.

Data Analysis

Patient characteristics and patient visit data, were analyzed descriptively. Drug therapy problems identified were coded by one of the study authors (SK) and counted. Drug therapy recommendations and acceptance rates were calculated. The survey was analyzed descriptively. All data were entered into IBM SPSS (version 27) for analysis.

Results

Among the 153 patients we recruited, 8 patients withdrew after receiving the informational letter. Of the 145 eligible subjects, 95 had at least one pre-visit pharmacist review during the 8-month study period. The mean age of the patients (N = 95) was 76.8 years; 57.9% were female (Table 1). The mean (SD) number of prescription medications was 6.3 (3.4).

Interventions Provided

Community pharmacists completed a total of 129 pre-visit medication reviews for 95 patients (Table 2). Community pharmacist pre-visit recommendations resulted in 169 patient-specific drug therapy recommendations and 76% of recommendations were accepted by the physician. Many of the drug therapy recommendations were for care gaps related to immunizations. The five most common types of pharmacist drug therapy recommendations related to: needs additional therapy (N = 70), low medication adherence (N = 28), potential adverse event (N = 22), unnecessary drug (N = 7), and dose too high (N = 7).

Economic Evaluation

There were 71 CCM billing claims submitted for the 95 patients during the study period (Table 3). Total net (with subtraction of software vendor processing fee) CCM revenue was $3596. Proration of revenue based upon the time each party contributed to each claim resulted in approximately an equal revenue allocation between the community pharmacy ($1800) and the clinic ($1796). The type and frequency of CPT codes billed were: 99 490 (N = 61), G2058 (N = 13), 99 487 (N = 10), 99 489 (N = 5), and 99 439 (N = 3). Some patients had more than one CPT code billed per claim.

For comparison, we also calculated what each party would have received from CCM billing if they would have provided the service independently of each other, rather than with our shared CCM service. Independently, pharmacy and clinic revenue would have been $1269 and $1300, respectively. With shared CCM billing the actual realized amounts were $1800 (pharmacy) and $1796 (clinic). This represents increased CCM revenue of 42% (pharmacy) and 38% (clinic) for each party due to combining CCM activities with more claim thresholds being achieved.

Physician Experience

There were 12 (9 resident physicians, and 3 faculty physicians) surveys completed out of 17 invitations (70.1% response). Eleven of 12 affirmed they had reviewed a community pharmacist note in the EHR during the project time period. All respondents “agreed” or “strongly agreed” that they had adequate time to review the pharmacist recommendations in the prep note section prior to seeing the patient. Ten of 11 physicians “agreed” or “strongly agreed” that the pharmacist recommendations were helpful to their practice.

Discussion

In this evaluation of a community pharmacist-provided previsit planning process, pharmacists provided pre-visit planning workups for 95 patients over 8 months with most patients either having 1 or 2 pre-visit notes during the study period. Pharmacists identified more than one drug therapy problem per patient which most often focused on vaccination needs (e.g., herpes zoster, pneumococcal, and influenza). Most recommendations were accepted by the physician. The service also was found to be a source of revenue for both the pharmacy and clinic, with pharmacists receiving $1800 in reimbursement for their pre-visit planning contributions.

Pharmacists were able to reach 66% (95 of 145) of shared patients for this effort, and this was likely aided by several facilitators. First, the community pharmacists were engaged by the clinic as part of the clinic “care team.” Key project structural elements included granting CPs access to the clinic EHR, creation of a pre-visit template to record the CP recommendations, advance sharing of scheduled patient clinic visits, and creation of a business agreement for CCM billing. Second, CPs had monthly in-person meetings with clinic pharmacists for the first five months to discuss any process issues or review difficult patient cases. The CPs and clinic pharmacists formed a partnership to improve patient care. Guiding statements have been created to facilitate collaboration between CPs and clinic-based pharmacists to improve medication optimization.18

Like with other CCM and pharmacist workup interventions, community pharmacists were able to routinely identify drug therapy problems, and propose actionable recommendations with a high rate acknowledged and accepted by the physician.14,19,20 The templated CP note was located in the prep-note section of the clinic EHR which includes all previsit planning documentation. The clinic physicians’ response to the project was favorable. Greater than 90% of clinic physician respondents noted they reviewed pharmacist recommendations, had adequate time to review such before the patient visit, and found them helpful to their practice which supports the feasibility and acceptability of the CP pre-visit planning intervention.

Pre-visit medication review is only one part of all previsit planning components,6,7 and pharmacists are well suited to perform this task. Pharmacists commonly perform pre-visit planning tasks related to medication-use optimization. While the term pre-visit planning may not be used, pharmacists routinely perform such activities in various practice settings. For example, pediatric ambulatory clinical pharmacists in one health system used telemedicine during the COVID-19 pandemic to perform pre-visit planning and other patient care services.21 Pharmacists have also contributed to pre-visit planning to improve pneumococcal vaccination rates.22 It has been observed that most descriptions and evaluations of pre-visit planning are highly varied and it is difficult to ascertain which aspects of the process are most beneficial.23

Lastly, this pre-visit planning collaboration was found to be a financially viable approach for community pharmacists to partner with local clinics to provide chronic care medication management services to shared patients. For patients enrolled in a CCM program, CCM service and billing is one method for clinician and pharmacist compensation for pre-visit planning. As of January 2022, over 64.2 million people are enrolled in Medicare,24 and it is estimated that two-thirds of Medicare patients have two or more chronic conditions,25 which is a CCM requirement. Pharmacists who want to provide CCM services in collaboration with a qualified health professional must either be directly employed, independently contracted, or leased by that QHP or their practice to meet billing requirements.10 We utilized an independent contractor agreement for the pharmacists to provide previsit medication reviews. Based upon our previous experience with shared CCM billing11 which evaluated time contributions within each individual billing claim, we simplified revenue sharing with this current project and prorated CCM revenue according to total CCM minutes provided by each party for each submitted claim. The overall revenue result was the same. Shared CCM service revenue was greater for each entity (clinic $1796 and pharmacy $1800) compared to what each would have billed independently ($1300 and $1269, respectively).

This feasibility study has several limitations. It involved a single group design with no comparison group, and clinical endpoints were not evaluated. The frequency of pre-visit reviews by the CP was not structured; it was entirely dependent on the frequency of physician-patient visits as determined by the physician. As a result, only one-third of subjects had more than one pre-visit review by the pharmacist during the 8-month study period. Direct pharmacist-patient interaction was limited in our project. CPs did not contact patients via telephone routinely; direct patient contact was limited to clarifications with medication reconciliation. Most of the pharmacist review was done via record review. To measure physician acceptance of the pharmacist recommendations we recorded (yes/no) if the physician denoted agreement for each recommendation in the templated pharmacist prep-note. We did not investigate prospectively what physician action was taken following their noting acceptance of the pharmacist recommendation. It is possible some “accepted recommendations” are yet to be enacted, were modified, or not enacted. The greatest project challenge was ensuring the CPs had adequate allotted time to complete the previsit medication reviews. However, the study pharmacy employs multiple pharmacists, offers other clinically oriented services, and already had a strong working relationship with the partnering family medicine clinic. Pharmacies with other staffing models and with less experience providing clinical services likely would have different experiences. Providing the CPs access to the clinic EHR was instrumental for our project success.

Conclusion

This project successfully incorporated CPs within the ambulatory care team to provide medication reviews as part of pre-visit planning services. CPs identified drug therapy problems, made appropriate drug therapy recommendations, and family medicine physicians found the reviews helpful to their practice. Providing this service to patients enrolled in the clinic CCM program provided a mechanism for CPs to receive payment for their service. Proration of shared CCM revenue between pharmacy and clinic resulted in increased CCM revenue for each entity beyond what they would have realized independently.

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