Leveraging MACRA for Pharmacists

"I highly recommend this webinar to pharmacists who try to establish a contract with a physician or a medical group to assist the medical office in providing CCM/AWV/TCM... services to patients.  This webinar not only summarizes the keys points about MACRA, it also points out the specific performance measures where the pharmacists can have an impact.  More importantly, it highlights how the pharmacists can use these measures to help relieve the physicians' pain points, generate extra incomes for their practice, and ultimately convince the physicians to collaborate with the pharmacists. I actually watched this webinar twice because it was packed with so much good information!" - D.N., RPh, PharmD

Click here to register for our brand new Advanced MACRA training!

As pharmacists, we know that the healthcare landscape is currently experiencing a major evolution, so a seismic shift, if you will. This shift was created by the new legislation from the Centers for Medicare and Medicaid Services.

You may have heard this legislation referred to a "pay-for-performance" or "value-based payment reform".

But what EXACTLY does that mean for pharmacists?

On October 14th, 2016, CMS released this final rule of the Medicare Access in Children's Health Insurance Program, the CHIP Reauthorization Act of 2015, which we refer to as MACRA. These reimbursement models shift us from the volume-based fee-for-service system to what we have now, the value-based payment system. This rule dramatically changes how physicians are compensated for their services under Medicare.

To give you an idea of the payment adjustments and how big of an impact this is having for physicians, it will dramatically change payment adjustments for physicians' offices.

In 2019, payments are going to be increased or decreased by up to 4% based on the data submitted during the 2017 reporting year. In 2018, that adjustment will increase to 5%. By 2022, we're looking at around a 9% payment adjustment.

For the first year of MIPS reporting, the providers (which includes physicians, physician assistants, nurse practitioners, clinical nurse specialist, certified registered nurse, anesthetist, dentist, podiatrist, optometrist, and chiropractors) can choose the amount of 2017 data to submit to MIPS for the 2019 payment adjustment.

These payment adjustments may be in the hundreds of thousands of dollars, and they could be positive or negative reimbursements for a practice.

Adjustments could equal hundreds of thousands of dollars in difference between the reimbursement for services already received that the clinic has to pay back, or alternatively receiving additionally as a bonus incentive. 

"There's still about $500 million set aside for exceptional performers and up to the 10% positive payment adjustment to be earned."

Understanding this model is a huge avenue of opportunity for pharmacists and for you when building your enhanced pharmacy services.

Click here to register for the Webinar.

While MACRA doesn't directly affect most pharmacists today, this value-based payment system is definitely here to stay, and we are seeing more and more private payers look towards this type of model.

It is important to be familiar with these quality-based payment models so that you can tailor your enhanced services to meet or exceed these quality measures.

Additionally, many of the measures providers are now required to report on can be impacted by stuff you're already doing, enhanced clinical services like medication therapy management and medication synchronizations programs.

Pharmacists can demonstrate to providers how enhanced pharmacy services can impact patients’ therapeutic outcomes and quality.

MACRA legislation created two value-based payment tracks, and these are described as MIPS, which stands for the Merit-based Incentive Payment Systems, and APMs, the Advanced Alternative Payment Models. 

Quality Payment Program = Merit-based Incentive Payment Systems + Advanced Alternative Payment Models

These two tracks together are collectively referred to as the Quality Payment Program. Of the two tracks of MACRA, MIPS is going to have the largest impact on independent physicians’ offices. So, what I want to focus on today is helping you help providers enhance their performance in these quality metrics.

MIPS actually measures providers’ performance in these four weighted categories, and we'll go though each of them.

First is quality, 60% for 2017. Then advancing care information 25%. And finally improvement activities, 15%. These will balance out in subsequent years, but for 2018, they expect to use these same percentages proposed for 2018. The cost resource use is 0% for 2017 and 2018. However, it is expected to increase in subsequent years.

Pharmacists, as the most accessible healthcare provider, can focus on increasing patients’ access to care, decreasing the overall number of hospitalization and re-admissions, and reducing total net healthcare spend.

That, in my opinion, makes pharmacists perfectly poised to offer assistance to providers as Quality Coordinators.

I. Quality

In 2017, the Quality measure category is going to hold the most weight in MIPS at 60%.

The Quality category will gradually lose weight as the other categories increase over time. The Quality category heavily weighted because it is a holdover from the Physician Quality Reporting System in which the providers used to choose nine measures to report on. 

The change requires providers to choose 6 quality measures from a list of over 271 subcategories. These six measures can be any metric they choose.

However, there are a few requirements. They do have to have one high-priority measure, which would be an outcome measurement and one cross-cutting measure which would be applicable to all provider specialties. The four others can be a mixture between the two.

Because of its weight, providers’ focus will likely weigh heavily on the Quality measure category for the MIPS reporting.

II. Advancing Care Information  

The second MIPS category that holds the most weight, the Advancing Care Information category. 

This category makes up about 25% of MIPS and expands on the meaningful use program. Pharmacists can leverage the physicians’ need to meet these measures in this category and request access to the providers’ electronic health records.

This will significantly improve patient care and quality. Pharmacists with access to the EHR either directly or through the sharing of electronic care plans can help save the healthcare system and the patients’ money.

Increasingly, pharmacists will be able to submit e-Care Plans ourselves through new technology.

Also, the expanding of meaningful use category means the inclusion of the ability for providers to send electronic prescriptions, to allow the patients access to their electronic medical records, to help them protect their electronic health information, and also share information with others involved in patient care.

This is a great opportunity for pharmacists to be able to leverage the technology and the EHR side of meeting those measures and collaborating with physicians through the advancing care information category.

III. Cost/Resource Use

This category, which is at 0% for 2017 and 2018, will increase in subsequent years.

It does not require active reporting by physicians, instead, it's pulled from Medicare claims data that is submitted throughout the year. Part of the goal of this measure is to encourage healthcare professionals to help beneficiaries understand their benefits and make medical decisions accordingly.

Sounds a lot like what we do in open enrollment already, doesn't it?

IV. Improvement Activities

The fourth MIPS Category pharmacists can focus on is Improvement Activities.

There are over 90 improvement activities defined for MIPS.

Improvement Activities is the ONLY Category in MACRA in which pharmacists are SPECIFICALLY mentioned in the entire document.

Some major subcategories of Improvement Activities are expanding practice access, care coordination, beneficiary engagement, patient safety and practice assessment, and emergency response and preparedness.

On the Leveraging MACRA for Pharmacists Webinar, we'll discuss 3 improvement activities that pharmacists can have a real impact on as well as some action steps for you to use when building your pharmacy programs to support those providers.

Click here to access this free advanced training!

Improvement Activities for Pharmacists

• The first Improvement Activity we'll talk about in the Leveraging MACRA WEBINAR is implementation of medication management practice improvements. The focus of this activity would be integrating pharmacists into care teams and designating clinic times for these pharmacists.

The pharmacist's role would be to conduct periodic structured medication reviews, reconcile and coordinate medications across transitions of care, identify and resolve drug utilization issues, adjust strength dosage form or suggest therapeutic substitutions as needed.

In the e-Course at the Pharmapreneur Academy, I discuss the details of using certain billing codes (such as incident-to billing codes or annual wellness visit billing codes) to see patients under the direct supervision of the provider in their clinic. 

Interested? Book a free call with me to see if the Pharmapreneur Academy is right for you!

• Improvement activity #2 is proactively manage chronic and preventative care for patients. The focus of is to utilize evidence-based protocols to guide treatment for chronic conditions and provide chronic care management services.

The pharmacists’ role would be to individualize care plans for the patients and educate them on their medication use.

A clinical retail consultant pharmacist can help enroll patients in medication synchronization programs, screen them for additional comorbid conditions, and perform routine medication reconciliations.

To bill for these services, a consultant pharmacist under a collaborative practice agreement acting as an auxiliary staff member can work under the general supervision of a physician. This means you could work in an offsite role as a consultant pharmacist and bill for chronic care management codes (CCM) under a physician's NPI.

Learn more about CCM codes and building a CPA with a collaborative physician in Lesson 7 & 8 of the e-Course at the PharmapreneurAcademy.com

• In improvement activity #3, communication and care coordination, the focus of this would be to address the sharing of information and coordination of clinical and preventative services among patients, caregivers, and multiple healthcare professionals.

Your role as a consultant pharmacist would be to identify and document the patient care activities using the chronic care management or transitional care management codes, document clinical and preventative services, such as immunizations, and notify the prescriber so that the patient's record is up to date. 

To bill for these services, you could use any of the ones we've talked about in your wellness visits, incident-to billing visits, chronic care management, or even transitional care management codes.

A pharmacist can offer the initial contact of the two-part transitional care management code service under a physician's collaborative practice agreement without being in the direct supervision under the physician.

More information about TCM in Lesson 8 of the e-Course at the Pharmapreneur Academy.

Key Takeaways:

• Understanding how quality is being measured in the physician space gives you insight into the prescriber's motivating factors and allows for constructive collaborative relationships.
• Developing a robust collaborative practice agreement to offer these enhanced services in a way that aligns with the goals of both the Merit-based Incentive Payment System, MIPS, and the Advanced Alternative Payment Models, APMs, could prove a mutually beneficial relationship for providers and pharmacists, as well as improving patient outcomes.
• As the most accessible healthcare provider, we can impact population health through point of care testing and by improving patient outcomes through chronic care and transitional care management programs.
• Retail Pharmacists have ability to help improve medication adherence through implementations of programs such as medication synchronization, delivery services, and adherence packaging.
• Pharmacists actively searching for new revenue-generating opportunities should seek out providers who support pharmacy involvement in clinical service activities. 

Action Steps:

1. Attend the Leveraging MACRA for Pharmacists Webinar to learn more and then reach out to your local high-volume prescribers and request an appointment to discuss these changes and their challenges. 
2. Share your pharmacy's commitment in supporting them in this new performance-based reimbursement landscape.
3. If you're ready to make a serious investment in creating and implementing these services, consider joining the Pharmapreneur Academy and work with pharmacists who are moving forward with building consulting-based business models.
4. And join our Pharmapreneur Community Newsletter for more information and trainings like this!

ABOUT THE AUTHOR:

Blair Green Thielemier, PharmD is an independent consultant pharmacist living in Arkansas with her husband and daughter. Her latest project was the first-ever virtual pharmacy conference, the Elevate Pharmacy Virtual Summit. She is also the founder of Pharmapreneur Academy, an online e-Course and Community where she guides pharmacist-entrepreneurs through the process and barriers of building a pharmacy consulting business. She is the author of How to Build a Pharmacy Consulting Business, a contributing author for Pharmacy Times and guest host on the Pharmacy Podcast. More information about Dr. Thielemier can be found on her website.