Retrospective financial analysis of medication therapy management services from the pharmacy's perspective

ObjectiveTo determine the net financial gain or loss for medication therapy management (MTM) services provided to patients by an independent community pharmacy during 16 months of operation.DesignRetrospective study.SettingIndependent community pharmacy in Iowa City, IA, from September 1, 2006, to December 31, 2007.PatientsPatients receiving MTM services during the specified period who had proper documentation of reimbursement for the services.InterventionMTM services were provided to the patient and documented by the pharmacist or student pharmacist.Main outcome measureNet financial gains or losses for providing MTM services. Sensitivity analyses included costs that might be incurred under various conditions of operation.Results103 initial and 88 follow-up MTM visits were conducted during a 16-month time period. The total cost for these services to the pharmacy was $11,191.72. Total revenue from these services was $11,195.00; therefore, the pharmacy experienced a net financial gain of $3.28. Sensitivity analyses were conducted, revealing the net gain/loss to the pharmacy if a student pharmacist was used and the net gain/loss if the pharmacist needed extra training to provide the services. Using a student pharmacist resulted in a net gain of $6,308.48, while extra training for the pharmacist resulted in a net loss of $1,602.72.ConclusionThe MTM service programs showed a positive financial gain after 16 months of operation, which should encourage pharmacists to incorporate these services into their practice.     

Billing for pharmacists' cognitive services in physicians' offices: Multiple methods of reimbursement

ObjectivesTo evaluate the charges and reimbursement for pharmacist services using multiple methods of billing and determine the number of patients that must be managed by a pharmacist to cover the cost of salary and fringe benefits.SettingLarge teaching ambulatory clinic in North Carolina.Main outcome measuresAnnual charges and reimbursement, patient no-show rate, clinic capacity, number of patients seen monthly and annually, and number of patients that must be seen to pay for a pharmacist's salary and benefits.ResultsA total of 6,930 patient encounters were documented during the study period. Four different clinics were managed by the pharmacists, including anticoagulation, pharmacotherapy, osteoporosis, and wellness clinics. “Incident to” level 1 billing was used for the anticoagulation and pharmacotherapy clinics, whereas level 4 codes were used for the osteoporosis clinic. The wellness clinic utilized a negotiated fee-for-service model. Mean annual charges were $65,022, and the mean reimbursement rate was 47%. The mean charge and collection per encounter were $41 and $19, respectively. Eleven encounters per day were necessary to generate enough charges to pay for the cost of the pharmacist. Considering actual reimbursement rates, the number of patient encounters necessary increased to 24 per day. “What if” sensitivity analysis indicated that billing at the level of service provided instead of level 1 decreased the number of patients needed to be seen daily. Billing a level 4 visit necessitated that five patients would need to be seen daily to generate adequate charges. Taking into account the 47% reimbursement rate, 10 level 4 encounters per day were necessary to generate appropriate reimbursement to pay for the pharmacist.ConclusionsUnique opportunities for pharmacists to provide direct patient care in the ambulatory setting continue to develop. Use of a combination of billing methods resulted in sustainable reimbursement. The ability to bill at the level of service provided instead of a level 1 visit would decrease the number of patients needed to pay for a pharmacist.     

Examining the association between the “My Pharmacist” model and the service quality of community pharmacies

BackgroundIn Japan, patients can freely choose medical facilities. Many visit different medical facilities for different diseases, and for convenience, often utilize the pharmacies neighboring these facilities. Accordingly, a “My Pharmacy” model was recommended, in which patients select a single pharmacy using their own judgement to receive proper medication services. A “My Pharmacist” model, in which the pharmacist is constantly involved in the treatment of a patient, was also proposed. However, patients’ evaluations of pharmacist/pharmacy services under these models have not been investigated.ObjectiveTo examine how a patient's constant involvement with the same pharmacist and pharmacy is associated with their evaluation of the quality of pharmacy services.MethodsA cross-sectional survey using a self-administered questionnaire was conducted among patients who used pharmacies periodically. Patients evaluated the pharmacist/pharmacy services and were classified into 4 groups (“My Pharmacy/My Pharmacist,” “My Pharmacy/Multiple Pharmacists,” “Multiple Pharmacies/My Pharmacist,” and “Multiple Pharmacies/Multiple Pharmacists”) according to the form of their usage of pharmacies and pharmacists. An intergroup comparison was then performed and correlations within each group analyzed.ResultsData from 3,492 individuals using 147 pharmacies were analyzed. “My Pharmacy” users had significantly higher scores than did “Multiple Pharmacies” users on patient experience of proper medication services (e.g., identifying duplicate medication) (p < 0.001). “My Pharmacy/My Pharmacist” users scored higher than the other three groups on four evaluation factors, including “pharmacy/pharmacist's interpersonal services” (“sharing and utilizing patient information,” “enhanced health support function,” and “consideration towards patients”), “patient satisfaction with the pharmacy,” “placing more emphasis on quality of interaction with pharmacist than on waiting time,” and “attitude when visiting healthcare facilities” (all p < 0.001).ConclusionThe findings indicate that highly tailored, in-person services provided by “My Pharmacists” are associated with not only with the degree of patients’ overall satisfaction, but also their evaluation of “the quality of pharmacist services.”     

Reimbursement for pharmacist-provided health care services: A multistate review

Objective(s)To better understand individual state approaches to reimbursement for pharmacist-provided health care services, we sought to (1) review existing statutes and regulations on pharmacist reimbursement from select states (Alaska, California, Idaho, New Mexico, Oregon, and Washington) and (2) suggest approaches to changing state statutes and regulations to allow for reimbursement.MethodsWe reviewed approaches taken by 4 states that currently allow for direct reimbursement of pharmacist-provided health services and 2 states that are in process. Washington requires commercial health plans to credential and privilege pharmacists as health care providers deeming reimbursement and coverage disparities among providers as compensation discrimination.ResultsOregon does not require insurers to provide payment but requires pharmacists to contract and credential with each individual insurer, without the mandate for payment. In California, pharmacists receive 85% of the established fee schedule that physicians receive for equivalent services, and payment is issued to the pharmacy, not the individual pharmacist. California and New Mexico both only allow specified pharmacies or pharmacists to bill (advanced credentials or a tiered licensing model).In Alaska, scope and payor regulations align to allow compensation for covered services; however, insurance credentialing portals are not configured to enroll pharmacists as billing providers. In May 2020, pharmacists were added as nonphysician ordering, referring, and prescribing providers in the Idaho Medicaid basic plan regulations, and licensed pharmacists with national provider identification numbers were auto-enrolled.ConclusionThe states we reviewed took different approaches on the basis of their established statutes and regulations (pharmacy, public and private insurance), resulting in variability in compensated services and reimbursement. An intentional alignment of statutes, regulations, and scope of practice is required to support reimbursement and sustainability of services.     

Characteristics of studies of pharmacist services registered in ClinicalTrials.gov

ObjectiveTo examine the characteristics of studies of pharmacist services registered in ClinicalTrials.gov.DesignCross-sectional study.Setting and participantsClinicalTrials.gov and MEDLINE databases were searched to identify studies of pharmacist services. Registration information was obtained from the Aggregate Analysis of ClinicalTrials.gov (AACT) database. Studies were excluded if the ClinicalTrials.gov submission date was after December 31, 2018; there were no U.S. study sites; pharmacist services were not mentioned; or pharmacist involvement was limited to medication dispensing, randomization, or measuring study outcomes.Outcome measuresCharacteristics of registered studies from ClinicalTrials.gov and AACT data, categories of pharmacist services, changes in registration and focus of pharmacist services over time, and relationships between funding source and result availability and between the focus of pharmacist services and types of outcomes and types of pharmacist interventions.ResultsOverall 401 studies were identified for initial review, with 151 included for detailed review. Pharmacist services were the only intervention in 68 studies (45.0%), a separate intervention in 14 (9.3%), and part of a combined intervention in 40 (26.5%). In 29 studies (19.2%), pharmacist services were not the focus. Registered studies primarily were interventional, randomized, and open-label; included behavioral or “other” interventions; were conducted in the outpatient setting; and were sponsored by “other” sources. The most common health conditions were hypertension and diabetes. Only 29 of the 104 completed studies (27.9%) posted results. Clinical outcomes were the most common primary (80; 53.0%) and secondary outcomes (66; 58.9%). Medication management (69; 45.7%) and patient education or counseling (88; 58.3%) were the most common types of pharmacist interventions.ConclusionThis analysis of ClinicalTrials.gov identified 151 studies of pharmacist services in the United States registered through the end of 2018. Given the breadth of the pharmacy services literature, there is room for improvement in the registration of these types of studies.     

Cost-utility analysis of offering a novel remunerated community pharmacist consultation service on influenza vaccination for seniors in Ontario,Canada

BackgroundDespite the availability of free and accessible influenza vaccine to all Ontarians, uptake has remained suboptimal. Although reasons to not receive the vaccine vary widely, health care provider recommendations remain the most effective strategy to positively influence vaccination decisions.ObjectivesThis study aimed to predict the relative quality of life, costs, and cost-effectiveness of introducing a remunerated community pharmacist consultation service on influenza vaccination for Ontarians aged ≥ 65 years.MethodsA cost-utility analysis was performed from a third-party public payer perspective over 1 year. The delivery of consultation services by community pharmacists on influenza vaccination, billable at CAD $15 was compared with current standard practices (absence of remunerated consultations). Model inputs were derived primarily from existing literature. The impact of parameter uncertainties was assessed through deterministic and probabilistic sensitivity analyses.ResultsThe provision of influenza vaccine consultation services was predicted to prevent 2407 cases of mild influenza and 3 influenza-related deaths at an additional cost of CAD $2.03 per person over current practices. The incremental costs per quality-adjusted life-year (QALY) gained for the enhanced care strategy compared with standard care was CAD $2087. The interpretation of the base-case result was found to be robust across all sensitivity analyses. The projected additional costs of implementing pharmacist consultations in Ontario was estimated at CAD $1.15 million per year, and the anticipated benefits included a gain of 507 QALY per year.ConclusionPharmacist-delivered consultation services on influenza vaccination are cost-effective and lead to improved clinical outcomes for Ontario seniors. Introduction of such services offers a promising strategy to address challenges related to poor vaccine uptake in this group.     

Pharmacist-led medication reviews in pre-dialysis and dialysis patients

BackgroundPre-dialysis and dialysis patients are at risk for drug related problems (DRPs) due to a high incidence of comorbidities. Pharmacist-led medication reviews might reduce the number of DRPs.ObjectivesThe aim of this study was to evaluate pharmacist-led medication reviews in pre-dialysis and dialysis patients by determining the number and type of DRPs, nephrologist acceptance of pharmacist interventions and time investment.MethodsFrom September 2017 until December 2018, pharmacist-led medication reviews were performed on pre-dialysis and dialysis patients. DRPs (medication discrepancies, prescribing issues related to drug and dose selection, drug use problems) were identified using the pharmacists’ expert opinion and the STOPP/START criteria. Number and type of accepted pharmacist interventions, sustainability of interventions after at least 1 month and time investment were determined. Practical barriers in the process were appraised.ResultsOne-hundred twenty five patients were reviewed: 37 pre-dialysis and 88 dialysis patients. In 100 (80%) patients 277 medication discrepancies were identified of which 224 (81%) were accepted by the nephrologist. Pharmacists suggested 422 interventions concerning drug or dose selection for 115 patients; 106 interventions were accepted by the nephrologist, which resulted in 60 patients having medication changed. Ninety percent of those changes remained implemented on follow-up after at least 1 month. In 46 (37%) patients, the clinical pharmacist detected DRPs concerning the drug use process and performed patient counseling. The average time investment was 85 min per patient for the clinical pharmacist and 15 min for the nephrologist. Besides time investment, unclear responsibility for medication management due to multiple prescribers was an important barrier in the process and the main reason for nephrologists to reject pharmacist interventions.ConclusionPharmacist-led medication reviews in pre-dialysis and dialysis patients led to medication changes in half of the patients. However, efficiency should be improved before adopting pharmacist-led medication reviews into clinical practice.     

The “affected” pharmacist and the “business as usual” pharmacist: Exploring the experiences of pharmacists during COVID-19 through cluster analysis

BackgroundThe global coronavirus disease 2019 (COVID-19) pandemic has necessitated considerable changes in the delivery of pharmacy services, with pharmacists experiencing increasing demands and a high rate of burnout. The ability to categorize pharmacists based on their burnout risk and associated factors could be used to tailor burnout interventions.ObjectiveThis study aimed to identify subgroups (profiles) of pharmacists and use these profiles to describe interventions tailored to improve pharmacist’s well-being.MethodsA survey was disseminated to pharmacists working in Australia during April and June 2020. The survey measured demographics, burnout, and psychosocial factors associated with working during COVID-19. A two-step cluster analysis was used to categorize pharmacists based on burnout and other variables.ResultsA total of 647 survey responses contained data that were used for analysis. Participants were mostly female (75.7%) and working full time (65.2%). The final cluster analysis yielded an acceptable two-cluster model describing 2 very different pharmacist experiences, using 10 variables. Cluster 2 (representing 53.1% of participants) describes the “affected” pharmacist, who has a high degree of burnout, works in community pharmacy, experiences incivility, is less likely to report sufficient precautionary measures in their workplace, and has had an increase in workload and overtime. In contrast, cluster 1 (representing 46.9% of participants) describes the profile of a “business as usual” hospital pharmacist with the opposite experiences.Interventions focused on the “affected” pharmacist such as financial support to employ specialized staff and equitable access to personal protective equipment should be available to community pharmacists, to reduce the risk to these frontline workers.ConclusionThe use of cluster analysis has identified 2 distinct profiles of pharmacists working during COVID-19. The “affected” pharmacist warrants targeted interventions to address the high burnout experienced in this group.     

Cost benefit analysis of clinical pharmacist interventions in medical intensive care unit in Palestine medical complex: Prospective interventional study

BackgroundClinical pharmacy services in the critical health care settings have expanded dramatically.Study problem.Clinical pharmacy services have limited implementation in Palestine. Many intensive care units (ICUs) patients do not get the intended beneficial effects of their treatment due to treatment related problems and their consequent cost burden.AimTo evaluate the impact of the clinical pharmacist interventions on costs of care and safety of patient by assessing treatment related problems among medical ICUs patients in Palestine.MethodologyA prospective interventional study was conducted at medical ICU of the major public hospital in Ramallah city over a 4-month period (between September and December 2020). Patients were randomly assigned to either an intervention or a control group (With / without clinical pharmacist involvement). Treatment related problems were identified in both study groups by the clinical pharmacist, but interventions were only provided to the intervention group. The total economic benefit included both cost savings from intervention and cost avoidance from preventable adverse drug events (ADEs) resulted from CP interventions. The primary outcomes with the clinical pharmacist interventions were net benefit and benefit to cost ratio, which were calculated using previously published methodologies and adjusted to the Palestinian settings. The analysis of CP interventions acceptance by physicians was performed.ResultsDuring the 4-month study period, the 117 patients admitted to the ICU were included into the analysis; 66 patients in the intervention group and 51 in the control group. The interventions made by a clinical pharmacist resulted in direct cost saving of NIS8,990.05 ($2799.63) and cost avoidance of NIS22,087.5 ($ 6878.37). Translated into a net savings of NIS188.35 ($58.65) per intervention and NIS470 ($146.36) per patient. Comparison of benefits (NIS31,077.55) ($9678.00) and costs (NIS19,043.928) ($5930.55) indicate a net economic benefit to the institution of (NIS 12,033.623) ($3747.44) and a benefit cost ratio of 1.63.ConclusionIntegrating a clinical pharmacist in the ICU team was investment that resulted in benefits in term of cost saving and cost avoidance.     

Impact on confidence and practice: How the ADAPT online patient care skills program made a difference for pharmacists

BackgroundThe ADAPT “ADapting pharmacists' skills and Approaches to maximize Patients' drug Therapy effectiveness” online education program was developed to enable pharmacists to overcome a lack of confidence in patient care and collaborative skills, enabling successful adoption of expanded scope of pharmacist practice.ObjectivesThis study examined responses of ADAPT participants, to determine if acquisition of knowledge, skill, and confidence is retained and translated into adoption of expanded scope of practice and billable services, perceived improvement in quality of patient care, and increased professional satisfaction.MethodsA sequential exploratory mixed methods approach was used for this study.ResultsFifty-four surveys were completed and 13 interviews were conducted. Greater than 86% agreed or strongly agreed that their confidence in their ability to perform ADAPT skills had improved. Billing for services varied based on province. Four themes emerged through the interview process: confidence, change, impact and barriers/facilitators.ConclusionsRespondents described confidence in their ability to use ADAPT skills to make changes in personal practice activities, and this appeared to lead to taking on new roles that provided both professional satisfaction and improved patient care and professional relations. However, some barriers remained in providing or billing for certain practice activities.     

Pharmacists' communication with Spanish-speaking patients: A review of the literature to establish an agenda for future research

BackgroundSpanish-speaking people represent more than 12% of the total population in the United States and are poised to become the largest minority group in the United States by 2015. Although researchers have studied pharmacist-patient communication for approximately 30 years, little emphasis has been placed on the interactions between pharmacists and Spanish-speaking patients.ObjectivesThe objectives of this review are (1) to describe empirical studies on Spanish-speaking patient/pharmacist communication examined relative to patient factors, pharmacist factors, and environmental factors that may influence Spanish-speaking patient/pharmacist communication and (2) to integrate medical and nursing literature to generate a research agenda for future study in this area.MethodsWe compiled articles from a systematic review of (1) CINAHL, International Pharmacy Abstracts, PubMed, and Web of Knowledge databases using “Hispanic limited English proficiency,” “Latino limited English proficiency,” “language-assistance services,” “Spanish-speaking patients,” “Latino patients,” “Spanish-speaking health literacy,” “pharmacy health literacy,” “patient-provider communication,” “pharmacy language barriers,” and (2) bibliographies of selected articles.ResultsThis search generated 1174 articles, 7 of which met the inclusion criteria. We categorized the results into 4 topic areas: “Spanish-speaking patient literacy,” “pharmacists knowledge of/proficiency in the Spanish language,” “pharmacy resources to overcome language barriers,” and “pharmacists' attitudes toward communicating with Spanish-speaking patients.”ConclusionsThese studies provide a macroscopic look at the linguistic services offered in pharmacies, gaps in services, and their subsequent impact on pharmacists and patients. Future research should investigate Spanish-speaking patients' literacy issues, pharmacy staff language skills, factors that influence pharmacists' counseling, and language-assistance programs for pharmacists and patients. Furthermore, these studies need to be conducted in large Hispanic/Latino populated areas where positive service models are likely to be present. Addressing these issues will provide pharmacists and pharmacies with information to overcome language barriers and provide Spanish-speaking patients with quality care.     

Evaluation of pharmacist-provided medication therapy management services in an oncology ambulatory setting

ObjectivesTo determine the effect of formal medication therapy management (MTM) services on pharmacist workload, as well as to describe the population receiving MTM, describe the services provided, and determine the reimbursement rate for billed MTM services.Data sourcesMTM Current Procedural Terminology (CPT) code claims, electronic medical records, and pharmacist MTM logs.Data synthesisA retrospective review of all MTM charges from January 1, 2010, to March 31, 2010, was performed. Data collected included location of the MTM visit, age, gender, insurance, primary malignancy, comorbidities, home medications, time to complete and document the MTM visit, and rate of reimbursement.ResultsIn the 3-month period, 239 MTM visits were completed. It took pharmacists a median of 20 minutes (range 15–127) of face-to-face time and 18 minutes (5–90) for documentation per visit. To date, no claims for MTM have been rejected, and reimbursement rates range from 47% to 79% depending on the insurance provider.ConclusionsMTM in the ambulatory clinic is feasible despite the increase in pharmacist workload from documenting and billing. The increased visibility of clinical pharmacy services justifies the extra time required for formal MTM.     

Exploring barriers and facilitators to pharmacist-provided diabetes self-management education and support

BackgroundPharmacists have the necessary clinical experience and medication knowledge to effectively provide diabetes self-management education and support (DSMES); however, barriers exist to DSMES implementation by community pharmacists.ObjectiveThe aim of this study is to explore DSMES from the community pharmacists’ perspectives, identify barriers and facilitators to pharmacist DSMES implementation, and guide development of pharmacist-provided DSMES programs in Idaho.MethodsImplementation climate, the theoretical framework for this project, is focused on how community pharmacists in Idaho perceive they will be supported by patients, health care providers, and insurers in DSMES implementation. Pharmacist investigators with qualitative research experience conducted semistructured interviews with 6 licensed community pharmacists from Idaho via Zoom between March and June 2020. Recordings were transcribed verbatim and analyzed using HyperRESEARCH 4.5.1. Themes, patterns, and dominant concepts that emerged from respondents’ about DSMES were explored, labeled, and categorized into modifiable and nonmodifiable barriers and facilitators. This study was granted expedited approval by the Idaho State University Investigational Review Board.ResultsRelevant themes included current scope of practice, barriers, and facilitators. Subthemes related to the current scope of pharmacy practice included unclear roles and responsibilities and legislative constraints to practice. For barriers, subthemes included cost of set-up, billing and coding education, and the sustainability of services based on current reimbursement models. For facilitators, subthemes included the need for additional collaborations (external and internal), technology access, and trained pharmacy staff.ConclusionPharmacists are underutilized health care providers, capable of providing DSMES services if provided the necessary resources. This work identifies barriers and facilitators to pharmacist-led DSMES that can be considered by others when implementing DSMES or other disease management services.