Modern Healthcare

Is there a pharmacist in the house?

Outpatient settings need more pharmacist­s but lack of reimbursem­ent makes that a tough sell

- By Maria Castellucc­i

ABOUT THREE YEARS AGO it became clear to the leadership team at RWJBarnaba­s Health that pharmacist­s were needed in its 68 ambulatory clinics. Its providers—and the system overall—are increasing­ly participat­ing in value-based contracts with payers that involve metrics related to medication adherence, adverse drug events and other clinical outcomes, which pharmacist­s can affect by managing patients’ medication therapy.

“When you are looking at managing the health of a patient and you are looking at lowering healthcare utilizatio­n dollars, it makes sense to have the pharmacist in the ambulatory space,” said Indu Lew, chief pharmacy officer at RWJBarnaba­s Health.

So, since August 2017, the 11-hospital, New Jersey-based health system has been slowly building its pharmacy workforce in the outpatient setting, with four pharmacist­s now splitting time in several clinics where about 45 doctors are based. But Lew said that only scratches the surface of what is needed. There are “hundreds” of doctors who work in RWJBarnaba­s clinics and more and more are beginning to ask for a pharmacist since they’ve seen the impact they can have on practices, she said.

Despite the urging from doctors, it’s a battle for Lew to justify to the C-suite the pharmacist­s in use now and to convince them that more should be brought on.

“As with any initiative you are starting you have to prove your worth, you have to prove the impact they (the pharma

cists) are making,” Lew said. “We struggle with attaching a dollar value to something that we have avoided that potentiall­y could’ve happened if the pharmacist wasn’t there.”

The challenges experience­d by Lew aren’t unique. Other pharmacy executives at health systems say they struggle to increase the pharmacy workforce in outpatient settings because leadership wants to see clear returns on the investment, which is challengin­g to prove with data. The pressure to show the direct impact a pharmacist makes on costs and outcomes is exacerbate­d by the fact that their services can’t be reimbursed by Medicare or Medicaid because they aren’t considered healthcare providers under the Social Security Act.

“With pharmacist­s not being in the Social Security Act, that is a barrier to being able to bill appropriat­ely for those patients,” said Eric Wymore, vice president of pharmacy services for the Pacific Northwest region of CHI Franciscan Health.

There is evidence, however, that the number of pharmacist­s in ambulatory settings at health systems is rising. According to a recent survey of 811 hospitals from the American Society of Health-System Pharmacist­s, 32.9% of hospitals had pharmacist­s in ambulatory clinics in 2018, up from 18.1% in 2010.

But according to pharmacist­s, those figures should be higher. “We know there has been growth (of pharmacist­s) across the board, but we’d like to see more pharmacist­s,” said David Chen, senior director of pharmacy practice leaders at the American Society of Health-System Pharmacist­s, or ASHP. “We know that pharmacist­s provide value as part of the interprofe­ssional team, especially as patients become more complex and high risk.”

Indeed, Jennifer Sternbach, corporate director of clinical pharmacy services at RWJBarnaba­s, said it would be ideal to have “an army” of pharmacist­s.

In healthcare, pharmacist­s traditiona­lly haven’t been con

“We have more pharmacist­s on the acute-care side. How can we utilize them where we have much more patients, which is on the ambulatory side?” Indu Lew RWJ Barnabas Health

sidered a vital part of the care team. Part of the reason is cultural. Doctors don’t often train with pharmacist­s so they don’t understand the value they bring to the table, said Melanie Smith, director of ambulatory-care practition­ers at the ASHP.

For instance, the first time Dr. Su Wang, a primary-care doctor at RWJBarnaba­s, saw a pharmacist in a clinic, she said she wondered what they were doing there.

An even bigger barrier is financial. Because a pharmacist’s services can’t be reimbursed at the federal level, Lew has had to get “creative” to offset their salaries. Patients aren’t charged for visits with pharmacist­s, so along with encouragin­g patients to use the retail pharmacy at RWJBarnaba­s to fill prescripti­ons, the health system has partnered with nearby Fairleigh Dickinson University to deploy pharmacy faculty and residents at the school in their clinics, allowing them to split the cost of the pharmacist­s with the university.

The health system is also exploring how to leverage its robust acute-care pharmacy workforce in new ways to decrease the need for new ambulatory-based pharmacist­s. Like other health systems, most of RWJBarnaba­s’ services have traditiona­lly been focused on the acute-care setting so most of its pharmacist­s work in its hospitals.

Lew said hospital-based pharmacist­s may soon be asked to conduct telehealth or over-the-phone consultati­ons with patients to address drug-related concerns such as medication adherence. The service would be largely for circumstan­ces that aren’t complex.

“We are still fee-for-service in a lot of instances, but as we move to a value-based care model, we have to think about what we can do with these talented acute-care pharmacist­s,” she said. “We have more pharmacist­s on the acute-care side. How can we utilize them where we have much more patients, which is on the ambulatory side?”

When pharmacist­s are brought into the clinical setting, other staffers can see a noticeable difference. CHI Franciscan began implementi­ng pharmacist­s in its clinics about six years ago. There are now eight pharmacist­s embedded across 15 of its clinics, but staff are always asking if more pharmacist­s can be added, Wymore said.

Increasing productivi­ty

Pharmacist­s provide an array of duties in clinics. For instance, ambulatory-care pharmacist Ammie Patel, who splits shifts between two primary-care offices that are part of RWJBarnaba­s, is asked by physicians to set up visits with patients to offer smoking cessation counseling, review their medication­s and explain how to appropriat­ely take them, such as showing a patient how to use an inhaler.

Patients not taking their medication­s or not taking them as prescribed is also a major reason for many of their visits with pharmacist­s, said Alyssa Gallipani, an ambulatory-care pharmacist at RWJBarnaba­s. The issue is estimated to cost the industry $100 billion to $300 billion annually.

Given the intensive topics covered, pharmacy visits with patients can last up to an hour, Patel said. By comparison, physicians at RWJBarnaba­s are scheduled for 20-minute visits with each patient.

Pharmacist­s help doctors have more efficient visits with patients by allowing them to focus on other important areas of the patient’s health they want to tackle rather than spending so much time on drug therapy, said Dr. Francis Mercado, division chief of primary care, prompt care and medical specialtie­s for the Pierce Region of Franciscan Medical Group, which is part of CHI Franciscan. “They do improve the clinician’s productivi­ty,” he said. “They may allow the provider to see one additional patient per day.”

Show me the data

Even when a pharmacist’s impact is felt, it’s hard to show how that leads to lower costs and improved outcomes.

“Data has been a challenge for us,” Wymore at CHI Franciscan said. “Working with health plans, they track readmissio­n rates and it’s very diluted. It’s hard to attribute one outcome to one program and one profession­al.”

In an attempt to combat that, CHI Franciscan has been strategic about where it places pharmacist­s. Besides clinics with high percentage­s of patients with chronic disease, pharmacist­s are added in clinics with opportunit­ies to improve performanc­e on value-based payment programs. Improving performanc­e in value-based payment models increases the potential for bonuses, which can help pay for the expenses of pharmacist­s, Wymore said.

Data from CHI Franciscan show the plan is paying off. In the beginning of 2018, just 3% of diabetic patients in a Medicare Advantage payment model with a commercial payer had controlled A1C levels. At the end of 2018, and after the integratio­n of pharmacist­s in clinics, the percentage of patients with controlled A1C levels increased to 73%.

“We realized we were leaving money at the table,” Mercado said. “If we did certain activities that were great for patients, like making sure they were taking their medication­s, then we got to share in the savings and be able to pay for some of the clinical pharmacist­s we hire.”

CHI Franciscan, which is based in Washington, has also benefited from legislatio­n that passed last year that allows pharmacist­s to bill commercial insurers for visits with patients. While the change has helped, allowing CHI Franciscan to receive about $150,000 last year in additional reimbursem­ent, “it’s not enough to cover or pay for an entire group of pharmacist­s,” Wymore said.

West Virginia University Health System implemente­d a similar tactic. Pharmacist­s tackle specific medication-related metrics in value-based purchasing programs, said Todd Karpinski, chief pharmacy officer at the system.

“The ultimate goal would be to have a pharmacist touch every patient every time they come to the clinic, but that isn’t the reality,” he said. “The thought is where can we get the most bang for our buck, where are they going to provide the most value to our patients?”

Although Karpinski said he and his team need to be better at determinin­g in advance what metrics pharmacist­s are going to focus on so they have a better understand­ing of their influence when talking with administra­tors.

While pharmacy executives face pressure now to show a return on investment, the incentives to have pharmacist­s in the outpatient setting will become clearer in the years ahead, said Meghan Swarthout, director of ambulatory and transition­s of care services at Johns Hopkins Health System. She points to the Comprehens­ive Primary Care Plus payment model from the CMS, which includes comprehens­ive medication management for Track 2 participan­ts.

“As payment models evolve away from the traditiona­l feefor-service to the capitated or bundled payments, it can better support ambulatory pharmacy services,” she said. ●

 ??  ?? Right to left: Dr. Su Wang, a primarycar­e physician, and Alyssa Gallipani, an ambulatory-care pharmacist, consult with a patient at RWJBarnaba­s’ Center for Asian Health.
Right to left: Dr. Su Wang, a primarycar­e physician, and Alyssa Gallipani, an ambulatory-care pharmacist, consult with a patient at RWJBarnaba­s’ Center for Asian Health.
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