Analysis of Provider-Generated Revenue and Impact on Medication Reconciliation from a Pharmacist-Led Chronic Care Management Service

Analysis of Provider-Generated Revenue and Impact on Medication Reconciliation from a Pharmacist-Led Chronic Care Management Service
Alexandra Vecchia, PharmD, M Health Fairview

Background: The Centers for Medicare and Medicaid Services (CMS) allows pharmacists to utilize incident-to-billing in order to be reimbursed for providing chronic care management (CCM) services to covered patients. CCM services aim to bridge gaps in care and to help patients manage their chronic conditions. CMS not only allows for face-to-face time with the patient to be submitted for reimbursement, but also time spent on activities, such as reviewing labs and communicating with other healthcare providers. There are few data on direct and indirect revenue generated by community pharmacies that offer these services.

Objective: This study of CCM services provided by a chain of community pharmacies aims to calculate the direct and indirect revenue generated by this service, and to analyze discrepancies found when completing medication reconciliations.

Practice Description: This practice is a small chain of independent community pharmacies, Realo Drugs, located in North Carolina. The pharmacies offer many services including comprehensive medication review (CMR), medication packaging, diabetes education, and transition of care management.

Practice Innovation: Realo Drugs began offering CCM services to their patients in coordination with a local patient-centered medical home in 2018. The CCM services are run by one pharmacist and one post-graduate year one (PGY-1) pharmacy resident. Patients are enrolled in the program by their provider. After receiving the referral, the clinical pharmacist contacts the patient to complete a health risk assessment and CMR. Thereafter, the pharmacist provides CCM services on an ongoing basis including performing medication reconciliation, coordinating referrals, identifying community resources, requesting appointments, communicating medication refill requests, providing vaccine recommendations, and conducting clinical screenings. These services are submitted to CMS for reimbursement every month using incident-to-billing under the referring provider. The referring provider is reimbursed for the services and a percentage of the reimbursement is passed on to the pharmacy.

Evaluation Methods: A retrospective analysis was conducted on CCM services provided from April 1, 2018 through June 30, 2019. Direct revenue to both the pharmacy and patient-centered medical home consisted of reimbursement from CMS for the CCM services. Indirect revenue included in-office visits with the provider resulting from a referral from the pharmacist. Medication changes made during medication reconciliation were tracked using the electronic health record.

Results: The study identified 112 patients that received CCM services, 18% of whom were patients of Realo Drugs. The direct and indirect revenue generated from these patients over the 15 month analysis was $26,148, equaling about $15.56 per patient per month. The vast majority (92%) of the revenue was directly from CCM services as opposed to indirect revenue from in-office appointments resulting from pharmacist referrals. The analysis discovered 609 medication discrepancies identified during medication reconciliation. The most common discrepancy involved patients no longer taking a medication that was still on the medication list (67%). Other discrepancies included patients taking a medication that was not on the list (23%) and incorrect strengths or doses (10%).

Limitations: Due to the retrospective design of this study, there were limitations in the data collection and results. There was no pre-specified way to determine if an in-office provider visit was made as a result of a pharmacist’s recommendation. Similarly, medication reconciliation visits were not prospectively tracked or documented. The only way to determine that a medication reconciliation occurred was to identify changes to the medication list under the pharmacist’s username in the electronic health record. Therefore, if a medication reconciliation visit was completed and no changes were made to the medication list, this visit would not have been included in the analysis.

Conclusion: This retrospective study of CCM services provided in a chain of community pharmacies demonstrated $26,148 in direct and indirect revenue over 15 months. It also highlights the importance of pharmacist-driven medication reconciliation in order to identify and resolve discrepancies.

 

References:

  1. Sotelo E, Nunemacher C, Holland CR, Rhodes LA, Marciniak MW. Analysis of provider-generated revenue and impact on medication reconciliation from a pharmacist-led chronic care management service [Pre-Proof]. JAPhA. 2021. https://doi.org/10.1016/j.japh.2021.01.017.