Low hanging fruit

Hopefully everyone had a good holiday break, and maybe even the chance to curl up with a good book…or better, with the Federal Register!  Yes, you heard that right, the Federal appleRegister from 2016 has a number of positive developments in areas that are or will soon be ‘ripe’ for pharmacist intervention.  Notices and rulemaking for Medicare are published by CMS in the Federal Register. These notices are often accompanied by CMS’ responses to comments received on proposed rulemaking as well as some interesting background data.  So let’s look at what CMS considers important (i.e. what they are willing to pay for).  First, they recognize that medication misadventures often result in costly adverse effects including ED visits and hospitalizations.  They recognized MTM as needed (Ref 1), and when it was clear that it wasn’t being used as often as they wanted, they expanded the criteria to qualify more patients for MTM.  Realizing that medication misadventures were more likely during care transitions, CMS decided to reimburse for Transitional Care Management (CPT 99495, 99496) that included Medication Reconciliation. (Ref 2) With CMS’ announced aggressive plan to move to a system of more value-based reimbursement, new payment models were recently release as MACRA-MIPS (Ref 3), and medication reconciliation was a key component for the Merit-based Incentive Payment System (Ref 3, see pgs 77225 and 77230).

Switching gears to a key condition recognized by CMS, diabetes, it is clear that they value Diabetes Self Management Education (CPT G0108, G0109), and that they have increased the reimbursement for provision of that service. (4) Recently, CMS has announced that it will reimburse diabetes prevention in the proposed Medicare Diabetes Prevention Program (Ref 5, see section III.J)  The preliminary structure proposal is in Ref 5, and establishes how you can be prepared for the final rulemaking in 2017, and implementation in 2018.  In this document you can find links to the proposed standards and to the proposed curriculum developed by CDC. This is a must read if you want to be prepared to offer this service!

Finally, CMS has not only established reimbursement for Chronic Care Management (CPT 99490), but updated their rules with new codes for more complex patients who are involved in CCM (CPT 99487-99489) so that the reimbursement could better reflect the amount of work involved with CCM in highly complex patients (Ref 5, see section E.4 and Table 11).  As most of you already know, CCM can be provided to patients with 2 or more chronic diseases, and thus nearly all your patients with diabetes would qualify.

It is clear that medications, diabetes and chronic care are not only on the CMS’ radar screen, but they are addressing concerns related to expansion of these services as well as augmenting reimbursement.  Members of the ACCP Endocrine & Metabolism PRN are particularly well positioned to take advantage of many of these services!

At the 2016 ACCP Annual Meeting in October, a session discussing TCM and CCM was poorly attended, yet just down the hall a session on PCSK-9 inhibitors was packed.  While being the local guru on pharmacodynamics of PCSK-9 inhibitors may bring personal satisfaction, providing services such as TCM, CCM, DSMT, and soon MDPP brings revenue.  We are fighting for recognition as ‘providers’, and in any fight, you are lucky when the other guy telegraphs his moves.  CMS is not telegraphing, they are shouting it from the rooftops, yet only a few ACCP members are doing any of these services.  My bias is obvious, if you want to be recognized as ‘providers’, then start providing what your customer wants!

  1. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003. Public Law 108-173. December 8, 2003. Available at: http://www.gpo.gov/fdsys/pkg/PLAW-108publ173/content-detail.html. [accessed 12/27/2016]
  2. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Transitional-Care-Management-Services-Fact-Sheet-ICN908628.pdf [accessed 12/27/2016]
  3. Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive Under the Physician Fee Schedule, and Criteria for Physician- Focused Payment Models. Federal Register / Vol. 81, No. 214 / Friday, November 4, 2016 / Rules and Regulations. https://www.federalregister.gov/documents/2016/11/04/2016-25240/medicare-program-merit-based-incentive-payment-system-mips-and-alternative-payment-model-apm [accessed 12/27/2016]
  4. Medicare Benefit Policy Manual Chapter 15 – Covered Medical and Other Health Services https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf [accessed 12/27/2016]
  5. Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2017; Medicare Advantage Bid Pricing Data Release; Medicare Advantage and Part D Medical Loss Ratio Data Release; Medicare Advantage Provider Network Requirements; Expansion of Medicare Diabetes Prevention Program Model; Medicare Shared Savings Program Requirements. https://www.federalregister.gov/documents/2016/11/15/2016-26668/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other-revisions [accessed 12/27/2016]
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You know what CCM is, why aren’t you doing it?

In January of 2015, CMS initiated a new code for managing Chronic Care patients. (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1516.pdf),
(https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ChronicCareManagement.pdf).
The code could be used when following patients with two or more chronic diseases from a rather extensive list of conditions we all know lead to higher medical care costs, and many which have significant morbidity and mortality associated with them. As you may know, identifying these patients and then providing follow up contact at a minimum of 20 minutes per month can result in reimbursement for the provider of roughly $40…which Medicare pays 80% of and the practice collects 20% from the patient. Of course the individual providing that 20 minutes needs to be part of the practice (employee or contractor), and the patient needs to agree to enroll in this service which is based on his/her plan of care. There are other requirements that are spelled out in the documents listed at the beginning of this Blog. It has been over a year, and yet only a few medical practices are offering this service, and only a very few members of ACCP are actually providing CCM. In a number of cases the service has been ‘assigned’ to the office nurse (read: Medical Assistant, or RN ‘chronic care coordinator,’ social worker, dietitian) or some other practitioner rather than the pharmacist. Indeed there are even commercial services that have sprung up to outsource this service.

ACCP rallies around the possibility of reimbursement for “Comprehensive Medication Management,” yet we have not been fighting tooth and nail for “Chronic Care Management” to be our responsibility. Indeed CCM is the low hanging fruit that could potentially lead to CMM. Nowhere will pharmacists be more valuable than the chronic care patient with multiple medications. It is a gateway to MTM (at least one of them) which has been recognized as valuable by CMS and worthy of extension to more and more patients as the provision of MTM was way less than CMS had planned yet was every bit a valuable as they knew it would be. Yes, a nurse can call patients and talk to them for 20 minutes. But having access to de facto risk stratified patients who are on multiple medications, often with conditions that have documented value via telemedicine follow-up is a gift that has been sitting under our Christmas Tree for over a year. Few ACCP members have taken up the gauntlet to ‘manage’ these patients. You can download blood glucose meters remotely, you can have patients monitor their blood pressure at home (a better way to do it anyway), you can monitor and reinforce medication adherence, or even find out patients who should be on certain medications (‘statins, ACE Inhibitors) yet somehow are not. There is even recognition that CCM services need to be expanded to increase reimbursement for more complicated patients, which means that reimbursement for those patients will be even higher in the future. Reimbursement for Diabetes Education was increased due to recognition of its value, MTM was expanded due to recognition of its value, Chronic Care Management was initiated and will likely soon be expanded due to recognition of its value (http://www.nachc.com/client/SFC%20Workgroup%20Options%20Paper%2012.15.pdf) [See:policy under consideration, pg 11].

The segue between CCM and the ‘holy grail’ of Comprehensive Medication Management seems obvious, and just needs to be fleshed out. Having clinical pharmacists involved in the first will more likely lead to the latter if we decide to make it so. So let’s get crackin’