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Chronic Care Management | Pharmacy

Physician-owned, Pharmacist-led: Chronic Care Management Partnerships

April 11th, 2023 | 11 min. read



Content Team

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Nearly half of all American adults have multiple chronic conditions, accounting for $1.1 trillion in healthcare costs annually. Additionally, two-thirds of Medicare beneficiaries have two or more chronic conditions. Yet, in recent surveys, 85% of physicians felt they didn’t have adequate time to provide needed care to these patients, and over 90% wanted help to ensure that patients with multiple chronic conditions could adhere to their care plans.

Pharmacists are an optimal partner for physicians to provide higher-quality, more continuous care to patients living with complex or multiple chronic conditions. Collaborating to create a Chronic Care Management (CCM) program can fill gaps in care while creating an additional revenue stream and enhancing quality and value-based performance metrics.

Claims data analysis suggests that patients enrolled in CCM programs require fewer healthcare services and spend less out-of-pocket. Additionally, pharmacist-led care management has been shown to lower the total cost of care and lead to fewer hospitalizations for patients with diabetes.

The pharmacist’s role is trusted and expanding

Primary care shortages, value-based contracting, and increasing chronic illness in a growing older population call for an expanded role for pharmacists in clinical care. This scenario was realized during the pandemic when the pharmacist's role on the patient’s care team expanded greatly. The Department of Health and Human Services (HHS) instilled pharmacists with the authority to order and administer COVID-19 tests and vaccines, as well as childhood vaccines. Beyond testing and vaccination, pharmacists provided needed education and critical services when other provider organizations were overwhelmed.

Research from the Columbia University Mailman School of Public Health revealed that pharmacists are well-trusted providers expected to play an “increasingly integral role in care management.” Deloitte’s The Pharmacist of the Future research report shared that “the profession is at a crossroads.” Industry experts see the current product-focused role moving more toward clinical services. As “trusted providers who sit in the center of many communities,” pharmacists are looked to provide added value to modern healthcare models, including:

  • Value-based contracting
  • Primary care support
  • Patient care activities
  • Specialty care
  • Digital health
  • Population health analytics

Pharmacists across community settings, ambulatory clinics, health systems or hospitals, and home delivery pharmacies are being tapped for more than their expertise in drug therapy management. Considering that more than half of US-licensed pharmacists hold a PharmD degree and receive as much classroom clinical instruction as allopathic physicians, it makes sense that they can perform a range of complex clinical functions.

Why should physicians partner with pharmacists to create and implement CCM services?

In 2015, the Centers for Medicare & Medicaid Services (CMS) authorized reimbursement to qualified providers for CCM services for Medicare beneficiaries diagnosed with two or more chronic health conditions. Pharmacists can lead CCM services as clinical staff under the supervision and billing of a qualified provider, like a primary care physician or specialist.

Physicians and pharmacists can leverage their strengths to achieve eight goals when collaborating to establish a CCM service:

  • Improve health outcomes for patients with complex, chronic illness
  • Provide a more consistent and personalized approach to patient care
  • Increase care plan and medication adherence
  • Meet value-based contracting requirements
  • Improve quality performance measures and scores
  • Enhance overall patient satisfaction and loyalty
  • Avoid costly exacerbations and unnecessary hospitalizations
  • Expand revenue sources

Through a CCM program for Medicare and dual-eligible patients with two or more chronic conditions, physicians can rely on community pharmacists to carry out almost every CCM activity under their general supervision. Beyond their expertise and dosing authority, pharmacists are uniquely suited to support patients with complex medication regimens while also contributing to a physician's quality measures.

Pharmacists are uniquely positioned and skilled to deliver CCM services

What makes a pharmacist the optimal partner for a physician to launch a CCM service?

  • Accessibility: Ninety percent of people in the US live within five miles of a community pharmacy.
  • Frequency: Patients interact with their pharmacist up to 12 times more frequently than their primary care physician.
  • Skills: Pharmacists have counseling and education skills that support CCM activities.
  • Chronic illness: Pharmacists understand many aspects of chronic diseases and their interactive influences.
  • Drug therapy: Pharmacists are drug therapy management experts, which is crucial because most chronic illnesses require multiple medications.

These factors make pharmacists reliable and suitable clinical partners for leading a CCM program. In addition to their unique position within the healthcare team, pharmacists can be vital to creating a profitable, sustainable, and compliant service.

According to the National Community Pharmacists Association: “Pharmacists are in a prime position to manage patients with complex medication regimens and improve a physician's quality measures.”

One example is a Federally Qualified Health Center (FQHC) in Northwest Florida that launched a CCM program along with medication therapy management (MTM). Leveraging ambulatory care pharmacists and student pharmacists under their supervision enabled the CCM program to deliver services to a diverse patient population with complex chronic conditions, including diabetes mellitus, hypertension, dyslipidemia, cardiovascular disease, and at risk for stroke. The program aims to help patients become more comfortable, educated, and empowered with consistent engagement to improve medication adherence and health outcomes.

Partnering to create an effective and profitable CCM revenue stream

Chronic Care Management can provide critically needed services to patients and a sustainable, profitable revenue stream for providers. Research studies have shown that CCM programs can yield a profit, reporting ROI levels of 27.8% and 15.6%. CMS supports multiple CPT codes, reimbursement rates, and billable time thresholds for complex and non-complex CCM services.

Beyond the financial benefits, creating an efficient and manageable CCM program requires several key components. One valuable resource is the CPESN® USA CCM Playbook, a project supported by a grant from the Department of Health and Human Services and CMS. With it and the guidance below, a physician and pharmacist can create a CCM service that changes the face of chronic illness for their shared patients.

What is needed for a physician and pharmacist to implement CCM?

First, let’s outline CMS’ Chronic Care Management program.

CMS pays for non-face-to-face care management and complex CCM services for Medicare (or dual-eligible) beneficiaries who live in a community setting. Eligible CCM patients have two or more chronic conditions, which are expected to last at least 12 months or until the patient’s death. Their chronic conditions place them at significant risk of death, acute exacerbation, decompensation, or functional decline. Eligible practitioners may bill for 20 minutes of non-face-to-face (or more, depending on complexity) chronic care services monthly.

CCM should include five core activities, including:

  • Record structured data in the patient’s health record
  • Maintain a comprehensive care plan for each patient
  • Providing 24/7 access to care
  • Comprehensive care management
  • Transitional care management

Both physicians and pharmacists work together to provide CCM services, but each has distinct responsibilities. As a Qualified Healthcare Professional, the physician has specific duties, including:

  • Share the care plan with the pharmacist via fax, software, or electronic prescription from the EHR
  • Bill CMS for CCM services
  • Pay the pharmacist for agreed-upon amounts for CCM services billed

As the primary clinical staff member that provides CCM services, pharmacists have specific duties, including:

  • Acquire patient consent, verbally or written, for entry into the program
  • Maintain documentation of the patient’s consent and comprehensive care plan in an electronic health record (EHR) or software solution
  • Oversee the patient care plan
  • Connect with each patient and carry out any of the five activities for at least 20 minutes each month for each CCM patient
  • Document clinical notes, goals, and next steps from each CCM session within a software solution, EHR, or other forms that can be shared digitally with the physician
  • Provide appropriate feedback to the physician that may require their attention or decision
  • Manage appropriate pharmacy staff to ensure adequate time available for CCM services
  • Invoice the physician each month for agreed-upon CMS services and rates

Aligned with the above-mentioned duties, the CPESN® provides a complete list of steps to start a CCM program in its guide titled Chronic Care Management for Community Based Pharmacies.

Four initial tasks to creating a CCM service

When considering launching a physician-owned, pharmacist-led CCM service, there are four areas that require collaboration, negotiation, and implementation.

Identify appropriate patients for CCM services

Some data analysis may be required to identify those patients ascribed to the physician that would be appropriate for CCM services. Conversely, the pharmacist will want to cross-reference the physician’s patient list with their own customer list to find overlap. Patients who already receive services from both may be more interested in CCM's benefits.

Identified patients should be Medicare (or dually-eligible) beneficiaries and must fit the program requirements regarding chronic illnesses. While most patients will fall into the “big 3” triad: hypertension, hyperlipidemia, or diabetes, other chronic conditions may be present, including dementia, asthma, COPD, depression, pain, HIV, Hepatitis C, or opioid use disorder.

Establish physician-pharmacist contracting and billing terms

Physicians and pharmacists should establish a contract for CCM services that outlines clear roles, responsibilities, negotiated rates, as well as billing processes and payment terms. Because pharmacists cannot bill CMS under Part B for services directly, their CCM services must be billed under a recognized provider’s number. The pharmacist will need to invoice the physician's practice per the contracted terms.

Manage communication throughout the patient care cycle

Because the pharmacist is working under general supervision and not via direct physician supervision, communication is vital. Developing a standard method for communicating and sharing feedback is crucial. Both professionals may schedule regular touch points to discuss particular patients or choose an electronic form for exchanging updates and feedback. What’s important to note is that the pharmacist is a complement to the team and not directing care as would be in a collaborative practice agreement (CPA).

Select CCM or EHR technologies

Software is crucial to streamlining CCM operations, communication, and oversight. Pharmacists may choose to use or integrate with a physician’s EHR, or they may select software specifically designed for Chronic Care Management.

ThoroughCare provides an intuitive platform explicitly designed for CCM’s rules and requirements. Technology can facilitate patient consent and enrollment, manage the entire CCM function, as well as simplify claim submission and documentation requirements. This tool provides all of the oversight, time tracking, and care coordination features, as well as providing standardized clinical notes to the physician via digital form or integrating with an EHR.

Maximizing the pharmacist’s value to the care team

CMS embraced chronic care management because it’s needed now and into the future. It also allows physicians to work with other clinical professionals—like pharmacists—to provide more consistent and accessible care. Through CCM services, physicians and pharmacists can partner to provide higher-quality care, enhance care plans and medication adherence, and improve performance measures while supplementing revenues.

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