Payment for Cognitive Service Group 3 Aubrey Garcia

Payment for Cognitive Service Group 3: Aubrey Garcia, Brandon Gutierrez, Lionel Ishikawa, Lan Nguyen, Lairyn Stimmel

Objectives • • • Importance Definitions Research Provider Status Implementation Plan for Payment

Importance • The cost to the health-care system from drug-related morbidity > $76 billion 1, 2 • Most pharmacists feel they cannot financially afford to offer cognitive services • When pharmacists are given enough time and are reimbursed for providing services, they identify more drug interactions 3

Cognitive Services • Defined as: strategies and initiatives that improve the quality of drug therapy and the health care delivery system by using pharmacists to the fullest extent of their training and education as medication experts. 4 • Examples of potential cognitive services (in addition to MTM, vaccination, health testing) include: • Anticoagulation management • Self-monitoring of blood glucose • Medication adherence • Asthma consultation service • Smoking cessation

Benefit of Cognitive Service • Brummel, et. al. followed 23 MTM pharmacists from 1999 to 2011 • Pharmacists cared for over 20, 000 patients • Resolved over 107, 000 medication-related problems • According to Fairview Health Service’s 10 -year study • About ½ of 13, 325 patients had 3+ drug therapy problems • ⅓ had at least 5 problems • Total annual health expenditures decreased from $11, 965 to $8, 197 person • Pharmacist-estimated cost savings over the 10 -year period were $2, 913, 850 ($86 per encounter), and the total cost of MTM was $2, 258, 302 ($67 per encounter), for an estimated ROI of $1. 29 per dollar 5

At the Community Pharmacy Level • The cognitive services which pharmacist get paid currently up to date are, ● MTM ● Health testing (cholesterol, BMI, BP, Blood glucose) ● Vaccination (influenza, tetanus, diphtheria, pertussis Td/Tdap, Varicella, HPV, female, Zoster, Measles, mumps, rubella MMR, Pneumococcal 13 - valent conjugate (PCV 13) pneumococcal polysaccharide PPSV 23, meningococcal, hepatitis A, hepatitis B, Haemophilus influenzae type b (Hib) for 18 years and older • Payment through Medicare, Medicaid, commercial insurances, and patients

Provider Status • The benefit of pharmacy cognitive services is starting to get recognized • Medicare Modernization Act of 2003 required Part D sponsors to incorporate a Medication Therapy Management Program (MTMP) into their plans' benefit structure • Obtaining provider status will enable pharmacists to expand cognitive services • Through active engagement of all pharmacists to gain public attention for the provider status campaign

Plan for Payment • According to American Pharmacists Association: 6 • Most billing needs to take place through a registered pharmacy or physician’s office • Obtain National Provider Identifier (NPI) • Determine fees • Medicare Part D is required to cover MTM services for eligible patients • Contact payers to determine criteria for patient eligibility • Complete superbill, submit to insurance, collect payment • Document, Document!

Payment Software • Software already developed to help pharmacies bill the insurance companies and/or patients for cognitive services • Following are examples of softwares that help the payment process for MTM • Mirixia • Outcomes. MTM • Aprexis

References 1. 2. 3. 4. 5. 6. Johnson JA, Bootman JL Drug-related morbidity and mortality: a cost-of illness model. Arch Intern Med. 1995; 155: 1949 -56 Ernst FR, Grizzle AJ. Drug-related morbidity and mortality: updating the cost-of-illness model. J Am Pharm Assoc. 2001; 41: 19299. Christensen DB, Neil N, Fassett WE, et al. Frequency and characteristics of cognitive services provided in response to a financial incentive. J Am Pharm Assoc. 2000; 40: 609 -17 "Policy Brief. " Journal of Health and Social Behavior 53. 3 (2012): 296. British Columbia Pharmacy Association. Web. 25 Oct. 2015. Brummel, Amanda. "Best Practices: Improving Patient Outcomes and Costs in an ACO Through Comprehensive Medication Therapy Management. " AMCP. Academy of Managed Care Pharmacy, 2014. Web. 25 Oct. 2015. "Billing for MTM Services Tips for Pharmacists. "[PDF] APh. A. American Pharmacists Association, 2008. Web. 30 Oct. 2015.

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