Outpatient settings need pharmacists, but lack of reimbursement makes that tough

Modern Healthcare– December 14, 2019

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.

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 considered 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.”

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 pharmacists) 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.

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 fee-for-service to the capitated or bundled payments, it can better support ambulatory pharmacy services,” she said.