Medicare reimbursements: Reform goals arouse skepticism

February 2, 2015

HHS wants to improve quality of care through a shift from fee-for-service to alternative payment models. Whether the timetable can be met remains to be seen.

The Department of Health and Human Services (HHS) has set goals to shift Medicare reimbursements to reward value and care coordination. Can this really have an impact on patient outcomes? Is it possible for HHS to improve the quality of care system-wide by moving away from fee-for-service payments to alternative payment models, such as primary care medical homes (PCMHs) or accountable care organizations (ACOs)?

Related content: Pharmacist-driven MTM could save ACOs a bundle

Quality vs. quantity

On Monday, January 26, HHS Secretary Sylvia M. Burwell announced a plan to move to a value-based payment system for the Medicare program, rewarding providers on the basis of quality of care for patients, rather than the quantity. HHS set a goal of 30% of fee-for-service Medicare payments to move to alternative payment models, such as PCMHs, ACOs, or bundled payment arrangements by the end of 2016, and a goal of 50% of reimbursements shifted to these models by the close of 2018.

See also: Below-cost reimbursements, exclusionary Medicare drug plans concern community pharmacists

Under reforms mandated by the Affordable Care Act and other changes, in 2014, approximately 20% of Medicare reimbursements moved away from fee-for-service and rewarded providers on the basis of the quality of care patients received, according to a media call with senior officials from the Centers for Medicare and Medicaid Services (CMS).

“This is the first time in the history of the program that explicit goals for alternative payment models and value-based payments have been set for Medicare. Changes assessed by these metrics will mark our progress in the near term, and we are engaging state Medicaid programs and private payers in efforts to make further progress toward value-based payment throughout the healthcare system,” wrote Secretary Burwell in an editorial published in The New England Journal of Medicine on January 26.

 

Skepticism exists

Until clinical pharmacists are included on the healthcare team of the PCMH or ACO, these alternative payment models will continue to produce the same results for patients, according to Allen Nichol, RPh, PharmD, COO and vice president of Clinical Operations, CeutiCare LLC.

Nichol, who has been working collaboratively as a clinical pharmacist for several years with a primary care physician in a shared practice in Columbus, Ohio, has helped to significantly improve patient care through clinical pharmacy services for chronic disease management.

“For example, the official average of getting diabetic patients to goal in all areas - hemoglobin A1c, blood pressure, and lipids - is only 14%, according to the American Diabetes Association guidelines,” Nichol said. “In my work over the last 15 years, we can get 50% of patients to goals simultaneously. In addition, we have been able to reduce global healthcare costs in our treatment group vs. physicians who are doing it the traditional way [without incorporating clinical pharmacists].”

If you want to move the needle on patient care, Nichol continued, clinical pharmacists have to become an integral part of the multidisciplinary healthcare team. The new statewide initiative established by Community Care of North Carolina (CCNC), headed by L. Allen Dobson, MD, has a real chance to succeed, Nichol believes.

Last month, CCNC embarked on a three-year project to develop and test a community pharmacy network with its 1,800 primary care practices, encompassing 95% of primary care delivery in North Carolina. This initiative will connect the clinical pharmacist with the primary care physician to help improve quality and lower costs. (See “N.C. program adds missing link to the medical home,” December 2014.)

“I guarantee you, the reason that Dr. Allen Dobson decided to go this route (adding clinical pharmacists to the PCMH) was because of his experience in North Carolina, working with clinical pharmacists,” Nichol said.

 

CMS removes payment barriers

Starting last month, CMS opened the door to greater reimbursement for collaborative care aimed at chronic disease management. Now physicians can use clinical pharmacists to help with drug therapy management and bill using the CPT codes 99211 through 99215.

See also: Pharmacy reimbursement: Make the most of MTM

“Pharmacists are not restricted to [the code] 99211 for their time working collaboratively with the physician. They can go as high as 99215,” Nichol noted. “A letter was sent from the CMS administrator to the American Academy of Family Physicians, and it was also put into the Federal Register.”

“With the new chronic care management of patients, there is plenty of money for pharmacists to go around, as long as physicians invite them into their world,” Nichol said.

For more about pharmacists involvement in different primary care practice models, read:

N.C. adds the missing link to the medical home

Patient-centered medical homes: Clinical pharmacy joins the team

The ACO Team: How pharmacists can make an impact as medication experts