The Pharmacist eCare Plan greatly increases dispensing productivity and metrics reporting, but it’s just not built for billing.
Pharmacist eCare Plan (PeCP) is one of the hottest buzzwords in pharmacy. Proponents call the PeCP the greatest innovation in pharmacy technology since electronic prescribing.
However, “there is a lot of confusion around the Pharmacist eCare Plan,” said Shelly Spiro, RPh, FASCP, executive director of the Pharmacy Health Information Technology Collaborative. “It’s not a clinical care system or a billing document. It’s a standard for the way data [are] sent from 1 health care provider or system to another. It’s a way to leverage technology that can help every pharmacist be more productive.”
How much more productive? Spiro recalled switching from payer-specific dispensing claim forms to the Universal Claim Form and seeing dispensing productivity shoot up by approximately 300%. Dispensing productivity received another boost from electronic prescribing. Both were based on newly developed data export standards that vendors, payers, and pharmacists turned into new productivity tools to standardize and streamline the dispensing workflow.
PeCP is on the same track to stand- ardize and streamline the clinical workflow. A few early adopters are billing through the PeCP, with more users focusing on clinical care documentation and quality measures.
An Unintended Platform
“If my patient has an outcome of interest, say blood pressure or A1c [glycated hemoglobin], I can use my pharmacy management software to collect and manage that data,”said Benjamin Jolley, PharmD, owner of Jolley’s Compound- ing Pharmacy in Salt Lake City, Utah.
“All my interventions are coded using SNOMED terminology, just like a physician or any other provider. All that information—baseline patient status, interventions, outcomes—[is] all in a structured, standard format. You can use it if you’re audited, you can use it to demonstrate quality of care, you can even use it to generate payment if you have a contract,” he said.
Jolley said clinical documentation collected by his PeCP-compliant pharmacy management system vendor is valuable for patient counseling and reinforcing medical-legal protections when dispensing controlled substances. But payer contracts remain scarce.
Spiro likened the adoption of PeCP to that of electronic prescribing. The National Council for Prescription Drug Programs adopted the first version of SCRIPT, the data standard for e-prescribing, in 2008. But vendors were slow to turn the new standard into viable electronic prescribing systems that streamlined pharmacy workflows. Early e-prescribing was more of a pain than a benefit.
“Pharmacists spent years printing out electronic scripts so someone could enter them manually because the interfaces weren’t there,” Spiro explained.“That’s where we are with eCare Plan. We have the standard to export clinical data, but we don’t yet have the systems or the connections to make it part of the regular workflow.”
The PeCP became a billing platform by default, not by design.
“It’s not intended to be a billing platform,” said Matthew Webber, PharmD, director of value-based contracting for the Community Pharmacy Enhanced Services Network (CPESN).“But there are clinical care data in the eCare Plan that we can extract and create a billing document as needed. There is still no easy way for pharmacists to bill for clinical services.”
One problem is that payers don’t know how to process claims from pharmacists, said Josh Howland, PharmD, MBA, vice president of clinical strategy for PioneerRx. PioneerRx was an early pharmacy system vendor to support the PeCP.
Pharmacy claims typically involve product dispensing. Specific pharmacy locations are credentialed by payers; individual pharmacists are not. Claims are usually routed through a pharmacy benefit manager using the Universal Claim Form and paid through pharmacy benefits.
Clinical services are typically paid through medical benefits. Claims are usually routed through medical inter- mediaries using the X12N 837P form and procedural terminology (CPT) codes. Pharmacy systems focused on dispensing do not include medical claim forms, CPT codes, or interfaces to medical intermediaries or directly to payers.
And although pharmacies are credentialed by pharmacy payers, individual providers are credentialed by medical payers using the providers’ National Provider Identifier (NPI) numbers. Howland said relatively few pharmacists have NPI numbers, although the number has increased as more pharmacists and pharmacy technicians began providing immunizations during the COVID-19 pandemic.
“There is a whole world of providers, say Blue Cross or UnitedHealthcare, [with] no idea how to credential pharmacists,” Howland said.“They’ve just never done it. In order for medical billing to be real, we have 200,000 pharmacists who need to credential themselves with every payer. The industry is going to have to figure that out, whether individually or some kind of mass credentialing.”
As payer and pharmacy groups work on pharmacist credentials, other organizations are tackling billing barriers.
In 2014, Community Care of North Car- olina created CPESN, initially funded by a grant from the Centers for Medicare & Medicaid Services Innovation Center. The network adopted an earlier version of PeCP and helped develop the standard.
“We started down the eCare Plan path because we wanted to docu- ment the care and the value we were providing,” Webber explained.“And not just prove our interventions and outcomes to payers, but [we wanted] to prove to our fellow pharmacists. When you join a network, you are basically linking arms with a bunch of pharmacists you may not know. Every pharmacy in the network wants [to] feel confident that all the other pharmacies are meeting the standards, and, frankly, [they want] to kick out the nonperformers.”
CPESN became the intermediary between network pharmacies and medical benefit payers. For lack of an alternative, PeCP became the de facto billing tool for participating pharmacies. CPESN is the only clinically integrated network of community pharmacists in the United States. The network contracts with payers, which typically are multistate or national insurers.
Typical services documented in the eCare Plan include as follows:
Local CPESN pharmacies provide the services and document their interventions and outcomes using PeCP. CPESN translates clinical services documented in the PeCP into an X12 or other billing document and sends it to the payer.
“Two years ago, pharmacies didn’t have this capability,” said Kim Roberts, PharmD, lead for pharmacy informatics partnerships and innovations at CPESN. “This helps pharmacists rely more on their clinical skills because, from the community perspective, the financials are just not there to rely on dispensing medications.”
The PeCP also can report quality metrics.
“Because lab values, vitals, medications, therapy problems, and interventions can all be embedded in each eCare Plan, that solves a growing need for quality reporting,” said Sam Anderegg, PharmD, MS. Anderegg is CEO of clinical management system DocStation, another early PeCP supporter. “Information about what’s going on with the patient and my role in achieving those outcomes is a huge value for me or any provider,” he said.
Anderegg sees a long-term benefit in clinical documentation and quality reporting via PeCP. He’s less confident about PeCP as a billing vehicle.
“We are...in a situation where pharmacies bring their own way of doing things that deviate from the industry standard,” Anderegg cautioned.“That might create problems in the long term.”
DocStation and CPESN see the PeCP as a temporary solution until system vendors roll out modules to give pharmacies direct access to medical billing resources. The ideal is a pharmacy system that documents both dispensing and clinical workflows, automatically generates the appropriate Universal Claim Form for pharmacy benefits or X12 for medical benefits, updates other providers on patient status, and accepts updates from other providers.
That system doesn’t exist—yet—but it’s coming. Spiro reported that the latest version of PeCP based on Fast Healthcare Interoperability Resources standard successfully transmitted clin- ical information to an Epic electronic medical record.
“We have dispensing systems [and] and medical systems that are evolving their technologies,” said Hannah Fish, PharmD, director of strategic initiatives for the National Community Pharmacists Association.“It’s all about how they work together. We have to collectively ask vendors for those services and systems and insist that they be interoperable.”