BETHESDA, MD 18 Mar 2013—For clinical pharmacist Maureen Lloy Groux, integration into a primary care setting is an old story. But this time around, she is looking for a new ending.
"This is my third shot," she said of a pilot program that has placed her into a Sutter Health family medicine practice in Davis, California, that functions as a patient-centered medical home (PCMH).
Also known as the primary care medical home model, the PCMH model of care provides comprehensive, coordinated, patient-focused care that is accessible and actively engaged in quality and safety improvement activities, according to the Agency for Healthcare Research and Quality.
Lloy Groux's work in the medical practice includes patient education, disease state management for multiple conditions, laboratory monitoring, and changing patients' medication regimens.
"She's able to be really a provider within that care team," said Angela Leahy, outcomes research pharmacist for Sutter Health. "She works really closely with the care manager along with the physicians one-on-one, and she's really embedded within that care center."
Lloy Groux—who goes by "Mo"—previously provided office-based patient care as part of an experiential education program with a college of pharmacy and, later, in a managed care setting. But she said both of those projects were ultimately doomed by the lack of data to show the value of the pharmacists' services or their continued support.
"What we weren't doing was actually documenting how much time and money we're saving the clinician and the health care system, and who's footing the bill," she said. "It was coming out of the budget of the pharmacy, not the medical office setting."
So even though the physicians wanted her to stay at her previous clinic-based position, she said, the practice was unwilling to pay for her efforts.
This time around, Lloy Groux said, she has strong administrative support as well as data to support an expanded role for pharmacists in the pilot project.
From March through May of 2012, the practice's physicians referred 197 patients to Lloy Groux, and she performed 1001 interventions. About half of these interventions were classified as coordination-of-care activities, such as providing drug information and performing medication reconciliation. Lloy Groux said these interventions were targeted at patients with complicated medication regimens and those admitted to the emergency room or recently discharged from a hospital.
Her disease management interventions included hypertension education and blood-pressure measurement, diabetes education, blood glucose measurement, and cardiovascular risk-reduction education.
More than half of the interventions were credited with potentially avoiding emergency department or skilled nursing facility visits, hospital readmissions, or visits to a primary care physician.
Initially, the pilot project called for Lloy Groux to split her time between three practice sites in the state—in Davis, Albany, and Santa Rosa.
"After Mo had integrated and really become part of the team at the PCMH, it was recognized that they just couldn't part with her and have her go to the other two sites on even a part-time basis," Leahy said. "So we were able to go back and ask for funding and actually have 0.7 FTEs at the other two sites."
Lloy Groux said her past experiences in office-based practice had taught her to document everything she does and whether each service saves money or avoids health care costs. She said Sutter Health provided information technology support that allowed her to transition from a homemade spreadsheet system to a more sophisticated Microsoft Access database that better captures her cognitive services.
An ideal solution, she said, would be an electronic medical record system that incorporates both clinical data and value-
related data on pharmacists' interventions.
"We really haven't found a system that would do that," Lloy Groux said. "Even my Access database is limited by how much I put into it."
Sutter Health has committed two years of funding for the pilot project, and neither patients nor insurers are billed for the pharmacists' services. Leahy said the health system is working to sustain the funding after the pilot period ends, and data from Lloy Groux and the other pharmacists are key to achieving that goal.
Pharmacists at the University of Michigan Health System (UMHS) have been successfully billing and being reimbursed by Blue Cross Blue Shield of Michigan (BSBCM) for services delivered in primary care practices since 2009, when the insurer began offering incentives for PCMH adoption. The project was described in a report in the June 15, 2012, issue of AJHP.
Since the report was published, pharmacists have been incorporated into all 14 of the health system's primary clinics, said He Mi Choe, director of innovative ambulatory care pharmacy practices for UMHS. She said nine pharmacists spend part of their time in the clinics, with their service adding up to 3.8 full-time-equivalent pharmacist positions. Two of the sites are asking for additional pharmacists' hours, she said.
Choe said BSBCM remains the only insurer that reimburses for the pharmacists' services. Billing occurs through the use of so-called T codes that allow ancillary practitioners to bill for services provided incident to a physician's care.
UMHS pharmacists in the PCMH setting focus on caring for patients with diabetes, hypertension, hyperlipidemia, or polypharmacy and will soon expand into asthma management, Choe said.
She said the PCMH program hasn't been tracking cost-avoidance data, and if sustainability is measured solely by the amount of reimbursement revenue the pharmacists provide, their services are probably not profitable.
"Pharmacists are expensive resources," she said. "But if you look at health care, we're really moving from the fee-for-service type of model into more of a capitated payment model focused on how do we decrease overall drug costs, overall health care costs—how do we improve the quality of care—rather than looking at how much money does a pharmacist generate by providing services."
She noted that pharmacists can demonstrate their value by contributing to improvements in process measures and quality-of-care goals that are being implemented under pay-for-performance programs.
Justine Coffey, director of ASHP's Section of Ambulatory Care Practitioners, said pharmacists "need to be recognized as essential care providers within the patient-centered medical home and across the health care continuum."
She urged pharmacists to be aware of billing mechanisms that can provide reimbursement for patient care but to think beyond this model as well.
"Within the PCMH model, pharmacists should demonstrate their value and positive financial impact to health-system administrators and other decision-makers to ensure their salaries are absorbed by the health system rather than the pharmacy department," she said.