UC Health
Cincinnati, Ohio
Primary Intended Outcome(s):
- Expand the scope of pharmacy services through the creation of advanced role opportunities for PTCB-Certified, Ohio Board of Pharmacy registered pharmacy technicians;
- Serve as a highly valuable patient advocate by providing a full review of medical and pharmacy insurance benefits for patients receiving treatment for an oncology diagnosis;
- Provide a 6-month cost estimate of the patient’s financial responsibility for oncology treatment as dictated by the CMS guidelines for Oncology Care Model (OCM) Cost Estimates.
Site Description:
UC Health is an integrated delivery network that services acute care and ambulatory patients in the southern Ohio, northern Kentucky, and southeast Indiana region. The University of Cincinnati Medical Center (UCMC) is the flagship academic medical center and serves as a leader in trauma, solid organ transplant, oncology, and ambulatory care. Additional UC Health acute care sites include West Chester Hospital (WCH), a full-service community hospital; Daniel Drake Center for Post-Acute Care, the region’s premier provider of long-term acute care; and Lindner Center of HOPE, a patient-centered, scientifically-advanced care center for individuals suffering from mental illness. UC Health has nearly 50 ambulatory care centers and approximately 375 ambulatory physicians’ offices. UC Health offers six infusion sites for patient convenience at UCMC and WCH campuses.
The UC Health Pharmacy Department provides expertise in all areas of the health system including inpatient, outpatient, ambulatory, infusion, and corporate settings. Pharmacy service members are embedded directly in the patient care teams. These team members include clinical staff pharmacists, pre-certification access supervisor and coordinators, and certified pharmacy technicians. Certified Pharmacy Technicians practice in advanced roles at UC Health as Sterile Compounding-Certified Pharmacy Technicians, Medication Access Services Coordinator and Advocates as well as the OCM Financial Care Specialist.
Advanced Role Description:
The OCM Financial Care Specialist is responsible for providing six-month out-of-pocket financial estimates to oncology patients receiving oral or infusion chemotherapy treatments. A full benefits review of each patient’s insurance coverage, including both medical and pharmacy benefits, is performed every six months or with any change in treatment. The OCM Financial Care Specialist evaluates patient financial resources and establishes a plan to address opportunities to reduce out-of-pocket costs for the patient and the healthcare system. Working as a patient advocate, the OCM Financial Care Specialist answers financial questions, coordinates care with the patient care team, and provides hospital and community-based resources to each patient (ex. billing, patient access to medications, prior authorization, coordination with specialty pharmacies, drug reimbursement programs).
The UC Health OCM Financial Care Specialist has a background in pharmacy services and Medication Access Services, which made the certified pharmacy technician an ideal candidate to coordinate financial assistance, medication assistance, and pharmacy services for patients with UCCI. The duties and responsibilities of the OCM Financial Care Specialist include: providing patients with an overview of their anticipated financial responsibility for oncology treatment, investigating the cost of pharmacotherapy in order to refer patients to appropriate financial resources within UC Health, and monitoring patients throughout their treatment to serve as a guide for financial questions regarding services received.
Additional responsibilities of the OCM Financial Care Specialist include: assessing new patients who are referred to the financial estimate service, identifying at-risk patients for financial concerns, establishing a process for financial navigation services, building relationships with outside agencies to identify additional financial assistance resources for patients, and educating patients on available financial options. The OCM Financial Care Specialist is responsible for monitoring and reporting quarterly outcomes of the OCM program to summarize the return on investment (ROI) for the health system.
How to Start:
To ensure the success of the OCM Financial Care Specialist, it is important to establish an effective patient referral system and increase the utilization of the electronic medical record (EMR). The EMR, EPIC (Verona, WI), was utilized at UC Health to create a referral process. In collaboration with pharmacy informatics technology analysts, the OCM Financial Care Specialist developed a work queue that triggers referral notifications once the pharmacy pre-certification team has approved a patient’s oncology treatment plan through third-party insurance coverage. This work queue is known as the Infusion Medication Estimates Queue. To populate into the work queue, the referral must meet three specific inclusion criteria: the treatment plan must be entered by an oncology provider, the treatment plan must be approved by the pre-certification team, and the patient’s primary insurance must be Medicare A/B. Referrals can be further filtered if the diagnoses are non-oncology based (ex. iron deficiency or osteoporosis).
An OCM Financial Estimate Smart Text was created in the EMR, which allows a simple and efficient way to document the estimate process and share it with the patient and healthcare providers. The EPIC Estimate Smart Text provides a detailed overview of the patient’s current insurance coverage, including the primary and secondary insurance premiums, deductible, and out-of-pocket requirements. Supplementary information is provided such as pharmacy plan coverage premiums and out-of-pocket expense, Medication Access Services assessment, and the estimate of the overall cost of care.
To provide a comprehensive Medication Access Services assessment, the OCM Financial Care Specialist reviews and verifies prescription insurance coverage and will assist patients in applying for Medicare Part D and Extra Help, if needed. Additionally, the OCM Financial Care Specialist will determine eligibility for pharmaceutical-specific copay assistance, diagnosis-specific foundation assistance and pharmaceutical-specific patient assistance programs. Each of these programs, along with a referral to UC Health Financial Assistance can assist patients in covering unaffordable deductibles, co-payments, and co-insurance amounts.
An area of opportunity for the OCM Financial Care Specialist is expanding the capture rates for patients receiving oral oncolytics at outside specialty and retail pharmacies.
Regulatory and/or Legal Requirements:
The role of the OCM Financial Care Specialist, under the supervision of UC Health pharmacists, maintains certification through a national accrediting body and registration as a certified technician with the State of Ohio.
Revenue & Expense Parameters (abbreviated financials as applicable):
Direct costs include salary and benefits for the OCM Financial Care Specialist. The OCM Financial Care Specialist’s workstation is outfitted with a computer, phone, printer, access to the electronic medical record (EMR), and office supplies. UC Health receives monthly-enhanced oncology services payments (MEOS) for each patient eligible for the OCM program. MEOS equal $160 per OCM patient per month. The payments received are reinvested in the organization for practice improvements that directly impact patient care. UC Health is also eligible for performance bonus payments if healthcare costs are less than 96% of CMS’ projections; quality measure scores dictate the actual bonus amounts.
Training and/or Education Requirements:
Required:
- Certified Pharmacy Technician (through a national accrediting body)
- High School Diploma or GED
- 1 - 2 years equivalent of pharmacy experience
- Excellent communication and patient interview skills
- Experience in managing financial and clinical information
- Experience working with financial eligibility or third party programs
- Familiarity working with databases and computer software programs
Preferred:
- Associate's or Bachelor’s Degree
- 3 - 5 years equivalent financial and/or pharmacy experience
Outcome Measures:
- Total Number of Cost Estimates Completed since August 2018 (350)
- Time to Complete an Estimate: 30-45 minutes
- Time to Complete an Estimate for a patient with Medicare A/B insurance and commercial secondary coverage: 1-2 hours
- Percentage of Patients with ONLY Medicare A/B insurance coverage (~10%)
- Percentage of Patients with Secondary Insurance Coverage (~90%)
Lesson Learned:
- Importance of pharmacy technician involvement in direct, patient care to apply knowledge of pharmacy information and workflows to a business setting;
- Developing an effective OCM program requires integration of the health system’s EMR through collaborative efforts of an interdisciplinary team, which include representatives from all healthcare disciplines (e.g., pharmacy services);
- Provide educational support to pharmacy technicians for ongoing professional development (e.g., insurance requirements and guidelines, communication with patients, understanding of alternative payment model in oncology (OCM), and financial assessment skills).
Visit the UC Health Pharmacy Services website for more information. #ASHPPharmTech
