Impact of Pharmacist Integration Into Primary Care on Reimbursement for Hospital Follow-Up Visits

Abstract

Background:

The financial and clinical impact of transitional care management (TCM) outcomes through pharmacist integration within primary care is not well described.

Objectives:

The primary objective of this study was to determine the financial impact of pharmacist conducted post-discharge phone calls. The secondary objectives included readmission rates and number of interventions.

Methods:

A computer-generated list identified patients discharged from St. Joseph’s/Candler Health System (SJ/C) with a listed primary care provider within the SJ/C Primary Care Medical Group at Eisenhower from November 1, 2019 to April 30, 2020. Eligible patients who received a post-discharge phone call from a pharmacist were compared to those who received a call by another staff member. Data was collected regarding the financial impact of pharmacist conducted post-discharge phone calls. Readmission rates and medication related interventions were also assessed.

Results:

There were 104 patients discharged meeting criteria. Twenty-four patients were contacted by a pharmacist resulting in 20 subsequent hospital follow up appointments scheduled with the provider. Total amount billed for those appointments was $4220 (average of $211 per visit). Twenty-five calls were made by non-pharmacist staff with 23 appointments scheduled. Total amount billed for those appointments was $2445 (average of $106 per visit). Increased reimbursement was generated by a qualifying 2-way communication by the pharmacist as outlined by Center for Medicaid and Medicare Services enabling providers to bill for a TCM visit versus standard office visit. Pharmacists made 33 clinical interventions including medication reconciliation, medication procurement, referrals, lab orders, and education. One intervention was made by non-pharmacist staff. The 30-day readmission rate for pharmacist contacted patients was 8% versus 12% for non-pharmacist contacted patients.

Conclusions:

Pharmacist involvement in TCM while integrated into a primary care office is previously not well described. This data highlights an opportunity for pharmacists to demonstrate sustainability and improved outcomes related to TCM.

Background

The period of transition following hospital discharge can be an overwhelming time for patients and their caregivers. The Centers for Medicare and Medicaid Services (CMS) defines transitions of care (TOC) as, “The movement of a patient from one setting of care (hospital, ambulatory primary care practice, ambulatory specialty care practice, long-term care, home health, rehabilitation facility) to another.” ¹ TOC often leads to medication errors, adverse events, and hospital readmissions. Previous studies have shown 60% of medication errors occur during care transitions, and approximately 50% of hospital medication errors occur at admission and/or discharge.^2,3 In fact, 66% of medical related adverse events are due to medications. ² Preventable hospital readmissions total almost 12 billion dollars in Medicare costs. ⁴

When a pharmacist participates in TOC services they can help decrease this cost with an approximate net savings of $35 000 per 100 patients. ⁴ As a result, a large effort has been made over the last 2 decades to increase coordination in relation to TOC in the inpatient and outpatient settings. One study recently published by Balling et al. found that when pharmacists are involved in the hospital discharge process, there are significantly less readmissions than when a pharmacist is not involved. ⁵ In addition to re-admissions, pharmacists were able to improve transitions of care by intervening on a variety of medication related errors such as omissions, duplications, dosing errors, and drug-drug interactions. In 2015, Sanchez et al. looked at the impact of a pharmacist telephone intervention on hospital readmission rates and found that patients who did not receive a call by a pharmacist will more likely to be readmitted or visit the emergency room 30 days following discharge. ⁶ A study published by Cavanaugh et al. evaluated the impact of an interdisciplinary, outpatient clinic-based care transition of care. Results showed a significant decrease all-cause 30-day readmission rates when pharmacists were included in the hospital follow-up visit. ⁷

Despite the growing amount of research involving pharmacists’ impact on TOC outcomes, these studies primarily focus on the impact on readmission rates with less focus on reduction of medication errors and sustainable business models. The majority of the literature describing the role of pharmacists in TOC initiatives centers on pharmacists practicing within hospitals. There is a paucity of data surrounding the impact of pharmacists on TOC outcomes when that pharmacist is working within a primary care office. Furthermore, it is difficult to showcase sustainable salary models in order to secure funding for pharmacists to consistently contribute to TOC services within primary settings. As pharmacists continue to become integrated within the primary care setting, it is crucial to explore sustainable business models in the absence of national provider status. CMS utilizes the term TCM to describe billable services related to TOC. ¹ CMS will reimburse for a TCM visit, provided there is a 2-way conversation between the patient and clinical staff within 2 business days of discharge and the patient is seen by their provider within 14 calendar days. TCM visits are typically reimbursed at a higher rate than standard office visits. The term “provider” refers to the billing clinician as recognized by CMS (physician, nurse practitioner, or physician assistant). Although many pharmacists are already involved in TOC services, the TCM criteria for “Healthcare Professionals who may furnish TCM services” does not include pharmacists. ¹ Due to this definition, pharmacists are unable to independently see the patient for their TCM office visit, however, they can participate in post-discharge phone call with the patient while operating as clinical staff. During these conversations, pharmacists are able to perform thorough medication reconciliations, identify and prevent medication errors, counsel patients on their medications, and coordinate future appointments with providers. The completion of the post-discharge phone call by the pharmacist within the primary care setting can also contribute to reduced readmission rates and optimization of pharmacotherapy. This presents an opportunity for pharmacists to utilize advanced Collaborative Practice Agreements while also contributing to overall increased reimbursement for supervising physicians. The primary objective of this study was to determine the financial impact of pharmacist driven post-discharge phone calls in the primary care setting. The secondary objectives included readmission rates and number of interventions.

Methods

A computer-generated list identified patients discharged from St. Joseph’s/Candler Health System from November 1, 2019 to April 30, 2020. Patients were included with a St. Joseph’s/Candler Primary Care on Eisenhower primary care provider. The included patients were separated into 2 cohorts—those that received the post-discharge phone call from the pharmacist and those that received the post-discharge phone call from a non-pharmacist staff member or provider. For patients in both groups, data was collected for predicted reimbursement for TCM visit, readmission rates, and medication interventions.

Description of Practice Site

At this primary care office, there are 5 physicians, 1 nurse practitioner, and 2 pharmacists. These 2 pharmacists work a combined total of 40 h/week. Their responsibilities include providing Medicare Annual Wellness visits, disease state management visits, assisting with medication procurement, precepting pharmacy students and residents, and providing transitions of care services. The post-discharge phone calls provided by pharmacists only account for an estimated 2 h a week of the pharmacists’ time due to the numerous other responsibilities of the primary care pharmacists within the office.

Intervention

The primary intervention of this study was pharmacist-led post-discharge phone calls to patients that were discharged from St. Joseph’s/Candler Health System with a primary care provider within the St. Joseph’s/Candler Health System Primary Care Eisenhower Clinic. During the post-discharge phone call conducted by the pharmacists, patients were counseled on their discharge diagnosis, educated on any new medications, assisted with issues with medication procurement, and scheduled for a follow-up office visit with the primary care provider within 14 days of discharge. A retrospective list was generated for the specified time period to compare post-discharge phone calls made by a pharmacist to those made by other staff. On a day to day basis, the pharmacists are notified through the electronic health record (EHR), either through quality driven notifications or directly from the supervising providers, of patients recently discharged in need of a post-discharge phone call. As the pharmacists’ schedules do not allow for completion of all post-discharge phone calls, other staff within the office often make the calls when the pharmacist is unable to do so. At times patient also called the office to advise of their hospitalization, in these cases the pharmacist was not always the individual to answer that call. When other staff members complete the post-discharge phone call, the necessary requirements for subsequent TCM billing are often left unsatisfied.

Data Collection

Data collection included follow-up appointments scheduled as a result of the post-discharge phone call (either TCM visit or standard office visit), the billing codes charged during visit, interventions made during the initial phone call, and 30-day readmission data. As lack of national provider status prohibits pharmacists from directly billing for their services, pharmacists within the primary care setting must often utilize a combination of multiple job responsibilities to ensure appropriate salary justification. The financial analysis of this service line allows for salary justification and streamlining of pharmacist responsibilities within the primary care setting. Thus, the interventions within this study were chosen based on their value to the institution and high potential for pharmacist salary justification. The EHR allows for streamlined tracking of the individual completing the post-discharge phone call. As such, it was possible to clearly delineate the phone calls made by the pharmacist from those made by other staff members. The patients’ subsequent in-person visit was examined to determine the visit type and corresponding billing charge, allowing for differentiation between TCM visits and standard office visits. Examining the reimbursement that directly resulted from the criteria met when pharmacists completed the post-discharge phone calls compared to other staff allowed for potential pharmacist salary justification for future Full Time Equivalents (FTEs). Readmission rates were also assessed in line with standard practice with regards to assessment of TCM related outcomes. Finally, medication related interventions were chosen as a measurable outcome to demonstrate how pharmacists can utilize advanced Collaborative Practice Agreements while also contributing to billable services under provider supervision. The analysis of medication related interventions for pharmacist versus non-pharmacist staff completing the post-discharge phone call also lends credibility beyond salary justification to pharmacist participation in TCM services within the primary care setting. The SJ/C Institutional Review Board approved procedures for this retrospective chart review. Informed consent was not required due to the retrospective and quality improvement nature of the initiative.

Statistical Analysis

Due to the small sample size, descriptive statistics were utilized to analyze the data. Complex statistical analysis was not conducted during data analysis. While variation surrounding the time of the call, complexity of individual patients, and qualifications of non-pharmacist staff cannot be completely eliminated, the nature of the observed outcomes did allow for succinct data collection. For example, the EHR tracks the caller for each post-discharge phone call. Subsequent billing and medication reconciliation or adjustment data can be easily collected and categorized for patients following the post-discharge phone call.

Results

There were 104 discharges from November 1, 2019 to April 30, 2020 meeting the inclusion criteria. Twenty-four patients were contacted by the pharmacist with 20 hospital follow up appointments scheduled. The predicted revenue generated from those appointments was $4220 (average of $211 per visit). Non-pharmacist staff made 25 calls and scheduled 23 appointments. Of the 25 calls made by non-pharmacist staff, 5 were made by medical assistants and 2 by front office personnel. The predicted revenue generated from those appointments was $2445 (average of $106 per visit). Of the patients contacted by someone other than the pharmacist, only 5 were by other TCM qualified clinical staff as specified by CMS. Pharmacists made 33 clinical interventions including medication reconciliation, medication procurement, referrals, lab orders, allergy updates, and education. One intervention was made by non-pharmacist staff. This intervention was the completion of a lab order. The 30-day readmission rate was 8% (2/24) for patients contacted by the pharmacist and 12% (3/25) for patients contacted by staff members other than the pharmacist. Of the 5 patients who were readmitted within 30 days, 3 were contacted within 2 business days of discharge but declined a follow-up appointment, one of which was contacted by a pharmacist. Advanced statistical analysis was not utilized in data analysis due to the small sample size in this study and the quality improvement nature of the initiative.

Discussion

Pharmacists are not nationally recognized as providers, which makes it difficult to establish reproducible and sustainable service lines that secure pharmacist FTEs. Primary care pharmacist involvement in TCM services allows for seamless integration into the electronic medical record to document transitions of care more effectively. Pharmacist driven TCM services within the primary care setting can contribute to optimization of TCM billing, decreased readmissions, additional provider co-visit opportunities, identification of medication related errors, and opportunities for pharmacotherapy optimization. It is necessary to describe business models that allow pharmacists to contribute to billable opportunities as it allows for salary sustainability and advancement of pharmacy practice within the primary care setting and ambulatory care sectors. This study demonstrated the correlation between pharmacist conducted post-discharge phone calls to increased reimbursement for the physician practice, reduction of readmission rates, and optimization of pharmacotherapy. The noted association lends credibility to pharmacist salary justification for similar institutions looking to incorporate pharmacists within the primary care setting. While pharmacists can be effective members of the primary care team, it can be difficult to establish core job responsibilities that result in remuneration. Dissemination of real-world examples describing sustainable business models is necessary to promote FTE sustainability for similar institutions.

Limitations

This study was quality improvement in nature, thus the small patient population studied did not allow for advanced statistical analysis of the data. The other responsibilities of the pharmacists within the primary care office did not allow for them to complete a larger number of post-discharge phone calls. However, the data here within can provide future delineation of responsibility or additional pharmacist FTEs. Future studies at this institution would be helpful to understand the impact and potential across the other affiliated primary care offices. Further studies are needed on a national level to showcase and describe sustainable business models for ambulatory care pharmacists.

Conclusion

Pharmacist involvement in TCM services through post-discharge phone calls while integrated into a primary care office of a health system is not well described. This data highlights an opportunity for pharmacists to contribute to increased revenue, reduced readmissions, and optimization of clinical interventions following hospital discharge. While other members of the healthcare team can ensure optimized billing related to post-discharge visits, pharmacist involvement can improve patient outcomes, identify medication errors, and add to collaboration within an interdisciplinary team.