Document to Advance Care & Receive Reimbursement

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Last week’s Tip described the importance of documentation. So does this week’s Tip; except that last week this was discussed in the context of disciplining an employee, and this week is in the context of documentation for reimbursement. Even though the predominant model of pharmacy reimbursement is through sheer volume of dispensing, things are beginning to change. Pharmacies with higher ratings through the CMS Star Ratings program for Medicare Part D are rewarded with increased reimbursements from health plans and with lower copays for their patients. A particular area of note is with regard to diabetes care, most notably gaps in that care, including lack of: A1C testing, eye and foot exams, lipid testing, and moderate-intensity statin therapy.

Moczygemba et al describe how pharmacists can report gaps in diabetes care by contracting with and reporting to a federally listed Patient Safety Organization (PSO) using a protected process (web portal) to address these gaps in therapy and improve quality of care.1  Their study attempted to: (1) identify the number of gaps, type of gaps, and contributing factors to gaps in diabetes care reported by pharmacists in the Diabetes Gaps in Care Portal (Gaps Portal), and (2) understand how pharmacists used the Gaps Portal and the resultant implications on quality diabetes care. During 15 months, 10 participating pharmacists entered 528 gaps in diabetes care. The most common category of gaps in diabetes care was Drug Therapy Gaps (n=420/528, 79.6%). Of the Drug Therapy Gaps reported, the most common gap occurred in those with diabetes also with or at risk for atherosclerotic cardiovascular disease and who were not on a high-intensity statin (122/420) followed by those not on a moderate statin (106/420). Themes focused on during subsequent pharmacist interviews included integration of diabetes coaching and documentation , impact of the Gaps Portal on workflow, and prioritization of gaps. The study concluded by acknowledging pharmacists’ active participation in reporting gaps and that the Portal template served as a useful checklist to identify gaps in care during diabetes coaching activities, and for reporting and monitoring.

Even in the absence of reimbursement strategies aimed SPECIFICALLY to promote quality services, it is nonetheless incumbent upon pharmacists to do so. With pharmacy practice and reimbursement incentives changing, pharmacy managers can seize upon opportunities such as this one (Drug Therapy Gaps) to position themselves for revenue stream diversification and higher-level practice.

Additional information about Customer Service in Pharmacy Management: Essentials for All Practice Settings, 5e. If you or your institution subscribes to AccessPharmacy, use or create your MyAccess Profile to sign-in to Pharmacy Management: Essentials for All Practice Settings, 5e. If your institution does not provide access, ask your medical librarian about subscribing.

1Moczygemba LR, Bhathena S, DiPiro CV, Snead SV. Pharmacist documentation of gaps in care identified during diabetes coaching. J Am Pharm Assoc. 2019;59(1):57-63.  

Shane Desselle

Professor of Social and Behavioral Pharmacy, Touro University California

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Go to the profile of Shane Desselle
about 1 year ago

Diversification of revenue streams will not happen without proper documentation.