3 Steps to Profitable Care Management for Medical Homes — Lessons from Networks and Community Pharmacies…

There is endless coverage from pundits about how value-based payment will change the future of physician practice.  However, go to any busy primary care provider and you see how difficult it is to keep the business going. Family physicians and pediatricians are an amazingly dedicated group of professionals that have demonstrated their value over several decades across the globe and the US.

When audiences ask me what the solution is to our increasingly complex and expensive health care system — I start with a simple idea.  Deliver more primary care and less specialty care. This is a call to action.

The problem with that idea is that we have an increasing shortage of primary care, expanding demand from aging baby boomers, and a regulatory environment which complicates the daily practice of medicine.  None of these trends is going to change and things are likely to get more challenging.

Given the complexity of sustaining primary care medical homes, it is critical to look at successes within the world of care management. I am fortunate to live in North Carolina, a region which has continuously innovated around care management and medical homes.  Community Care of North Carolina is a managed network of networks that continues to foster clinically and financially integrated models of care.  In this article, I will include the current state of programs in North Carolina and nationally.  Not surprisingly all of the models are delivered through a network of people, services, and technology.

There are enormous risks for our most vulnerable citizens (behavioral health and elderly) during transitions in care from the hospital and emergency care back to primary care.  70% of the time the risk from transitions is associated with preventable adverse drug events.  Experts from the UNC’s Center for Medication Optimization Through Practice and Policy are evaluating the outcomes of a variety of interventions for these drug therapy problems. Here are 3 steps to consider.

The center is involved in a formal collaboration with Community Care of North Carolina in an effort to innovate and create best practices around medication optimization and the role of the pharmacist as an integral member of the health care team in the delivery of high quality, patient-centered care. The collaborative partnership utilizes existing Community Pharmacy Enhanced Services Networks, which were created by CCNC in 2014, to broaden capacity for care management and medication optimization services. The CPESN encourages relationships between pharmacists, nurse-care managers, and physicians in order to help provide patients with the best care possible.

  1. Primary care physicians and leaders can partner with pharmacy colleagues who participate in 20 states (and growing) network called the Community Pharmacy Enhanced Services Network. This network includes well-established pharmacies that see patients more than 4 times as frequently as primary care practices. These pharmacies are paid to provide additional services for Medicare patients which include medication synchronization, medication therapy management, and care planning.  The pharmacists are required to produce an eCarePlan which includes dispensed medications and drug therapy problems in an industry standard CCDA. CCDA is a standardized electronic care summary developed by the American Academy of Family Practice and is required by Meaningful Use 2.  This step will save your practice staff time and help them be more effective when patients have 5 or more medications as drug therapy problems are evitable when they receive care by specialists, go to the emergency department, and especially if they are hospitalized. During my 7 years running a health information exchange in Southern Indiana, my staff worked with both primary care and behavioral health organizations to optimize medication management at care transitions.
  2. Evaluate your practice’s financial opportunity to participate in CMS payment for Chronic Care Management (CCM). During my role as senior vice president for a health system in coastal South Carolina, we estimated that the 60 physician group could generate an additional $500,000 of annual revenue if we enrolled eligible Medicare patients into this program.  CMS has enhanced the program to include 3 levels of coding and automatic enrollment which makes this program more feasible for physician practices.  Despite this improvement, it is still difficult to change workflow within busy medical practices. Rather than do this alone, physician practices can work smarter by partnering with pharmacies in the CPESN program from step 1. These CPESN pharmacies have already made the cultural commitment to care management and are learning how to deliver these services at the lowest possible cost.  CCM coding requires a practice to document 20 minutes of care coordination per month that almost always includes medication optimization.
  3. Work with your electronic health records (EHR) vendor to see how their CCM module works. Almost all outpatient EHRs now include a timer which automates the sending of CCM codes for billing.  One CEO of largest vendors proudly told me “this is our fastest growing service with primary care and we are helping our customers be more profitable.”

Karen L. Smith, MD, FAAFP shares her experience with offering Chronic Care Management (CCM) services to her Medicare patients in a rural North Carolina community. Watch this short video to learn more about the benefits of providing CCM to patients living with multiple chronic conditions.

I am excited to share this information and more in a talk on May 12th at the National Physician Conference in Ft. Lauderdale, Florida.




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