Lecture 1 & 2: Amb Care & Benchmarking

performance measurement

process when an org establishes parameters where programs, investments, and acquisitions are meeting desired results

key performance indicators (KPIs)

mission + process + pharmacy service outcome measures

• measure of performance and key indicators progress towards intended result

• focuses on strategic and operational improvement

• creates analytical basis for decision making and helps focus attention on most important stuff

benchmarking

continuous process where an org measures and compares its processes with other orgs that are leading in a particular area

3 components of benchmarking

• submission

• comparisons/reports

• quality improvement

  • *continuous* (CQI)

4 benchmarking considerations

• compare your benchmark to similar orgs/individuals

• consider size (# of scripts filled) or location (rural vs urban) if possible

• differences in benchmarks should be explainable (not apple to orange)

• equitable makes easier to achieve goal

benchmarking benefits

• determines value and effectiveness

• quantifies how much time spent on cognitive work

• compares performance to similar institutions

• highlights value of services

• identifies opportunities to reduce costs

• compares effectiveness of initiatives with similar efforts from other places

• quantifies opportunities for performance improvement

• determines next steps to achieve cost reducing target and utilization improvement

internal benchmarking

measures performance of org against the org over time (compare current/future to past performance)

internal benchmarking goals

• develop progress tracking tool and measure data accurately

• document major processes regularly

• document work efforts required to achieve desired outcomes

• track & trend work efforts (pt volume change, new pt care areas, tech)

• identify suboptimal outcomes to be corrected & remeasured

external benchmarking strategies

• explore and understand reporting options

• understand how measures will be reported

• review available labor productivity and cost measures

• develop systems to measure inpt drug $ separately

• select meaningful peer reporting groups

• identify & follow most important KPIs to compare to peers

• review KPIs and compare with 25th, 50th, 75th percentile of peers

• train dept benchmarking expert

• develop routine process to review KPIs & benchmarking results

• understand limitations of external systems

• determine ≥1 opportunity for overall labor efficiency improvement and total cost performance

• if don’t like pharmacy labor productivity ratios then review nursing’s and compare to peers

• market what’s learned and understand admin expectations

• understand benefits of internal benchmarking > external

external benchmarking challenges

• consistent data defns and clear data collection

• data cleaning

• adjusted vs unadjusted outcomes

• case mix (address diff across orgs)

• challenges determine right comparison groups

why should pharmacists be included in amb care clinics?

• improve quality of care

• enhance pt outcomes

• contribute to cost avoidance

4 amb care pharmacy practice models

• employed - employed as staff member (large group practice)

• embedded - partnership with hospital/pharm school (part time)

• regional - serve multiple sites across area in health system (pop health)

• shared resource network - contracted by provider group to provide service to specific pts (assumes admin responsibilities)

4 pharmacist workflow patterns

• pre-appointment planning

• coincident referral/covisit (“warm handoff”)

• follow-up referral

• targeted consultations

pre-appointment planning

1. Rx reviews chart or meets with pt

2. Rx makes recommendation to PCP

3. PCP meets pt

coincident referral/covisit

1. PCP meets patient

2. Rx joins end of visit or after (back-back)

3. Rx makes recommendation to PCP

follow-up referral

1. PCP meets pt

2. PCP refers pt to meet with Rx

3. Rx meets separately with pt

targeted consultations

1. pt meets criteria for Rx consult

2. consultation placed by PCP or Rx

3. Rx provides service

why must pharmacists use indirect billing in the clinic?

recognized as “non-physician providers” (NPP) under Medicare so can’t directly bill for services

—> Rx can receives billing indirectly by submitting bill to payer through another recognized provider

HCPS codes

Healthcare Common Procedure Coding System

based on CPT but more dimensional

• level 1 - identical to CPT (5 #s)

• level 2 - nonphysician services & J-codes (non-oral meds & chemo)

• level 3 - local HCPCS codes

CPT codes

Current Procedural Terminology

describe procedure/service given to pt

6 services that contribute to generating revenue under Medicare Pt B

• incident-to-physician

• facility fee

• annual wellness visit

• transitional care management

• chronic care management

• diabetes self management training

medicare incident-to-physician billing

• hospital or physician based clinic

• requires direct physician supervision

• avoid w/ preappointment planning & coincidental referral

• only bill up to least complext level = “nurse-only”

medicare facility fee billing

• only hospital-based clinics

• flat fee (reimbursed the same regardless of time/effort)

• requires direct physician supervision

• avoid w/ preappointment planning & coincidental referral

medicare annual wellness visit

• promotes preventative service

• requires direct physician supervision

• able to bill service on same day as PCP visit

medicare transitional care management

• following discharge to prevent/decrease hospital readmission

• bundled payment for all HCPs on team for the month

medicare chronic care management

• non face-face

• pt gives consent

• bundled payment for all HCPs on team for the month

medicare diabetes self management training

• must be accredited program but CDE not necessary

• bill using pharmacy’s NPI

• referral from PCP or NPP

approaches for demonstrating financial value of a service (justification)

• revenue generator

• cost avoidance

• quality improvement (should lead to revenue generation & cost avoidance)

calculate expected payment for Pt B drug using J-code billing units

(drug dose/J-code dose)(J-code payment)