Developing + Managing A Clinical Practice Flashcards
An accountable care organization (ACO) recently hired
you as the first clinical pharmacist for its internal medicine clinic. Providers have been overwhelmed with the number and complexity of the medication-related problems in their patient population. They believe they need a pharmacist’s skills; however, they are unclear about your role and service and ask you to develop a proposal.
Which is the most important first step in preparing
your service proposal?
A. Do an external environmental scan to determine
which types of services others have provided to a
similar population.
B. Do an internal environmental scan to determine
which type of medication problems patients are
experiencing.
C. Determine the payer mix and current reimbursement opportunities for pharmacist-provided
patient care services.
D. Focus on your specific training and strengths,
such as detailing your role and service in diabetes
patient care.
The first step in planning any service is determining your organization’s needs. The optimal method is to perform what is termed an internal environmental scan, which is the collection of needed internal data that will identify important needs of the organization (Answer B is correct). Once these are identified, you can use other strategies to develop your proposal such that it becomes viable solution for the organization’s needs. Such strategies include the external environmental scan. To build the case for your services, you can use what is reported in the literature or provide examples of competitive organizations in your community that are already providing such services. You can also use your literature search to learn best practices and design your service to avoid barriers that others have
identified and that may affect your services (Answer A
is incorrect). Determining payer mix and reimbursement potential is crucial but is a secondary step after organizational needs are identified (Answer C is incorrect). Although you may be proud of your training and expertise, it may not mesh with the needs of the current job you are undertaking. Be confident that your training provides you with sufficient knowledge and self-directed learning skills to gain the necessary knowledge to develop services outside your comfort zone. If this development is well beyond
your scope of knowledge, you may need to include hiring personnel with the desired training in your proposal. Never start a service that is not needed; it will be doomed to failure (Answer D is incorrect).
Correct Answer: B
An accountable care organization (ACO) recently hired
you as the first clinical pharmacist for its internal medicine clinic. Providers have been overwhelmed with the number and complexity of the medication-related problems in their patient population. They believe they need a pharmacist’s skills; however, they are unclear about your role and service and ask you to develop a proposal.
You recognize that the success of your service depends on the efficiency of your workflow and how effectively it integrates with the workflow of other providers.
Which is the optimal implementation strategy for your
proposed daily workflow in the clinic?
A. Perform all patient scheduling for the services you
provide to prevent losing patients to follow-up.
B. Use the clinic’s patient service representatives to
perform patient scheduling services.
C. Develop a rigid patient visit schedule set at 45
minutes for new patient visits and 30 minutes for
follow-up appointments.
D. Establish a separate referral process from providers in the ACO to control your schedule.
A common mistake made by pharmacists is to undertake duties that less-qualified support personnel can perform. Although it may seem reasonable to perform these duties when starting your clinic, it will be difficult to pass this work back to others as your practice becomes increasingly busy. It is wise to develop your workflow from the planning stages so that the work provided by the pharmacist is
work that only you or another provider with similar skills can perform. Plan and negotiate using existing staff such as a medical assistants, schedulers, and front desk staff to perform functions and support they are already doing for others that you also will need. Provide them with guidelines and expectations for your services. They can make sure no patients are lost to follow-up if the expectation and process are clear (Answer A is incorrect; Answer B is correct). Rigid scheduling, an approach that health care has used for
many years, is not optimal because it is not patient centered (Answer C is incorrect). Allowing flexibility in scheduling (e.g., building 10-minute catch-up slots or saving spots for daily unexpected needs) improves patient satisfaction and may even improve efficiency. Establishing a separate referral process is not a good choice because trying to create a new process only for your clinic requires your referral sources to learn and remember something different from what they are used to performing. This change in usual process would ultimately negatively affect your referrals
(Answer D is incorrect).
Correct Answer: B
You are developing a Centers for Disease Control
and Prevention (CDC)-recognized diabetes prevention program for your community pharmacy. When
performing an analysis for strengths, weaknesses,
opportunities, and threats (SWOT), which is the best
opportunity for you to develop and create the program?
A. Hiring a new pharmacist with a community
postgraduate year one residency (PGY1) and an
interest in diabetes management.
B. Remodeling your pharmacy for immunizations
with a private area to perform the service.
C. Identifying that a large percentage of your patient
population is of Southeast Asian descent, which
is the fastest-growing population with diabetes in
the United States.
D. Reviewing billing codes that exist for this service,
though you have not calculated whether this avenue for directly generating revenue will cover the
program costs.
Opportunities are situations and information that are
external to your business or service that will support your
initiative. That the population your pharmacy serves is
primarily that for which data show is the fasting-growing
population with diabetes suggests a need for and sustainability of your service (Answer C is correct). A strength of your proposed program is hiring a pharmacist with interest and competency in the prevention program. Strengths are internal criteria that support the program (Answer A is incorrect). The same is true for Answer B; it is a strength of your pharmacy that you have existing appropriate space (Answer B is incorrect). The availability of billing codes is a benefit but a questionable opportunity if costs are not fully covered (Answer D is incorrect)
Correct Answer: C
To produce the desired health outcomes, pharmacists
can use a business tactic known as the balanced scorecard. Which group of organizational measures best reflects a balanced scorecard?
A. Percentage of providers trained in correct blood
pressure measurement technique; percentage of
patients with blood pressure values documented
at each visit; percentage of blood pressure values
less than 140/90 mm Hg; performance reimbursement for meeting blood pressure value goals.
B. Number of errors made in computerized provider
order entry system; patient satisfaction scores;
hospital readmissions for heart failure; weight
documentation in chart.
C. Number of faxes versus electronic medical record
use for communication with the laboratory; A1C
values less than 8%; adherence rates to oral antihyperglycemic medications; number of diabetes
visits per month per patient.
D. “Incident-to” evaluation and management
(E/M) code revenue; number of referrals for
smoking cessation; documentation of smoking cessation education; maintenance of Board
Certified Ambulatory Care Pharmacist (BCACP)
credentials.
Ensuring the providers are trained in correct blood pressure technique is a measure of your clinic structure,
ensuring that blood pressure is documented at each visit
is a process measure, achieving a blood pressure goal is
an outcome, and knowing how that outcome influences
the organization’s financial status is an important financial measure, thus meeting the four key elements of the balanced scorecard: structure, process, outcomes, and financial measurement (Answer A is correct). Answer B is lacking a structure measurement. The computerized provider order entry system would be a structure measure that could be used in this case to meet a balanced scorecard with the other measures listed. Answer C does not have a financial measure component, and Answer D does not have an outcome measure component.
Correct Answer: A
Your organization is moving toward value-based payment models and recently became part of the Medicare Shared Savings Program (MSSP). To sustain your services within the organization, you want to ensure that you are contributing to the quality measure set for this Medicare-based Alternative Payment Model (APM). Which measure set is best to review?
A. Healthcare Effectiveness Data and Information
Set (HEDIS) measures.
B. Merit-Based Incentive Payment System (MIPS)
measures.
C. Interoperability measures.
D. ACO measures.
The MSSP was established by CMS under the ACA as a new approach to health care delivery to facilitate coordination and cooperation among providers to improve the quality of care for Medicare beneficiaries and reduce unnecessary costs. To participate in the MSSP, providers should either be an ACO or participate in an ACO. Participants must report on the ACO quality measures established by CMS (Answer D is correct). The MIPS measurement of interoperability is for Medicare Part B, which is a FFS model (Answers B and C are incorrect). The HEDIS measure set is for commercial plans (Answer A is incorrect).
Correct Answer: D
Your practice is growing and needs another pharmacist practitioner. Your physician partners have clearly stated their desire for the new hire to have the same level of skills as you in order for them to be comfortable in extending the collaborative practice agreement (CPA) to that practitioner. The risk management team is also concerned with consistency and the same standard of practice and skill. To mimic what the organization uses to ensure highly competent physicians, nurse practitioners, and physician assistants, you develop a credentialing and privileging program for patient care pharmacists. Which tactic is best to use to assure your organization that the best hire has
been made?
A. BCACP credentials.
B. Postgraduate year two (PGY2) training.
C. Peer review of services at 90 days.
D. Medication therapy management (MTM) training
certification.
Although BCACP status, PGY2 training, and MTM certification may all be desired credentials, they within
themselves will not guarantee that the new hire meets the needs of your organization or be at the same skill level as you, the organization’s current patient care pharmacist (Answers A, B, and D are incorrect). The necessary degree of trust for that individual will develop on the basis of his or her performance, thus making peer review of services the best option for building the needed trust and confidence (Answer C is correct).
Correct Answer: C
You are a pharmacy director of a community hospital that lost 3% of its Medicare revenue this past year
because of the readmission penalty. To rectify this
problem, the hospital has a strategic plan to improve
its ambulatory care presence. You have pharmacists
currently in the ambulatory clinic attached to the hospital; however, you have not pursued billing for their services. You believe the current pharmacists’ services will meet the intent of the new strategic plan, but you also know that the ability to generate revenue directly will be a key component in sustaining these services. Which group of codes will be most beneficial to pursue in sustaining and potentially growing these services?
A. 99605–99607 MTM service codes.
B. 99211–99215 incident-to E/M codes.
C. Ambulatory Payment Classification (APC) 5012,
G0463 facility fee codes.
D. APC 5011, Current Procedural Terminology
(CPT) 99490 chronic care management (CCM)
codes.
Under HOPPS, all mid-level practitioners who are employees of the hospital and meet incident-to rules bill the same facility fee code. The current revenue for that code is a reasonable reimbursement (Answer C is correct). Codes for MTM are not currently recognized or payable under Medicare Part B (Answer A is incorrect), nor are the incident-to E/M codes submitted by pharmacists currently recognized under HOPPS (Answer B is incorrect). The CCM codes can only be used for patients who meet the criteria established by CMS (Answer D is incorrect). In addition, the reimbursement for CCM codes is currently less than that for the facility fee code.
Correct Answer: C
Which billing opportunity is currently best for a physician group to use to generate revenue for patient services performed by pharmacists under general supervision?
A. MTM codes.
B. CCM codes.
C. Incident-to codes.
D. Wellness visits.
Medicare relaxed the incident-to rules of direct supervision for CCM and TCM services that can be performed by auxiliary personnel within their scope of practice (includes pharmacists) to bill these particular codes. General supervision is thought to be sufficient because the Medicare-approved provider in these cases would be setting, sharing, and reviewing patients’ plans of care, thus providing general supervision (Answer B is correct). Incident-to E/M codes and AWVs are incorrect because they require direct supervision (Answers C and D are incorrect). Medication therapy management is not a recognized billing code under Medicare Part B (Answer A is
incorrect).
Correct Answer: B
A pharmacy manager at a rural community outpatient clinic is thinking about starting a diabetes disease management service. What is the first step the pharmacist should take to justify this new service?
A. Collect patient data to assess the need for the service
B. Develop a mission statement to provide a focus for the service
C. Perform a SWOT analysis to determine if the service is justified
D. Perform a thorough financial analysis to determine startup costs
A. Collect patient data to assess the need for the service
According to recommendations from the senders for Medicare and Medicaid services what is the minimum number of allotted comprehensive medication reviews and targeted medication reviews for MTM for which Medicare patients are eligible?
A. Quarterly CMR with targeted medication reviews monthly
B. CMR twice annually with annual targeted medication reviews
C. CMR every 5 years with annual targeted medication reviews
D. Annual CMR with quarterly targeted medication reviews
D annual CMR with quarterly targeted medication reviews
What are the 4 criteria that make a balanced scorecard
structure, process, outcomes, and financial measurement
