Developing & managing a clinical practice Flashcards
1
Q
Questions 1 and 2 pertain to the following case.
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.
1. 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.
A
- Answer: B
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).
2
Q
- 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
- Answer: B
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).
3
Q
- 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.
A
- Answer: C
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).
4
Q
- 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.
A
- Answer: A
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.
5
Q
- 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.
A
- Answer: D
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).
6
Q
- 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.
A
- Answer: C
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).
7
Q
- 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.
A
- Answer: C
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.
8
Q
- 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.
A
- Answer: B
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).
9
Q
Practice Case
1. You recently completed a residency with an ambulatory care focus and have been hired by the pharmacy department
of a health system to start ambulatory services. The health system has an outpatient clinic with primary care
and medical specialty services. Historically, the pharmacy department has only provided inpatient services to the
organization. The health system’s goal is to expand into ambulatory care in preparation for value-based payment
contracts. The director of pharmacy asks you to develop a plan regarding which service would be best to start
with: transitional care, MTM, polypharmacy management, or specialty services. Which is your best first step?
A. Review the literature on successful practices for each service.
B. Pursue transitional care services because you had a residency rotation on these.
C. Choose specialty services because of the associated use of high-cost medications.
D. Perform a gap analysis to determine which services are most needed in the organization.
A
- Answer: D
The best first step is to use the skills you gained during
residency to collect the necessary information to determine
what is most needed by your organization and what
can be resolved with pharmacist services (Answer D is
correct). Performing this gap analysis and developing your
service while keeping your organization’s needs in mind
provide the best chance for your program to be approved
and continue to be successful. Review of the literature is
an important step; however, it would be a second step after
the optimal service is determined on the basis of need and
resources (Answer A is incorrect). Your residency training
should provide you with the critical thinking skills and
understanding of how to start a new service, and although
it would be convenient to perform a service with which you
have experience, that service may not meet the organization’s
needs (Answer B is incorrect). Although managing
high-cost specialty medications is needed by many organizations,
it may not be needed by your organization (Answer
C is incorrect).
10
Q
- You have been providing clinical pharmacy services in an antithrombosis clinic in your organization for 2 years
and would like to expand your services. You routinely document vital signs and have noticed that blood pressure
values are above goal for many clinic patients; however, you have not had time to address this medication-related
issue for most patients. At a recent clinic staff meeting, measures where the practice was not performing well were
presented. Blood pressure control was one of the measures. You would like to develop a new pharmacist-led blood
pressure management service and present the proposal to your clinic administrator. Which information will be
most important to obtain from an external environmental scan to use in your initial proposal?
A. Literature that supports positive financial and clinical patient outcomes from pharmacist services in blood
pressure management.
B. Advice solicited from an e-mail list of ambulatory care pharmacists providing blood pressure management
services.
C. Established practice standards specifically for pharmacists in blood pressure management.
D. The advertising brochure from the clinic 2 miles away detailing that it is part of the Million Hearts initiative.
A
- Answer: A
The most important information to obtain from an external
environmental scan is supportive literature because evidence
is strong for positive outcomes and the value of using
pharmacists in blood pressure management (Answer A is
correct). Answers B, C, and D might provide information
that would support your expansion of services; however,
with the strength of evidence, Answer A would best justify
the expansion of pharmacy services.
11
Q
- You have been hired as an assistant professor focused on ambulatory care at a new college of pharmacy. The college
has secured a new practice site in a family practice office that is reengineering its practice to align with the
Medicare and commercial ACO programs in which it is now participating. The service wants you to begin seeing
individuals with diabetes because the practice needs to improve its quality measures for both Medicare and commercial
payer contracts. Which best describes the optimal referral process to provide your service with the most
appropriate patients to affect the stated quality measures?
A. Referral by a physician for each qualified patient.
B. Automatic referral for patients with A1C 9% or greater.
C. Offer for patients to choose to participate in the pharmacist-provided patient care service.
D. Automatic referral only for individuals with diabetes insured through the commercial ACO.
A
- Answer: B
It is best to have a group of patients identified and scheduled
when the doors of your service open. This approach
accomplishes several goals, including efficiency with no
excessive downtime, whereas use of other approaches may
cause other employees in the service to question what you
are doing. In addition, this approach allows you to begin
generating outcomes sooner that sufficiently demonstrate
your value (Answer B is correct). Waiting for referrals by
a physician is problematic, primarily because of the following:
in their busy schedule, physicians may not often
think about referring their patients; they may have incentives
not to refer, depending on the billing incentives in
the ACO; and they may not initially trust in the pharmacist’s
skill set (Answer A is incorrect). Asking patients to
make another appointment with a provider with whom they are not familiar or for a reason they may not understand
can be problematic (Answer C is incorrect). It is difficult
for any organization to treat one payer population by providing
services different from other payer organizations.
This approach is also problematic with Medicare if the
Medicare population is not receiving the same service as
other populations for financial reasons; therefore, this process
is not recommended (Answer D is incorrect).
12
Q
- You are creating your referral template for a comprehensive medication management clinic available to all providers
in the medical group. Because most of your patients will likely be older, supervision will be provided by the
Medicare Part B providers (e.g., physicians, nurse practitioners) in the primary care clinic to meet the Medicare
rules for reimbursement. Which is most critical to include in your referral form?
A. Provider generating the referral.
B. Pharmacist for whom the provider is directing the referral.
C. Reason for referral.
D. Expectations of referral.
A
- Answer: C
A standard in Medicare billing, especially in the FFS billing
that eligible providers use for delegated services such
as pharmacist-provided patient care services, is the concept
of medical necessity. It requires the billing provider to document
a statement of medical necessity or the reason why
the patient must see the provider to whom he or she was
referred. Although this can be documented in the assessment
and plan of the note of the referring provider, its
inclusion in a referral form ensures that this step is documented.
Payers such as Medicare will audit billed services.
Not having this information may constitute fraud and usually
results in any payment for the referred service being
returned to the payer. This consideration makes the reason
for referral the most important item that is nonnegotiable
when creating your referral template or process (Answer
C is correct). The points in Answers A, B, and D are also
important for optimal coordination and communication.
13
Q
- Both in your proposal and after its approval, you will need a timeline for establishing your program. Which is the
optimal time interval from approval to seeing first patients for your service (in months)?
A. 3.
B. 6.
C. 12.
D. 18.
A
- Answer: B
Although reasonable timelines will vary depending on
when investment revenue is available or whether any construction
is required, in general, you will want to take
enough time to make sure you have addressed all considerations
so that, when your clinic opens, it can focus primarily
on patients and less on management issues. You also do not
want to have excessive delays because, to administrators,
“time is money.” The ideal time is 6 months (Answer B
is correct). Three months is likely too short to address all
the items required in developing and operating a service
(Answer A is incorrect). Going beyond 12 months is likely
too long and may discourage your stakeholders from supporting
your clinic (Answers C and D are incorrect).
14
Q
- You have a well-established heart failure clinic and have consistently decreased readmission rates for heart failure.
Many of your patients have comorbid diabetes, and you have also begun managing this condition through
recommendations to clinic providers. However, treating patients with diabetes is slowing the clinic workflow
because of needed approval for any medical decision-making you perform for patients with comorbid diabetes.
Which is the best course of action to resolve this inefficiency?
A. Adjust your schedule to spend one day in the endocrinologist’s office to further develop professional
relationships.
B. Work with your medical group to expand your CPA to include diabetes medication management.
C. Hire an additional pharmacist to focus solely on diabetes management for these patients.
D. Establish an electronic-based communication system to allow for faster communication.
A
- Answer: B
Answer B is correct. An initial CPA is often narrow in
scope. It often requires time to build trust in your competency
and skill with your team and supervising providers. As that trust progresses, your team will refer more patients
with a broader range of conditions. Expanding your scope
of practice in a CPA is the quickest and simplest fix.
Adjusting your schedule is an option if you have an endocrinologist’s
supervision to manage diabetes; however,
many of the patients you see routinely may be treated by
primary care and not need that level of specialist care or
cost (Answer A is incorrect). Hiring an additional pharmacist
is an option, though costly and unnecessary if you can
handle the workload (Answer C is incorrect). Establishing
an electronic-based communication system is not the root
cause of the problem you are facing (Answer D is incorrect).
15
Q
- An audit by the compliance officer results in a notification that you cannot use incident-to billing for the patients
for whom you are managing diabetes and heart failure with sodium-glucose cotransporter-2 inhibitors. Your current
CPA and protocol have not been updated since 2015. Which is the most likely reason for the result of this
audit?
A. Not within the pharmacist’s state scope of practice.
B. Change in Medicare payment rules.
C. Outdated CPA.
D. Not outlined in your policy and procedure.
A
- Answer: C
Answer C is correct. As new therapies and updated guidelines
are available, it is important to review your CPAs to
ensure the allowed practices are current and fully reflect
the pharmacist’s services. If CPAs are not reviewed at
least yearly, they may quickly become outdated. Because
Medicare billing requirements include that services provided
by auxiliary staff must be within their scope of
practice, a CPA that does not cover a provided service
results in that service not being within the scope of practice
(i.e., a state pharmacy practice act allows such services only
under a CPA). In such situations under a Medicare audit,
CMS may require that all payments for such services be
returned. Answer A is incorrect because if sodium-glucose
cotransporter-2 inhibitors were part of the CPA, it would
be within the state scope of practice. Answer B is currently
incorrect because Medicare allows reimbursement for auxiliary
services if they are within the pharmacist’s scope of
practice. Medicare can change the rules at any time, which
stresses the importance of staying current on billing rules
and regulations. Answer D is incorrect because billing
rules and regulations are not governed by organizational
policy and procedures.
