Last week, one of the Medicare Part D plans using Mirixa for Medication Therapy Management (MTM) “dropped” a new batch of “Star Measure” alerts to our pharmacy. These have been previously discussed here on this blog.
This “drop” was not unlike previous iterations our pharmacy has seen; the patients highlighted for possible compliance issues were exclusively patients residing in group homes. Each of the patients have staff working with them to ensure that they take their medications, and all of their medications are in compliance packaging (either OPUS cassettes or other systems to enable the staff to make sure that all doses are given). Every time the patient misses a dose, the staff report the incident to us, and we document the pertinent details in our clinical documentation system (PharmClin). Needless to say, if a patient is severely non-compliant, we would know quickly (because we would be receiving calls several times a week).
If it is not obvious by now, every one of these Star Measures cases were a false positive. Each patient was, and continues to be, nearly 100% compliant (as a percentage of days covered or PDC). So why were these cases brought to our attention? The answer relates workflow.
The workflow required to handle the large number of prescriptions dispensed on the same day each month to a large group home population requires a fairly involved process that is mostly automated by our pharmacy dispensing system. Even with this automation, billing may be delayed by up to 10 days for some prescriptions*. Keep in mind that it is the billing that is delayed, not the delivery of the medications.
Discussion
What is surprising is how quickly the plan and Mirixa identified what they perceived as compliance issues. We received the notices just short of 2 weeks after the due date of the prescriptions. That is just short of amazing, and some of our patients would consider this type of “short leash” offensive (and even an invasion of their privacy) if they were aware of how tightly the benefit manager is tracking them.
In this case, the delay in billing within our workflow resulted in sixteen “opportunities” to document and collect some “clinical” reimbursement from the program. Each of these cases is an opportunity to earn $12 by responding to the case (without respect to outcome). There are, however, two caveats about this program that should be noted.
- Each of these $12 interventions will be withheld from the performance incentive paid to the pharmacy (by the plan) at the end of the year (assuming we exceed drug specific patient compliance metrics). In other words, each $12 is effectively just an “early” performance payment.
- The Mirixa system for addressing these issues is time-consuming. If a pharmacist completes the intervention completely (updating each medication and answering all prompts), it takes a minimum of fifteen minutes to complete the intervention (not counting any patient contact time). This is not cost effective, as it does not come close to covering the time spent by the pharmacist.
The Pearl
These Star Measure interventions (or SSI Performance Network Program) are a much more focused intervention than a complete Medication Therapy Management Program encounter (MTMP). The reimbursement level (at just $12 per incident) reinforces this statement. To handle these interventions efficiently, make a call to the patient (this does not merit a face-to-face) and ask some open-ended questions. Patients can become defensive when approached about compliance, so it is wise to deflect this initially, noting that there are many possible reasons for this (like physician samples, dose changes, side effects etc) and let the patient fill in the rest of the story. For example:
We have noticed that your refills of lisinopril have not been as frequent as we expected. Often, changes are made by the prescriber, and the pharmacy is the last to know. How are you currently taking the medication? What difficulties, if any, are you having with the medication?
At $12 per intervention, break-even time (at a pharmacist salary of $50/hr) for this case is 14 minutes, so this phone call has to be efficient. You need only to establish if there is a real problem and a brief explanation. The phone call might take three to five minutes to complete.
Data entry must also has to be efficient. A tip for pharmacists working this type of problem in Mirixa: do not spend time updating the medication profile. It is not obvious, but leaving this portion of the intervention unfinished will not prevent (at least for now) the intervention from being completed. By omitting this information (and only addressing the fields that relate to the compliance issue at hand), a pharmacist should be able to complete the Star Measure intervention (call and data entry) in less than 10 minutes. This is much more in line with the actual reimbursement being offered.
Footnotes
* July 2015, with the observed holiday of Friday July 3rd, is a worst case scenario of delayed billing.