Developing and Managing a Clinical Practice

Question 1

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.
2. 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

Answer 1

1. 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. 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).

Question 2

3. 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.

Answer 2

3. 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)

Question 3

4. 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.

Answer 3

4. 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

Question 4

5. 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

Answer 4

5. 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)

Question 5

6. 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

Answer 5

6. 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)

Question 6

7. 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

Answer 6

7. 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

Question 7

8. 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

Answer 7

8. 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)