Financial Sustainability of an Oregon Rural Health, Primary Care, and Pharmacist-Run Comprehensive Medication Management Program Through Direct Medical Billing.

BACKGROUND: Although several states recognize pharmacists as providers and allow credentialing, this practice is not recognized nationwide. Following adoption of Oregon House Bill 2028, pharmacists are recognized as providers, allowing "health insurers to provide payment or reimbursement for their services to patients." Before this law, and in several instances currently, pharmacist-run programs were financially justified through soft dollars saved by improving patient outcomes, reducing emergency department use, and decreasing readmission rates. OBJECTIVE: To determine if direct billing of third-party payers covers the direct cost of a comprehensive medication management (CMM) program in an ambulatory rural health adult population with uncontrolled diabetes or hypertension. METHODS: This study of a population derived from 2 Oregon rural health primary care clinics was a retrospective chart review of adults (aged ≥18 years) with a primary diagnosis of diabetes mellitus or hypertension who completed a CMM visit with a clinical pharmacist from March 2017 to June 2018. In determining the financial sustainability of a pharmacist-run CMM program, the following primary outcomes were evaluated: (a) percentage of visits completed per insurance type; (b) median reimbursement rate (dollars per visit) per insurance type; and (c) the estimated number of visits per day to cover 100% of the total CMM cost annually. The secondary outcome was the percentage of the major third-party payers that allowed credentialing of pharmacists. All outcomes were evaluated using descriptive statistics. RESULTS: 664 CMM visits were included. Visits per insurance type comprised Medicare Advantage (34%), traditional Medicare (25%), Oregon State Medicaid (20.9%), commercial (17.8%), and self-pay (cash; 1.4%). Median reimbursement rate (dollars per visit) was highest from Oregon Medicaid, followed by Medicare Advantage, and lowest among commercial, self-pay (cash), and traditional Medicare. Total reimbursement received throughout the duration of this pilot project covered 14.1% of the total CMM program cost. It was estimated that approximately 17 visits per day are needed to cover 100% of the total CMM cost annually per pharmacist relying solely on direct revenue within these clinics. Currently, of the 18 contracted insurance companies, only 50% recognize and allow credentialing of pharmacists as providers. CONCLUSIONS: Pharmacist-run services within the 2 rural health primary care clinics were not financially justifiable via direct billing of third-party payers alone. The lack of credentialing, recognition of pharmacists as providers, and reimbursement is inadequate for program expansion and sustainability without relying on additional revenue streams or benefits from improved patient outcomes. Currently, federal insurance significantly contributes to this lack of funding. DISCLOSURES: No outside funding provided support for this research; however, funding from Willamette Valley Community Health was given in the form of a grant to partially fund the comprehensive medication management pilot program. Pharmacists were paid from this grant, while Sublimity Pharmacy compensated pharmacists in the form of benefits. The authors have nothing to disclose. This work was presented in part as a poster at the ASHP Midyear Clinical Meeting; December 4, 2018; Anaheim, CA, and as a peer-reviewed podium presentation at the Northwestern States Residency Conference; May 4, 2019; Portland, OR.

Nurse Credentials: What Is the Economic Value?

A workshop sponsored by the Institute of Medicine brought together health care leaders to focus on the impact of credentials on nurse, patient, and organization outcomes. Demonstrating the value of credentials is very challenging. Does the credential cause improvement? Or does it simply indicate which organizations are the better performers (and thus does not cause improvement)? As our health care system moves toward rewarding the value of health care, proponents of credentials will need to demonstrate credentials reflect true differences in the capacity to deliver health care. Credentialing is expensive; thus, it is imperative to critically assess the overall value of credentials, whether some credentials are more important than others, and how to support attainment of the most important credentials.

Ethics been very good to us.

This commentary asks whether ongoing efforts to accredit, certify, and credential hospital ethics consultants are nothing other than an illegal restraint on trade masquerading as an effort to protect the public from harm.

The making and transnationalization of an ethnic niche: Vietnamese manicurists.

The article addresses how Vietnamese immigrant women developed an urban employment niche in the beauty industry, in manicuring. They are shown to have done so by creating a market for professional nail care, through the transformation of nailwork into what might be called McNails, entailing inexpensive, walk-in, impersonal service, in stand-alone salons, nationwide, and by making manicures and pedicures de riguer across class and racial strata. Vietnamese are shown to have simultaneously gained access to institutional means to surmount professional manicure credentializing barriers, and to have developed formal and informal ethnic networks that fueled their growing monopolization of jobs in the sector, to the exclusion of non-Vietnamese. The article also elucidates conditions contributing to the Vietnamese build-up and transformation of the niche, to the nation-wide formation of the niche and, most recently, to the transnationalization of the niche. It also extrapolates from the Vietnamese manicure experience propositions concerning the development, expansion, maintenance, and transnationalization of immigrant-formed labor market niches.

A path to nursing excellence.

The return on investment for achieving Magnet status can be found in improved quality and reduced turnover.

Facing economic realities at the General Dental Council.

An often quoted description of professionalism I like is 'doing the right thing even when no one is looking'. We all have professional responsibilities; some are easier to meet than others, but being a professional is all about trust. Richard Emms as chair of this year's LDC conference put it very movingly: 'It's a great privilege to metaphorically take a patient by the hand (CRB and ISA checks permitting of course) and lead them through an agreed treatment plan, and it's why patients stay with us because they trust us to inform them and to do the right thing.' And that describes how most of the profession - my profession - behaves. But who can forget the big show of hands during the sessions at both the BDA and LDC conferences when Phil Hammond asked if the audience knew a fellow dentist they wouldn't want as their own and that most of the hands stayed up when he asked if we perhaps knew more than one colleague we wouldn't recommend? But we take no action. We all have pride in our profession, but we all know colleagues who may be letting that profession down. This is reflected in the increase in the GDC's Fitness to Practise caseload.

Physician tiering by health plans in Massachusetts.

BACKGROUND: Physician tiering is an emerging health-care strategy that purports to grade physicians on the basis of cost-efficiency and quality-performance measures. We investigated the consistency of tiering of orthopaedic surgeons by examining tier agreement between health plans and physician factors associated with top-tier ranking. METHODS: Health plan tier, demographic, and training data were collected on 615 licensed orthopaedic surgeons who accepted one or more of three health plans and practiced in Massachusetts. We then computed the concordance of physician tier rankings between the health plans. We further examined the factors associated with top-tier ranking, such as malpractice claims and socioeconomic conditions of the practice area. RESULTS: The concordance of physician tiering between health plans was poor to fair (range, 8% to 28%, κ = 0.06 to 0.25). The percentage of physicians ranked as top-tier varied widely among the health plans, from 21% to 62%. Thirty-eight percent of physicians were not rated top-tier by any of the health plans, whereas only 5.2% of physicians were rated top-tier by all three health plans. Multivariate analysis showed that board certification, accepting Medicaid, and practicing in a suburban location were the independent factors associated with being ranked in the top tier. More years in practice or fewer malpractice claims were not related to tier. CONCLUSIONS: Current methods of physician tiering have low consistency and manifest evidence of geographic and demographic biases.

Revenue cycle management.

With the widening gap between overhead expenses and reimbursement, management of the revenue cycle is a critical part of a successful vascular surgery practice. It is important to review the data on all the components of the revenue cycle: payer contracting, appointment scheduling, preregistration, registration process, coding and capturing charges, proper billing of patients and insurers, follow-up of accounts receivable, and finally using appropriate benchmarking. The industry benchmarks used should be those of peers in identical groups. Warning signs of poor performance are discussed enabling the practice to formulate a performance improvement plan.

Reimbursement as a legitimizing strategy for health education.

The health education profession has made significant advances throughout the past few decades. However, health education is still described as an emerging profession. This article suggests strategies to move health education from its status as an emerging profession into that of an acknowledged profession. The authors assert that actively seeking direct third-party reimbursement will advance health education's emergence as a profession as well as increase its legitimacy in the eyes of other professions. The benefits of direct third-party reimbursement, experiences of the nursing profession's pursuit of direct third-party reimbursement, and the current status of health education are discussed. The article concludes by offering strategies for pursuing direct third-party reimbursement.