by David Pope, PharmD, CDE, Chief Innovation Officer
Let’s take a look back at the pharmacy immunization landscape just four years ago.
In 2016, one in four patients received their flu shot at a pharmacy, which was evidence of the impact retail pharmacy could have on population health through immunizations. However, only two and a half percent of those flu vaccine patients also received an appropriate companion vaccine. Furthermore, only three percent of eligible Med B patients had received both pneumococcal vaccines.
Around that time, the Health People 2020 initiative and CMS quality measures related to improving population health were top-of-mind for a lot of leaders in pharmacy. Pharmacy was well-positioned to make an even more meaningful impact on population health through immunizations, but how could we expand beyond flu?
Many patients understand the need for an annual flu shot, but they are less clear on the need for other recommended immunizations. Pharmacies needed a reliable way to leverage the power of growing access to patients seeking flu vaccines to start providing other companion vaccines as well.
Developing a complete patient immunization history
At OmniSYS, we knew the first obstacle to tackle was patient history. The challenge is that there was not (and still is not) a single source that that can provide a patient’s complete immunization history.
State immunization registries are important, but their average adult participation rate is only around fifty percent. There is helpful data in registries for the patients who have records, and this data should absolutely be used. But it needs to be supplemented with additional information.
Next up: Centers for Medicaid and Medicare Services (CMS), which has valuable information when it comes to Medicare beneficiaries. CMS has visibility into vaccines across all settings of care, which means you have visibility into the patient’s immunization history whether they received the vaccine at a doctor’s office, in another pharmacy or at any other setting of care.
And last but certainly not least, pharmacy data. With pharmacies becoming major players in immunizations, there is valuable data held within pharmacy immunization records. Understanding not only if a patient has had a vaccine at your pharmacy in the past, but also the pharmacy down the street or even a pharmacy in another state is a valuable piece of the puzzle.
Any of these data sources take alone gives a limited view of patient history. But when combined, they provide a complete immunization history across multiple settings of care. Here at OmniSYS, this combination of data is what we use to present patient history to you from within your workflow. Also, as we look ahead to an upcoming COVID-19 vaccine, it is anticipated that reviewing patient history will be a requirement before providing the vaccine, making this information even more critical.
Accurately identifying vaccine opportunities
Once you understand a patient’s history, the next step is to determine if the vaccine is necessary. The two main factors in vaccine necessity are clinical indication and financial eligibility, and these two elements must be combined (similar to patient history).
Let’s start with clinical indication. Generally based on ACIP guidelines, this tells you if a vaccine is clinically necessary based on factors like age and pre-existing conditions, which is critically important information before administering a vaccine. But clinical indication alone means you could immunize a patient for a vaccine that is not covered by their insurance, as clinical and finical guidelines differ.
That leads us to financial eligibility. A good example of why this matters is pneumococcal vaccines. While clinically the second dose can be given six months after the first, Medicare Part B and a number of other payers will not reimburse you for the second vaccine until twelve months after the first vaccine is given. If you provide the second vaccine based solely on clinical indication, your patient will be immunized but your reimbursement could be at risk.
With a significant number of vaccines covered under the medical benefit, solving financial eligibility requires medical benefit management expertise. Unlike pharmacy claims which are processed in real-time, medical benefit claims are more complex. The ability to check payer eligibility and patient coverage in real time before you provide the vaccine is critical to ensuring you get accurate reimbursement for the vaccine.
Bringing it all together
Now what’s a pharmacist to do with all of this great data? View it in workflow, of course, so it’s actionable for you and the patient. Upon claim adjudication, OmniSYS performs all of the “magic” outlined above behind the scenes, and sends back an alert for any eligible patients.
If you’re one of the 20,000 pharmacies already in the OmniSYS network, everything I just outlined above is already at work in your pharmacy! I hope peeling back the layers and revealing exactly what’s happening behind the scenes was helpful and informative. Throughout this immunization season, we encourage you to use the hashtag #ImmyWithOmni to share your immunization stories and successes!
If you are not already a member of the OmniSYS network and you’d like more information, let us know by filling out this form and someone will be in touch!