by David Pope, PharmD, CDE, Chief Innovation Officer
It’s easy to feel threatened in today’s pharmacy landscape – market consolidation, DIR fees, generic effective rate (GER) clauses and clawbacks are just a few of the challenges you have to face every day.
To combat these threats, many pharmacies focus on improving operational efficiencies by leveraging the purchasing power of buying groups and seeking better payer agreements through PSAO relationships. While it’s always a good idea to improve operational efficiencies, the problem with this strategy is that it focuses on improving what you already have versus growing your business to prepare for a future that looks different from today.
Reacting to threats is a necessary part of any business. But what if we shifted our focus from managing threats to leveraging opportunities that the changing pharmacy landscape has to offer? As Steve Jobs once said, “innovation is the ability to see change as an opportunity, not a threat.”
It’s no secret that pharmacies must diversify their business model beyond dispensing in order to stay viable long term. And most pharmacies have already taken an important step in that direction by providing immunizations. This model has been incredibly successful, both for patients who now have a more convenient setting of care to receive vaccines and for pharmacies that receive a high ROI from providing this service.
While the pharmacy industry has embraced immunizations, the expansion into other clinical services has not been nearly as widespread. If immunizations are the only clinical service you provide, you could be missing out on other high-value clinical services that are actively being reimbursed by payers.
So why aren’t more pharmacies involved in clinical services beyond immunizations?
Reimbursement for clinical services varies by state and payer. It can be tough to figure out the financial value without dedicating some focused time to research and figure out the impact for the business. In addition, understanding the different credentialing and training requirements can be overwhelming. Much like figuring out the financial value of reimbursement for clinical services, learning the different credentialing and training requirements also requires focused time to research.
However the effort to make these changes is worth it if you want to grow your business. Every single pharmacy has the opportunity to improve patient care and increase revenue through clinical services. Many pharmacies already provide clinical services that may qualify for reimbursement after establishing a relationship with a payer, or can begin to offer those services with the proper training.
Here are three actionable steps you can take to start expanding your footprint in clinical services.
1) Understand the opportunity for clinical services in your community.
Determining which clinical services to offer at your pharmacy starts with understanding which services are allowed in your state, defining payers that reimburse for each service and determining the credentialing and contracting process with payers. Fortunately, there are organizations that have taken the guesswork out of each of these potential barriers, allowing a smooth process for those ready to engage in clinical services.
When you are researching the right resource to help you understand the clinical services landscape, look for these key aspects:
- A list of clinical services that pharmacists can provide in each state(s). This is influenced both by state law and payer acceptance.
- The necessary accreditation steps your pharmacy needs to provide certain services.
- Access to training and credentialing requirements for pharmacists.
- A list of payers within your state(s) that will reimburse for each service as well as CPT codes.
- Links to the necessary documentation for payer contracting.
2) Evaluate the impact of the following emerging clinical services.
Requirements vary by state and payer; however, there are a few key clinical services that are rapidly emerging and quickly expanding among other states. They include:
There are other clinical services you can offer in addition to the four categories listed above, such as Medication Therapy Management (MTM), pharmacogenomic counseling and more. Once you select the clinical services that best fit your patient population and your organization, start the process as soon as possible. Completing the credentialing and contracting process with a payer for a medical benefit can take up to three months, sometimes longer.
3) Choose the right technology to support your clinical services focus.
Once you determine which clinical services to pursue in your pharmacy, it’s imperative you build the right infrastructure to support the documentation and reimbursement of these services. The good news is there are technology solutions for electronic documentation that will streamline your workflow and ensure that you’re capturing all the information necessary for proper reimbursement. Leveraging technology in this area will put the right guardrails around your clinical services program to ensure that you are capturing all the information needed for reimbursement.
It’s also important to note the majority of clinical services are billed as medical claims, not pharmacy claims. You need to ensure your documentation technology provides a way to bill medical claims that includes built-in guardrails to ensure high collection rates.
The pharmacy industry is moving towards providing enhanced clinical services, and now is the time to act. Start laying the groundwork to deliver these services in your pharmacy in order to realize a meaningful impact on your patients and the financial health of your pharmacy. There are foundational requirements, such as credentialing and contracting, that will be required regardless of the clinical service you select. Pharmacies that are able to capitalize on this trend now will propel their organization forward in the new landscape.
Ready to take the next step towards clinical services?
Check out Strand-Rx – the only certified, cloud-based and billing-enabled EHR for retail pharmacy, designed to support you in making your pharmacy a destination for clinical services.
David Pope, PharmD, CDE Chief Innovation Officer
In his role as chief innovation officer, David Pope, PharmD, CDE, leads OmniSYS’s efforts to develop innovative solutions that support the evolving role of pharmacy in healthcare delivery. Dr. Pope is a nationally-recognized expert in medical informatics and clinical services in the pharmacy space, and has served as an advisor for the Center for Disease Control (CDC) as well as multiple Fortune 500 healthcare-related organizations.