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Iowa Medicaid Pharmaceutical Case Management

The Iowa Medicaid Pharmaceutical Case Management (PCM) program was designed by an advisory committee of physicians and pharmacists to benefit a subset of Medicaid eligible patients at very high risk to experience adverse effects from their medications. The PCM program began with funds appropriated during the 2000 Iowa Legislative session.

PCM provides an opportunity for physicians and pharmacists to closely manage the total medication regimens of their most complex patients. Working together, they can find the best combination of medications and doses for a particular patient with multiple disease states. The innovative care delivered through this program is based on a model of care known to improve medication safety in hospital and clinic settings where pharmacists and physicians practice under the same roof and have access to patient care records.

PCM also provides for a new payment system wherein pharmacists and physicians are compensated for the additional care associated with drug therapy management services. The payment incentives associated with PCM serve to facilitate a new patient care model in the ambulatory setting that offers significant potential for improving both the quality and cost effectiveness of care.

PCM Pharmacist Application
PCM Pharmacy Application
PCM Patient Eligibility Request - Required
Executive Summary of the PCM Program Evaluation
News Release Announcing PCM Results
Final Report of the PCM Program Evaluation
PCM Billing Tool
Initial Fax Communication with Dispensing Pharmacy
Follow-Up Fax Communication with Primary Dispensing Pharmacy
Authorization to Release Medical Information
Care Plan Submission for RPh Applications

A Basic Description for Pharmacists

Eligible physician/pharmacy teams can now be reimbursed for providing Pharmaceutical Case Management services for eligible Medicaid recipients who are identified as at high risk for having trouble taking their medicines safely and effectively according to specific criteria.

Pharmaceutical Case Management (PCM) services involve physicians and pharmacists working together to help patients use their medications safely and effectively. Physician team members prescribe and establish treatment goals for their patients enrolled in the PCM program. Pharmacist team members provide supplemental follow-up and feedback between physician visits about patient compliance, achievement of treatment goals, and occurrence of side effects. Pharmacists must partner with a physician to participate. Pharmacists and physicians must meet eligibility requirements to participate.

As instructed by the Iowa Legislature, the University of Iowa evaluated the impact of PCM on patient care. An advisory committee of physicians and pharmacists was assembled to provide input to the research team. The research team provided periodic reports to the legislature and a final report in December 2002.

Frequently Asked Questions

How is a physician-pharmacist team established?
Generally, physicians and pharmacists are already working together on an as-needed basis. The PCM program strives to strengthen these relationships, make them more intentional, with focus on patients with special medication needs. The real team building will happen over time as the team interacts around the care of the enrolled patients. Teams for some patients will include a single physician and a single pharmacist. For other patients, particularly in urban areas, several pharmacists from a single pharmacy and several physicians from a group practice will build a team.

When and where is the care delivered? How does it get started?
Under the direction of the Department of Human Services, patients can be identified by physicians or pharmacists as eligible to receive services if they meet specific criteria outlined on the PCM Patient Eligibility Request form. (This form is a requirement and must be sent in before care is provided.)  Participating providers may also receive lists of eligible patients in their practice. The pharmacist contacts the patient to encourage them to participate. The pharmacist will also contact the patients’ physicians to discuss pharmaceutical case management, discuss eligible patients whom they are collectively serving, and explore the particular roles of each team member. Once each member of the team and patient have indicated a willingness to participate, the care team can choose communication methods and begin providing PCM services for the eligible patient.

The pharmacist will schedule an appointment with the patient to conduct an "initial assessment." During the initial assessment, the pharmacist will:

  • Take a medication history
  • Determine the indication for each medication, and record progress toward achieving treatment goals
  • Assess patient compliance
  • Detect any side effects or side effect risks that can be reduced (e.g., by changing dose, choosing lower risk medications, or using particular monitoring procedures)
  • Assess the need for regimen change, patient self-management education, and for administration and monitoring device training
  • Make written recommendations to the physician about any actions the team should consider, and about desired follow-up methods and frequency
  • Care team discussion regarding assessments can be conducted in person or by telephone, but a brief written version must also be created

The physician will finalize the action plan by:

  • Reviewing the pharmacist’s report
  • Approving or modifying (in writing to the pharmacist) the action plan proposed by the pharmacist
  • The action plan may include a physician visit, but a visit is not required for physician reimbursement for PCM services

After the team agrees upon an action plan, the pharmacist may directly initiate the plan, or may assist the patient in scheduling a physician visit if this is the next agreed-upon step. In either case, a "follow-up assessment" is scheduled with the pharmacist at the interval agreed upon by the team.

What is a problem follow-up assessment?
During the problem follow-up assessment, the pharmacist will:

  • Assess progress toward achieving the objectives of the action plan
  • Update the action plan by recording the progress made and making a written recommendation about what, if any, further action is needed and when the pharmacist should see the patient for follow-up.
  • The physician will review the pharmacist’s recommendations and, in writing, approve or modify them to finalize the current action plan.

What happens when the goals of the action plan have been achieved?
When the patient no longer requires follow-up for the medication action plan, the pharmacist and physician will continue to see the patient for their prescription and medical needs, respectively. During this usual care, new medications may be prescribed, other medications adjusted, and new medication use issues may arise. The "new problem assessment" is the mechanism by which the physician/pharmacist patient assessment cycle of the PCM program can be restarted if new medication use issues arise. This process allows for continual patient monitoring for problems due to medications.

During the new problem assessment, the pharmacist will:

  • Briefly review the patient’s medication history for changes
  • Identify any aspects of the new or adjusted medication that increases risk of medication side effects, compliance problems, or difficulty achieving treatment goals
  • Make recommendations to the physician about any actions the team should consider and about desired follow-up methods and frequency

If no new medication use problems arise by the time the goals of the action plan have been achieved, the pharmacist will schedule a six-month "preventive follow-up assessment" with the patient. During the preventive follow-up assessment, the pharmacist will:

  • Update the medication history
  • Assess patient compliance
  • Assess progress toward achieving treatment goals
  • Reinforce desired self-management behaviors
  • Detect new risk factors
  • Assess the need for regimen change and new patient education
  • Make written recommendations to the physician about any actions the team should consider about desired follow-up methods and frequency

Which patients are eligible?
Eligible patients are those who take four or more regularly scheduled non-topical medications, are not nursing home residents, and who have at least one of twelve select disease states (congestive heart failure, ischemic heart disease, diabetes mellitus, hypertension, hyperlipidemia, asthma, depression, atrial fibrillation, osteoarthritis, gastroesophageal reflux disease, peptic ulcer disease, and chronic obstructive pulmonary disease.) Other disease states may be added as the program matures. Patients who have been identified via a list are eligible for the services. Patients who currently meet the eligibility criteria may also receive services if referred by a participating provider.

How are providers reimbursed?
As of May 1, 2009, there are new billing codes for Pharmacy Billing of pharmaceutical case management (PCM) services rendered to Iowa Medicaid members. The previous “W” codes (W4100, W4200, W4300, W4400) implemented when this program started will no longer be used since these “W” codes are not HIPAA-compliant, nor subject to CMS exemptions allowing their continued use. The “W” codes have been replaced with the following HIPAA-compliant “CPT” codes, the fees for which are indicated below:

· 99605 - Medication therapy management service(s) provided by a pharmacist, individual face-to-face with patient, with assessment and intervention if provided; initial 15 minutes, new patient. ($45.00)

· 99606 - initial 15 minutes, established patient. ($20.00)

· 99607 - each additional 15 minutes (to be listed separately in addition to code for primary service). ($10.00)

 

Reimbursement Maximum

Maximum Number of Payments

Bill CPT Code(s)

Units

Initial Assessment

$75

One Initial Assessment/Patient

99605 +

99607

1

1, 2, or 3

Problem Follow-up

$40

Four Problem Follow-up/patient every 12 months

99606 +

99607

1

1 or 2

New Problem

$40

Two New Problem/patient every 12 months

99606 +

99607

1

1 or 2

Preventative Follow-up

$30

One Preventative Follow-up/patient every 6 months

99606 +

99607

1

1

These new CPT codes have been made effective for dates of service back to January 1, 2008 going forward. Please note the old “W” codes will be end-dated effective May 31, 2009.

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