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On the Cusp of Change: Social Determinants of Health Garner Attention

Dr. Cynthia C. Nwaubani, BCGP, CMTM

Synopsis: The social determinants of health are being explored by pundits as the root cause of inefficient healthcare spending. This article discusses Health and Human Services Secretary Alex Azar’s recent nod to forthcoming changes in Medicare reimbursement for non-clinical care.

The social determinants of health—economic and social factors that impact health status—have received considerable attention from Health and Human Services (HHS) Secretary Alex Azar. In his November 14th speech at The Hatch Foundation for Civility and Solutions, Secretary Azar names the social determinants of health as the root cause of much of today’s healthcare spending.

Azar states, “We believe we could spend less money on healthcare—and, most important, help Americans live healthier lives—if we did a better job of aligning federal health investments with our investments in non-healthcare needs.”

As a clinical pharmacist delivering chronic care management (CCM) services, I have seen many patients whose health conditions are impacted or solely caused by social and economic factors. Ongoing medication therapies, emergency room visits, and extended hospital stays are often underpinned by factors outside of clinical care. The well-being of patients and families is thwarted, health outcomes compromised and a plethora of wasteful spending that ignores root cause and common sense. Asthma patients living in homes contaminated with mold, non-adherence to life-dependent medications due to cost, and diabetics without access to healthy food are commonplace.

Sweeping changes to healthcare delivery are expected in 2019, as the journey to a value-based healthcare economy continues. One of these changes will likely be an uptick in chronic care management services provided to Medicare patients with two or more chronic conditions. Addressing the social determinants of health is a compulsory aspect of Medicare-reimbursable CCM services—so it is reasonable to assume more patients will be adequately screened. Community resources (with paper-thin budgets) will likely be tapped for resource provision—healthy meals, transportation or funding for electricity bills. Addressing social determinants of health through CCM services is promising for Medicare patients; however, much work will need to be done to ensure adequate funding for resources.

In his November speech, Azar stated, “Just like how every patient is different in healthcare, every person has unique social service needs—and we are intent on designing models that connect them to the services they need, rather than offering a one-size-fits-all approach.”

A 2014 study by Dr. Seth Berkowitz evaluated the relationship between material need insecurities, control of diabetes mellitus and the use of healthcare resources. Berkowitz concluded, “Health care systems are increasingly accountable for health outcomes that have roots outside of clinical care. Because of this development, strategies that increase access to health care resources might reasonably be coupled with those that address social determinants of health, including material need insecurities. In particular, food insecurity and cost-related medication underuse may be promising targets for real-world management of diabetes mellitus.”

In the context of the study, addressing the social determinants of health is aligned with The Quadruple Aim: improved population health, reduced care cost, satisfied patients and satisfied providers. And Secretary Azar seems to agree: “What if we provided [sic] solutions for the whole person, including addressing housing, nutrition and other social needs? What if we gave organizations more flexibility so they could pay a beneficiary’s rent if they were in unstable housing, or make sure that a diabetic had access to, and could afford nutritious food? If that sounds like an exciting idea...I want you to stay tuned to what CMMI is up to.”

Yes, Secretary Azar, our curiosity is piqued!

Dr. Nwaubani is Founder and CEO of PharmD Live, an emerging digital health company focused on pharmacist-led innovative solutions to improve patient outcomes and ease the transition to value-based care. This article originally appeared as a guest post on healthcareguys.com.

MIPS Tips: Procrastinator’s Edition

Dr. Cynthia C. Nwaubani, BCGP, CMTM

The decision to enter the medical profession is personal—and for most of us, it precluded mountains of paperwork and coils of red tape. It had to do with people, healing and working for the greater good. As a pharmacist and CEO, it is easy to envision why business planning so often takes a back seat to patient care.

But as 2018 draws to a close, business plans for 2019 are demanding attention, especially for practices who treat a high volume of Medicare patients. Magnitudinous changes to reimbursement models are imminent, but there is still time to accelerate your MIPS plan and ensure it is aligned with 2019 practice objectives.

Of the myriad of concerns I have heard from stakeholders during past months, reducing physician burden tops the list. Studies show 28% of physician’s time is spent on non-clinical paperwork, translating to lost revenue for practices and increased physician dissatisfaction. It trends as a hashtag on Twitter for good reason—the role of the physician has expanded to include serving as a steward of the healthcare economy—no small task. And, success in the new healthcare model relies on between-visit care, which adds exponential demands on physician time.

If diving into the 2019 QPP requirements on CMS.gov feels daunting, read on. Caveat—consider this a conversation starter rather than an exhaustive list.

Quick Tips to get MIPS ready:

  1. Check your eligibility status. CMS requirements change from year to year, so this may vary over time. Remember, you can participate as an individual clinician or as part of a group. According to CMS.gov, “to be excluded from MIPS, clinicians or groups would need to meet one of the following three criterion: have ≤ $90K in Part B allowed charges for covered professional services, provide care to ≤ 200 beneficiaries, or provide ≤ 200 covered professional services under the Physician Fee Schedule (PFS).

  2. Choose your track: MIPS or APMs.

  3. Select six measures based on your patient population; focus on quality measures, as they will have the greatest impact on your final MIPS score. Improving patient care means quality measures will become increasingly stringent over time. Cost measures are weighted at 30% for the 2019 performance year and will increase over time—a cost-reduction strategy is a crucial element of a successful long-term plan.

  4. Innovate. In the context of the profound paradigm shift, physicians open to innovating their care models are most likely to thrive. CMS’ approval of several codes for chronic care management services via telehealth is a nod to the critical nature of innovation. Explore partnering with a third party CCM provider, such as PharmD Live, to shoulder between-visit care, adding value for patients and serving as a seamless extension of your practice.   

  5. Earn. In 2018, physicians could earn up to 5 extra points for caring for complex patients. CPT codes 99487 and 99489 allow reimbursement for CCM for complex patients, which can be outsourced to a third party vendor, such as PharmD Live, to optimize clinical and financial outcomes.

As January 1 approaches, explore evidence-based solutions, such as implementing pharmacist-led CCM services to meet and track quality measures. Clinical pharmacists are equipped to manage complex medical pictures, and make high-level clinical decisions to support your care plan.  

Ready or not, change is coming.


Leveraging Pharmacist-Led Chronic Care Management (CCM) Services to Decrease Acute Care Stays for Diabetic Patients

Dr. Cynthia C. Nwaubani, BCGP, CMTM

As the national healthcare model has transitioned from volume-based to value-based care, the role of the physician has also shifted. In the value-based care model, physicians are held accountable to deliver the best outcome at the lowest cost. The role of the physician has been redefined to include stewardship of the healthcare economy. November is Diabetes Awareness Month; we will examine the significance of this shift and the impact on the diabetic patient. The American Diabetes Association reports an annual cost of $327B for diagnosed cases of diabetes. One of seven healthcare dollars spent is on diabetic care. Because a significant portion of this spend is derived from costs of acute care, redesigning care delivery to keep diabetic patients out of acute care has been a focus of private and public payers. Chronic care management services—reimbursable by the country’s largest payer, Medicare—were borne from those efforts.

Because complex chronic conditions, such as diabetes, require significant care between office visits—developing a comprehensive patient-centered care plan, care coordination, transitions of care management and increasing access to care via telehealth and 24/7/365 clinician availability are elements of CCM.   

PharmD Live’s CCM services were designed to prevent acute care stays through effective management of the chronic condition. Here’s how PharmD Live’s CCM services are implemented:  

A dedicated clinical PharmD Live pharmacist collaborates with the physician to create a comprehensive care plan, using a patient-centric approach. Patient education and disease-state management plays a paramount role in care. The clinical pharmacist addresses the patient’s ongoing adherence to the care plan, ensures referrals are made to specialists for diabetes-related care (such as podiatrists for foot exams), identifies root cause of shifting bloodwork trends, addresses impact from social determinants of health and ensures diabetes supplies are stocked. Clinical pharmacists rely on PharmD Live’s software, with an advanced clinical rules engine which ensures consistent, timely care and real time communication with practice electronic health records (EHR). PharmD Live  pharmacists provides services virtually, telephonically or via home visit.

PharmD Live tracks quality metrics and provides streamlined billing reports to practice administrators. PharmD Live, a telehealth company committed to improving patient outcome and helping physicians earn quality bonus payments and avoid financial penalties, serves as a seamless extension of physician practices. To fortify your value-based care strategy, schedule a capabilities presentation with Ellery Plowman.



Diabetic Patients in Value-Based Care: Creating the Win for Patients and Physicians

By: Dr. Cynthia Nwaubani, BCGP, CMTM

National Diabetes Month presents the opportunity to examine the process of improving diabetic health outcomes and boosting quality metrics. As a clinical pharmacist and medication expert, I understand the complexities of diabetes and believe it is critical to examine changes through the continuum of care as the national healthcare paradigm has shifted and the market has welcomed innovations. Changes in CMS (the Centers for Medicare and Medicaid Services) reimbursement models have allowed chronic care management (CCM) to be re-engineered; however, the cumbersome process involved in a shift of this magnitude has dictated the pace of change thus far.

As you may know, both tracks of the Medicare Access and CHIP Reauthorization Act’s  (MACRA) Quality Payment Programs, MIPS (Merit-Based Incentive Payment System) and APMs (Alternative Payment Models), tie Medicare reimbursements to patient health outcomes. Physicians are charged financial penalties or awarded financial incentives for reporting on six chosen quality metrics.

The diabetic population, which includes more than 30M Americans, and the prediabetic population, which includes 84M Americans, will comprise a significant portion of the patient population whose health outcomes will be tracked through quality metrics. Meeting quality metrics relies on between-visit care, which has historically added to physician workloads and detracted from practice bottom lines. Compounding the issue of outcome accountability and physician burden is the human tendency to delay physician visits until they reach critical status, creating administrative and physician burden derived from same-day visits.

The Institute for Healthcare Improvement’s (IHI) Triple Aim (which some have expanded to the Quadruple Aim and included physician satisfaction) emphasizes improved patient care and better population health while reducing per capita costs. During the past several years, CMS has made significant changes to reimbursement of chronic care management services to improve population health, hold physicians accountable, and control spiraling healthcare costs based on the Triple Aim. Many physicians I have spoken with agree: in theory, pharmacist-led CCM services are a promising solution to challenges in population health management. But, in practice, how do these services help physicians manage diabetic patient health, meet quality measures and avoid burnout?

Here’s how:

Clinical pharmacists are uniquely qualified to make high-level decisions regarding patient care, including management of the health complexities of diabetic patients. As medication experts, pharmacists can reconcile medication lists from various specialists between primary care visits. Clinical pharmacists serve as a patient resource for questions and concerns around-the-clock, including weekends and holidays, ensuring patients have the appropriate referrals and resources to care for all diabetic issues and complications. Clinical pharmacists are equipped to identify root cause and adjust patient therapy as needed. PharmD Live’s proprietary software relies on an advanced clinical rules engine and artificial intelligence to assist in identifying and managing care and medication side effects.

PharmD Live, a telehealth company committed to improving patient outcome and helping physicians earn quality bonus payments and avoid financial penalties, serves as a seamless extension of physician practices. To fortify your value-based care strategy, schedule a capabilities presentation with Ellery Plowman.

Reducing Burden in a Value-Based Care Model: What Physicians Need to Know

By: Dr. Cynthia C. Nwaubani, BCGP, CMTM

Physicians who treat a high-volume of Medicare patients will see changes January 1, as changes to Quality Payment Program (QPP) reimbursement models—MIPS (Merit-Based Incentive Payment System) and APMS (Alternative Payment Models)—take effect as part of the nation’s transition to value-based care. Value-based care ties reimbursements to outcomes, replacing the outdated fee-for-service model which garnered criticism for catalyzing wasteful healthcare spending. Value-based care is expected to control spiraling costs, improve clinical outcomes, empower patients and reimburse physicians for quality care. But physicians have been vocal about their struggle to incorporate added demands into their workflow—gathering data, reporting metrics and providing additional between-visit care will be shoehorned into already demanding schedules.

In an April, 2018 letter from the American Medical Association (AMA) to Centers for Medicare and Medicaid Services (CMS) top administrator Seema Verma, a “reduced reporting period for future MIPS program years in order to reduce administrative burden” was requested, further illustrating the stress felt by practices bracing for a sea change.

Capitol Hill staffers cited physician workload and administrative burden as the primary catalysts for physician meeting requests with their congressman in an October 11, 2018 meeting with PharmD Live’s executive team. They further described the uptick in administrative burden due to increased QPP reporting requirements as the root cause.  

Dr. Paul Williams, PharmD Live’s Chief Medical Officer, stated, “Many QPP measures focus on between-visit care, which can add significantly to the physician’s workload. Many practices have chosen to partner with third-party vendors, such as PharmD Live, which have the potential to reduce physician burden and boost quality metrics while increasing direct and indirect practice revenue.”

But how does a partnership with PharmD Live alleviate the administrative burden and reduce physician workload?

PharmD Live’s chronic care management services are designed to ease the transition to value-based care. As you know, Medicare reimburses for chronic care management and complex chronic care management delivered via telehealth between office visits. PharmD Live’s board-certified pharmacists deliver between-visit care and are medication experts capable of making high-level clinical decisions. Pharmacists are available around-the-clock to deliver care, answer questions and tend to patient needs.

Because the PharmD Live technology solution is integrated with the physician’s electronic health record (EHR), patient information is updated in real time. PharmD Live provides billing reports and metrics data to streamline Medicare billing and communications.

To learn how a partnership with PharmD Live can ease your transition to value-based care, schedule a demo.




Celebrating Pharmacists: Examining the Virtues of Pharmacist-Led Care

By: Dr. Cynthia C. Nwaubani, BCGP, CMTM

October is National Pharmacists Month, and the PharmD Live team is pleased to celebrate and recognize pharmacists for their prolific contributions to the evolving landscape of healthcare. As laws, regulations and paradigms change and affect healthcare provision, pharmacists are expanding their scope of practice. Clinical pharmacists have been tapped to lead chronic care management (CCM) services, as pharmacist-provided care has been shown to reduce drug expenditures, hospital readmissions, length of stay, and emergency department visits.

Research reveals pharmacists are one of the most accessible medical care professionals, as patients report interacting with a pharmacist nearly nine times more frequently than a primary care provider or specialist. As medication experts, pharmacists are uniquely positioned to prevent medication errors and drug interactions and minimize side effects and adverse medication events. This makes them well-suited to manage patients with chronic conditions and complex medical pictures.  

Pharmacist-led CCM solutions:

  • Mitigate medication-related risks

  • Effectively manage chronic conditions between physician visits

  • Improve medication and care plan adherence

  • Reduce overall healthcare expenditure

  • Improve patient's quality of life

  • Improve quality metrics

  • Reduce physician workload and administrative burden

In addition to managing and preventing chronic conditions and diseases, such as chronic obstructive pulmonary disease, pain, diabetes, congestive heart failure, hypertension, cancer, chronic kidney disease, clinical pharmacists are equipped to make high-level clinical decisions. This enables them to reduce physician workload and on-call burden in a third-party CCM arrangement.  

With the national shift to value-based care, leveraging pharmacist-led care will assist medical practices in meeting quality metrics, reducing physician workload, minimizing administrative burden and improving clinical and commercial outcomes.

PharmD Live’s pharmacist-led CCM services integrate with physician practices and care teams to fortify clinical and commercial outcomes. To learn more about the benefits of pharmacist-led care, contact Ellery Plowman.


Eltaki, Sara M., PharmD, BCPS; Gernant, Stephanie A., PharmD, MS; Hale, Genevieve M., PharmD, BCPS; Jones, Renee, PharmD, CPh; Joseph, Tina, PharmD, BCACP; Moreau, Cynthia, PharmD; Prados, Yesenia, PharmD; and Seamon, Matthew J., PharmD, JD. Integration Strategies of Pharmacists in Primary Care-Based Accountable Care Organizations: A Report from the Accountable Care Organization Research Network, Services, and Education. Academy of Managed Care Pharmacy. May, 2017. https://www.jmcp.org/doi/pdf/10.18553/jmcp.2017.23.5.541

Moose, Joseph PharmD, and Branham, Ashley PharmD, BCACP. Pharmacists as Influencers of Patient Adherence. Pharmacy Times. August 24, 2014. https://www.pharmacytimes.com/publications/directions-in-pharmacy/2014/august2014/pharmacists-as-influencers-of-patient-adherence-


Choosing MIPS Measures: Catalyzing Success

Choosing MIPS Measures: Catalyzing Success

By: Dr. Cynthia C. Nwaubani, BCGP, CMTM

Preparing for the Merit-Based Incentive Payment System (MIPS) is steadily moving up the priority list of physicians and healthcare executives as January 1, 2019 draws near. The financial implications—and upside and downside swings—are iminent. Changes are coming—and proponents and opponents can agree on one thing: a shift of this magnitude requires deft planning.

Preparing for MIPS: From Idea to Implementation

By: Dr. Cynthia C. Nwaubani, BCGP, CMTM

January 1 is the hallmark of new beginnings—and for physicians and hospital clinics, this year will be no different. January 1, 2019 marks the first opportunity for eligible physicians and hospital clinics to earn penalties and incentives for performance through one of Medicare’s Quality Payment Programs, the Merit Incentive-Based Payment System (MIPS).

MIPS replaces the PQRS (Physician Quality Reporting System), the Value-Based Payment Modifier and the Electronic Health Record (EHR) incentive program. Borne from the Medicare and CHIP Reauthorization Act (MACRA) of 2015, MIPS and APM (Alternative Payment Models) are the two available options for quality payment tracks. MIPS is the default track, and its performance categories include Quality (60%), Improvement Activities (25%) and Promoting Interoperability (15%).

In theory, value-based care makes perfect sense. Catalyzing the best outcome at the lowest cost seems straightforward and reasonable by any measure. The Centers for Medicaid and Medicare Services (CMS) couches it as a four-step process: “Collect data, Report data, Feedback available, Payment adjustment.”

But moving from theory to practice has presented challenges, sowing frustration in physicians driven by patient care. Physicians and practice administrators envision stacks of paperwork, a quagmire of regulations and processes ad nauseum.

And studies reveal physician’s fears and perceptions are based in reality. Research by Weill Cornell Medical College and the Medical Group Management Association (MGMA) in 2016 showed physicians spent 15.1 hours every week processing quality metrics. Time spent on the intricacies of reporting, tracking metrics and understanding accompanying regulations cuts into patient care.

Success in the value-based framework requires deft planning and patience—which demands the scarcest resource for many physicians: time. As you know, value-based care is not an ephemeral trend; rather, a way of providing care that will catalyze a seismic change in its provision.

To begin planning for 2019:

Review the timeline of implementation.  

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  1. Review quality measures and compare against current top-performing practice areas.

  2. Review your business model. Get acquainted with new reimbursement codes which enable telehealth.

  3. Choose a third party telehealth chronic care management provider, such as PharmD Live, adept in streamlining billing reports and quality measures data and providing care coordination and management.  

Many physicians and hospital clinics have chosen to partner with a third party care management team, such as PharmD Live, as an element of their MACRA strategy. PharmD Live serves as a seamless extension of your practice, providing turnkey, pharmacist-led chronic care management services to boost quality metrics, increase revenue and streamline care. To learn more about PharmD Live’s pharmacist-led care, schedule a consultation.

This article is the first in a series dedicated to helping physicians and hospital clinics prepare for MIPS in 2019.