Advancing The Profession of Pharmacy

Leveraging MACRA for Pharmacist: Building a Business Model Around CMS’s Pay-for-Performance Structure

by | Oct 23, 2017 | Consulting Pharmacist Education

As pharmacists, we know that the healthcare landscape is currently experiencing a major evolution, so a seismic shift, if you will. This shift was set in motion by the new legislation from the Centers for Medicare and Medicaid Services (CMS).

You may have heard this legislation referred to a “pay-for-performance” or “value-based payment reform”.


What EXACTLY does that mean for us as pharmacists?

On October 14th, 2016, CMS released this final rule of the Medicare Access in Children’s Health Insurance Program, the CHIP Reauthorization Act of 2015, which we refer to as MACRA. These reimbursement models shift from a volume-based fee-for-service system to what we have now, the value-based payment system. This rule dramatically changes how physicians are compensated for their services under Medicare.

To give you an idea of the payment adjustments and how big of an impact this is having for physicians, it will dramatically change payment adjustments for physicians’ offices.

In 2019, payments are going to be increased or decreased by up to 4% based on the data submitted during the 2017 reporting year. In 2018, that adjustment will increase to 5%, and by 2022, we’re looking at about a 9% payment adjustment.

For the first year of MIPS reporting, the providers (which would include physicians, physician assistants, nurse practitioners, clinical nurse specialist, certified registered nurse, anesthetist, dentist, podiatrist, optometrist, and chiropractors) can choose the amount of 2017 data to submit to MIPS for the 2019 payment adjustment.

These payment adjustments could be in the hundreds of thousands of dollars, and they could be positive or negative reimbursements for a practice. This could equal hundreds of thousands of dollars in difference between the reimbursement that they may have already received and may have to pay back, or they could be receiving as a bonus incentive.


“There’s still about $500 million set aside for exceptional performers and up to the 10% positive payment adjustment to be earned.”

Understanding this is going to be a huge avenue of opportunity for you when building your enhanced pharmacy services.

While MACRA doesn’t directly affect most pharmacists today, this value-based payment system is definitely here to stay, and we are seeing more and more private payers look towards this type of model.

It is important to be familiar with these quality-based payment models so that you can tailor your enhanced services to meet or exceed these quality measures.

Additionally, many of the measures providers are now required to report on can be impacted by stuff you’re already doing, enhanced clinical services like medication therapy management and medication synchronizations programs.

Pharmacists can demonstrate to providers how enhanced pharmacy services can impact patients’ therapeutic outcomes and quality.

Basically, MACRA created two value-based payment tracks, and these are described as MIPS, which stands for the Merit-based Incentive Payment Systems, and APMs, the Advanced Alternative Payment Models.


Quality Payment Program = Merit-based Incentive Payment Systems + Advanced Alternative Payment Models

These two tracks together are collectively referred to as the Quality Payment Program. Of the two tracks of MACRA, MIPS is going to have the largest impact on independent physicians’ offices. So, what I want to focus on today is helping you help providers enhance their performance in these quality metrics.

MIPS actually measures providers’ performance in these four weighted categories, and we’ll go through each of them.

First is quality, 60% for 2017,  then advancing care information 25%, and improvement activities, 15%. These will balance out in subsequent years, but for 2018, they expect to use these same percentages proposed for 2018. The cost resource use is 0% for 2017 and 2018. However, it is expected to increase in subsequent years.

Pharmacists, as the most accessible healthcare provider, can focus on increasing patients’ access to care, decreasing the overall number of hospitalization and re-admissions, and reducing total net healthcare spend.

That, in my opinion, makes pharmacists perfectly poised to offer assistance to providers as Quality Coordinators.


I.  Quality

In 2017, the Quality measure category is going to hold the most weight in MIPS at 60%. It will gradually lose weight as the other categories increase over time, but this quality category is a holdover from the Physician Quality Reporting System in which the providers used to choose nine measures to report on.

The change requires providers to choose 6 quality measures from a list of over 271 subcategories. These six measures can be any metric they choose.

However, there are a few requirements. They do have to have one high-priority measure, which would be an outcome measurement, one cross-cutting measure which would be applicable to all provider specialties, and then the four others can be a mixture between the two.

Because of its weight, providers’ focus will likely weigh heavily on the Quality measure category for the MIPS reporting.


II.  Advancing Care Information

The second MIPS category that holds the most weight, the Advancing Care Information category.

This category makes up about 25% of MIPS and expands on the meaningful use program.

Pharmacists can leverage the physicians’ need to meet these measures in this category and request access to the providers’ electronic health records.

This will significantly improve patient care and quality. Pharmacists with access to the EHR either directly or through the sharing of electronic care plans can help save the healthcare system and the patients’ money.

Increasingly, we are able to submit e-Care Plans ourselves through some new technology.

Also, the expanding of meaningful use category means the inclusion of the ability for providers to send electronic prescriptions, to allow the patients access to their electronic medical records, to help them protect their electronic health information, and also share information with others involved in patient care.

This is a great opportunity for pharmacists to be able to leverage the technology and the EHR side of meeting those measures and collaborating with physicians through the advancing care information category.


III.  Cost/Resource Use

This category, which is at 0% for 2017 and 2018, does not require active reporting by physicians, instead, it’s pulled from Medicare claims data that is submitted throughout the year. Part of the goal of this measure is to encourage healthcare professionals to help beneficiaries understand their benefits and make medical decisions accordingly.

Sounds a lot like what we do in open enrollment already, doesn’t it?


IV.  Improvement Activities

The fourth category pharmacists can focus on is the Improvement Activities category. There are over 90 improvement activities defined for the MIPS.

Some major subcategories of Improvement Activities are expanding practice access, care coordination, beneficiary engagement, patient safety and practice assessment, and emergency response and preparedness.

On the Leveraging MACRA for Pharmacists Webinar, we discuss 3 improvement activities that pharmacists can have a real impact on as well as some action steps for you to use when building your pharmacy programs to support those providers.

Click here to access the Advanced Training: Leveraging MACRA Webinar

The first Improvement Activity we’ll talk about in the Leveraging MACRA WEBINAR is the implementation of medication management practice improvements. The focus of this activity would be integrating pharmacists into care teams and designating clinic times for these pharmacists.

The pharmacist’s role would be to conduct periodic structured medication reviews, reconcile and coordinate medications across transitions of care, identify and resolve drug utilization issues, adjust strength dosage form or suggest therapeutic substitutions as needed.

In the e-Course at the Pharmapreneur Academy, I discuss the details of using certain billing codes (such as incident-to billing codes or annual wellness visit billing codes) to see patients under the direct supervision of the provider in their clinic.


Interested?  Book a free call with me to see if the Pharmapreneur Academy is right for you!

Improvement activity #2 is proactively manage chronic and preventative care for patients. The focus of is to utilize evidence-based protocols to guide treatment for chronic conditions and provide chronic care management services.

The pharmacists’ role would be to individualize care plans for the patients and educate them on their medication use. You could also help enroll them in medication synchronization programs, screen them for additional comorbid conditions, and perform routine medication reconciliations.

To bill for these services, a consultant pharmacist under a collaborative practice agreement acting as an auxiliary staff member can work under the general supervision of a physician. This means you could work in an offsite role as a consultant pharmacist and bill for chronic care management codes (CCM) under a physician’s NPI.


Learn more about CCM codes and building a CPA with a collaborative physician in Lesson 7 & 8 of the e-Course at the

In improvement activity #3, communication and care coordination, the focus of this would be to address the sharing of information and coordination of clinical and preventative services among patients, caregivers, and multiple healthcare professionals.

Your role as a consultant pharmacist would be to identify and document the patient care activities using the chronic care management or transitional care management codes, document clinical and preventative services, such as immunizations, and notify the prescriber so that the patient’s record is up to date.

To bill for these services, you could use any of the ones we’ve talked about in your wellness visits, incident-to billing visits, chronic care management, or even transitional care management codes. A pharmacist can offer the initial contact of the two-part transitional care management code service under a physician’s collaborative practice agreement without being under the direct supervision of the physician.

More information about TCM in Lesson 8 of the e-Course at the Pharmapreneur Academy.


Key Takeaways:

  • Understanding how quality is being measured in the physician space gives you insight into the prescriber’s motivating factors and allows for constructive collaborative relationships.
  • Developing a robust collaborative practice agreement to offer these enhanced services in a way that aligns with the goals of both the Merit-based Incentive Payment System, MIPS, and the Advanced Alternative Payment Models, APMs, could prove a mutually beneficial relationship for providers and pharmacists, as well as improve patient outcomes.
  • As the most accessible healthcare provider, pharmacists can impact population health through point of care testing and by improving patient outcomes through chronic care and transitional care management programs.
  • Community Pharmacists have the ability to help improve medication adherence through implementations of programs such as medication synchronization, delivery services, and adherence packaging.
  • Pharmacists actively searching for new revenue-generating opportunities should seek out providers who support pharmacy involvement in clinical service activities.

I encourage you to attend the Leveraging MACRA for Pharmacists Webinar and then reach out to your local high-volume prescribers and request an appointment to discuss these changes and their challenges.

I also encourage you to share your pharmacy’s commitment to supporting them in this new performance-based reimbursement landscape.

If you’re ready to make a serious investment in creating and implementing these services, consider joining the Pharmapreneur Academy and work with pharmacists who are moving forward with building consulting-based business models.


And join our email list for more information and trainings like this!

About the Author

Blair Thielemier, PharmD, is a business development consultant specializing in pharmacist-led billing models. She has set the industry standard for virtual pharmacy conferences with the Elevate Pharmacy Virtual Summit in 2017. She has consulted with national pharmacy organizations, drug wholesalers, point of sale companies, and Fortune 5 health insurers. She has books and online courses available for individuals looking to leverage their pharmacy knowledge into monetized clinical programs at She speaks internationally about trends in leveraging pharmacists to improve value-based care.


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