TY - JOUR
AU - Mercier,, Renee-Claude
AB - Abstract Purpose This report describes an innovative pharmacy practice model assisting in the care of patients living with or at risk of acquiring human immunodeficiency virus (HIV) and/or hepatitis C virus (HCV). Summary In the state of New Mexico, pharmacists can obtain prescribing privileges through a Pharmacist Clinician (PhC) license. The license allows PhCs to assess patients, order laboratory/diagnostic tests, prescribe medication, and bill select insurances. PhCs have developed a practice model for patients living with or at risk of HIV and/or HCV at a Level 3 National Committee for Quality Assurance Patient-Centered Medical Home in Albuquerque, New Mexico. In 2015, 5 PhCs, employed part time, were involved with 8 different clinics: (1) HIV Adherence and Complex Care, (2) HIV Transitions of Care, (3) HCV Mono- and Co-Infection, (4) HIV Pre-Exposure Prophylaxis (PrEP), (5) HIV Primary Care and Cardiovascular Risk Reduction, (6) Young Adult Clinic, (7) Perinatal HIV, and (8) Pediatric HIV. In 2015, PhCs at the clinic billed for 774 direct patient encounters. Conclusion Pharmacists with the PhC license are able to provide high-quality medical care to patients living with or at risk of HIV and/or HCV infections within an interprofessional medical home model. clinical pharmacist, HCV, HIV, pharmaceutical care, preexposure prophylaxis KEY POINTS Further development of advanced pharmacy practice models, as well as funding models, need to be pursued to address potential HIV provider shortages. The New Mexico (NM) Pharmacist Clinician licensure allows pharmacists, with advanced training, prescriptive authority approved by both the NM Medical Association and NM. Pharmacists clinicians at Truman Health Services have been successfully integrated into every aspect of the HIV continuum of care, as well as additional areas of HCV care. In 1993 the New Mexico (NM) Board of Pharmacy (BOP) approved the Pharmacist Prescriptive Authority Act.1,2 This act expanded the traditional scope of pharmacy practice by creating the pharmacist clinician (PhC) license. Pharmacists completing the requirements of a 60-hour physical examination course, 150 supervised patient contacts, and 300 supervised patient contact hours are eligible to apply for a PhC license. To maintain the license an additional 20 live continuing education credits are required per 2-year licensing period. The PhC license was created to help provide and improve access to health care in a state that is geographically large, socioeconomically disadvantaged, and underrepresented in health care providers. The NM PhC regulations were created to be similar to the physician assistant regulations, which include a supervising physician. Each PhC’s individualized protocol is approved by the NM Board of Pharmacy and NM Medical Board. The PhC has the independent ability to prescribe dangerous drug therapy (i.e., prescription medications), including controlled substances in Schedules II through V, and order laboratory and diagnostic studies. The PhC also performs physical assessment as needed for medication and disease state management and diagnosing. The PhC can accept patients, make referrals, and recommend admission to the hospital independently as indicated.1 In 1990, the Ryan White Comprehensive AIDS Resources Emergency Act was passed, creating a comprehensive care program, under the Department of Health and Human Services (DHHS), for people living with HIV. Currently, the Ryan White program provides coverage for over 50% of patients living with HIV in the United States.3 Beginning in 1998, the DHHS required HIV clinics to document adherence monitoring and adherence support in order to receive Ryan White Funding. To meet this requirement, the University of New Mexico (UNM) HIV clinic, known today as Truman Health Services (THS), hired its first PhC. The initial PhC responsibilities revolved around medication adherence counseling and antiretroviral therapy (ART) education. These responsibilities have significantly evolved; THS now employs 5 PhCs who are involved in most aspects of care of patients living with HIV. The purpose of this report is to describe an innovative pharmacy practice model involving integration of PhCs with expanded scope of practice into a patient-centered medical home serving patients living with or at risk of acquiring HIV and/or hepatitis C virus (HCV) infection. The innovative pharmacy practice model also expanded care to transgender and gender nonbinary patients at THS.4 Clinic setting As of December 2016, THS is a Level 3 National Committee for Quality Assurance Patient-Centered Medical Home for more than 1,060 patients living with HIV in NM. Baseline demographics of THS patients living with HIV are further described in Table 1. THS offers comprehensive primary care, behavioral health, and complementary therapies for patients living with HIV. The HIV/AIDS Bureau of the Health Resources and Services Administration (HRSA) established revised core performance measures in 2013 for Ryan White HIV/AIDS Programs. One of these measures is viral suppression, defined as the most recent reported HIV RNA level being <200 copies/mL. In 2015, the national average for viral suppression was 83%.5 Despite the challenges of care in NM (low socioeconomic status, late diagnosis of HIV), THS clients’ HIV viral suppression in 2015 was 89% and increased to 90% in 2016 and 2017. This cannot be solely attributed to PhC involvement but is a testament to the interprofessional medical home model. Table 1. Truman Health Services Demographics For Patients Living With HIVa Demographics n (%) HIV status Positive 1,057 99.7 Indeterminate (< 2 yr) 3 0.3 Gender Male 932 87.9 Female 119 11.2 Transgender 9 0.8 Age (yrs) < 2 3 0.3 2–12 5 0.5 13–24 37 3.5 25–44 355 33.5 45–64 594 56.0 ≥ 65 66 6.2 Race White 819 81.1 Black or AA 63 5.9 AI/AN 60 5.6 Asian 8 0.8 NH or PI 1 0.1 Unknown 61 5.8 > 1 race 48 4.5 HIV risk group MSM 747 70.5 IDU 63 5.9 MSM/IDU 59 5.6 Hematology/coagulopathy disorder 13 1.2 Heterosexual contact 279 26.3 Blood transfusion 37 3.5 Perinatal transmission 14 1.3 HIV risk group insurance Medicaid 305 28.8 Medicare 277 26.1 Private—employer 152 14.3 Private—individual 136 12.8 Other plan 9 0.8 Unknown 22 2.1 Uninsured 16 1.5 Unreported 165 15.6 Demographics n (%) HIV status Positive 1,057 99.7 Indeterminate (< 2 yr) 3 0.3 Gender Male 932 87.9 Female 119 11.2 Transgender 9 0.8 Age (yrs) < 2 3 0.3 2–12 5 0.5 13–24 37 3.5 25–44 355 33.5 45–64 594 56.0 ≥ 65 66 6.2 Race White 819 81.1 Black or AA 63 5.9 AI/AN 60 5.6 Asian 8 0.8 NH or PI 1 0.1 Unknown 61 5.8 > 1 race 48 4.5 HIV risk group MSM 747 70.5 IDU 63 5.9 MSM/IDU 59 5.6 Hematology/coagulopathy disorder 13 1.2 Heterosexual contact 279 26.3 Blood transfusion 37 3.5 Perinatal transmission 14 1.3 HIV risk group insurance Medicaid 305 28.8 Medicare 277 26.1 Private—employer 152 14.3 Private—individual 136 12.8 Other plan 9 0.8 Unknown 22 2.1 Uninsured 16 1.5 Unreported 165 15.6 aAA = African American, AI = American Indian, AN = Alaska Native, NH = Native Hawaiian, PI = Pacific Islander, MSM = men who have sex with men, IDU = injection drug user. View Large Table 1. Truman Health Services Demographics For Patients Living With HIVa Demographics n (%) HIV status Positive 1,057 99.7 Indeterminate (< 2 yr) 3 0.3 Gender Male 932 87.9 Female 119 11.2 Transgender 9 0.8 Age (yrs) < 2 3 0.3 2–12 5 0.5 13–24 37 3.5 25–44 355 33.5 45–64 594 56.0 ≥ 65 66 6.2 Race White 819 81.1 Black or AA 63 5.9 AI/AN 60 5.6 Asian 8 0.8 NH or PI 1 0.1 Unknown 61 5.8 > 1 race 48 4.5 HIV risk group MSM 747 70.5 IDU 63 5.9 MSM/IDU 59 5.6 Hematology/coagulopathy disorder 13 1.2 Heterosexual contact 279 26.3 Blood transfusion 37 3.5 Perinatal transmission 14 1.3 HIV risk group insurance Medicaid 305 28.8 Medicare 277 26.1 Private—employer 152 14.3 Private—individual 136 12.8 Other plan 9 0.8 Unknown 22 2.1 Uninsured 16 1.5 Unreported 165 15.6 Demographics n (%) HIV status Positive 1,057 99.7 Indeterminate (< 2 yr) 3 0.3 Gender Male 932 87.9 Female 119 11.2 Transgender 9 0.8 Age (yrs) < 2 3 0.3 2–12 5 0.5 13–24 37 3.5 25–44 355 33.5 45–64 594 56.0 ≥ 65 66 6.2 Race White 819 81.1 Black or AA 63 5.9 AI/AN 60 5.6 Asian 8 0.8 NH or PI 1 0.1 Unknown 61 5.8 > 1 race 48 4.5 HIV risk group MSM 747 70.5 IDU 63 5.9 MSM/IDU 59 5.6 Hematology/coagulopathy disorder 13 1.2 Heterosexual contact 279 26.3 Blood transfusion 37 3.5 Perinatal transmission 14 1.3 HIV risk group insurance Medicaid 305 28.8 Medicare 277 26.1 Private—employer 152 14.3 Private—individual 136 12.8 Other plan 9 0.8 Unknown 22 2.1 Uninsured 16 1.5 Unreported 165 15.6 aAA = African American, AI = American Indian, AN = Alaska Native, NH = Native Hawaiian, PI = Pacific Islander, MSM = men who have sex with men, IDU = injection drug user. View Large Pharmaceutical care model The THS PhCs are involved in 2 types of clinics: (1) interprofessional clinics and (2) PhC-run clinics. Interprofessional clinics are designed to meet the serious medical needs of patients by providing them with intensive support within the medical home. All disciplines (medicine, behavioral health, pharmacy, nutrition, nursing, case management, etc.) are available for patients during the interprofessional clinics with the hope of improving care while decreasing the time the patient spends in clinic. PhC-run clinics are designed as additive specialty services, with the goal of optimizing patient care through independent clinical decision-making by the PhC. No clinic is mutually exclusive, and patients can be enrolled in as many clinics as necessary to meet their needs. An overview of the THS clinics is described in Table 2, with specific clinic descriptions below. Table 2. Clinic Descriptionsa Clinic PhC-Run Clinic Year PhC Established in Clinic Clinic Hours Number of Patients Seen Per Clinic Adherence & Complex Care Yes 1998 ½ day per week 4–8 Care Transitions Yes 2015 3 days per week 4–8 HCV-HIV No 2013 ½ day per week 4–8 Pediatric No 2011 ½ day every week 1–4 PrEP Yes 2015 ½ day per week 10–14 Primary Risk Reduction Yes 2013 3 days per week 4–5 Young Adult No 2008 ½ day per week 9–12 Clinic PhC-Run Clinic Year PhC Established in Clinic Clinic Hours Number of Patients Seen Per Clinic Adherence & Complex Care Yes 1998 ½ day per week 4–8 Care Transitions Yes 2015 3 days per week 4–8 HCV-HIV No 2013 ½ day per week 4–8 Pediatric No 2011 ½ day every week 1–4 PrEP Yes 2015 ½ day per week 10–14 Primary Risk Reduction Yes 2013 3 days per week 4–5 Young Adult No 2008 ½ day per week 9–12 aPhC = pharmacist clinician, HCV = hepatitis C virus, PrEP = preexposure prophylaxis. View Large Table 2. Clinic Descriptionsa Clinic PhC-Run Clinic Year PhC Established in Clinic Clinic Hours Number of Patients Seen Per Clinic Adherence & Complex Care Yes 1998 ½ day per week 4–8 Care Transitions Yes 2015 3 days per week 4–8 HCV-HIV No 2013 ½ day per week 4–8 Pediatric No 2011 ½ day every week 1–4 PrEP Yes 2015 ½ day per week 10–14 Primary Risk Reduction Yes 2013 3 days per week 4–5 Young Adult No 2008 ½ day per week 9–12 Clinic PhC-Run Clinic Year PhC Established in Clinic Clinic Hours Number of Patients Seen Per Clinic Adherence & Complex Care Yes 1998 ½ day per week 4–8 Care Transitions Yes 2015 3 days per week 4–8 HCV-HIV No 2013 ½ day per week 4–8 Pediatric No 2011 ½ day every week 1–4 PrEP Yes 2015 ½ day per week 10–14 Primary Risk Reduction Yes 2013 3 days per week 4–5 Young Adult No 2008 ½ day per week 9–12 aPhC = pharmacist clinician, HCV = hepatitis C virus, PrEP = preexposure prophylaxis. View Large Clinic descriptions Adherence and HIV complex care pharmacy clinic The adherence and HIV complex care pharmacy (AHCCP) clinic was the original PhC-run clinic at THS, established in 1998 as an HIV adherence clinic. The clinic evolved over time to provide additional pharmaceutical services for management of complex HIV patients. Patients are referred to the clinic by their HIV primary care provider (PCP) (e.g., physician, physician assistant [PA], certified nurse practitioner [NP]) or clinic nurse, or are also able to self-refer if they have medication-related questions. The goal of the clinic is to improve ART adherence, assist in the selection of evidence-based HIV treatment, and optimize patient outcomes (i.e., achieve undetectable viral load, increase CD4 count, decrease number of opportunistic infections, and decrease hospitalizations). Reasons for referral to this clinic include, but are not limited to: pre- and post-ART initiation/re-initiation and adherence counseling, evaluation of ART failure, adverse effects, interpretation of complex resistance data, other medication considerations (e.g., liquid formulation alternatives, pill burden considerations, central nervous system penetration, comorbidities, absorption considerations), therapeutic drug monitoring, management of drug–drug interactions (e.g., methadone titrations during initiation/discontinuation of ART, developing management plans for patients with complicated drug interactions for other comorbid conditions such as transplant), and other polypharmacy issues. The PhC can independently initiate, discontinue, or adjust ART and non-ART medications. HIV care transitions pharmacy clinic Established in 2015, the HIV care transitions pharmacy clinic provides pharmaceutical care to THS patients that are transitioning between health care settings. The PhC practices as part of the care transitions team (CTT) made up of a PhC, a nurse, and a case manager. The CTT was created to reduce medication errors, hospital readmissions, and facilitate transfer to HIV outpatient medical care for patients being discharged from the hospital. The CTT is notified of all new diagnoses of HIV within the hospital. The patient’s medications are reviewed by the PhC to ensure appropriateness during the hospital admission. Newly diagnosed patients with HIV are seen by the CTT and receive intensive education and counseling prior to discharge from the hospital, in addition to new diagnosis counseling provided by the state department of health. The CTT also routinely visit patients at their place of residence (e.g., home, nursing facility). The PhC takes responsibility for providing dosing recommendations, evaluating medication changes, verifying insurance coverage, and ensures communication between the inpatient and outpatient setting. Once patients are discharged, they receive a follow-up telephone call within 72 hours and, if it is deemed necessary, are seen by the PhC at THS within 1 week from hospital discharge. If warranted, additional adjustments or changes to existing therapies are performed independently at the discharge follow-up visit. Should the patient require additional care from other disciplines, the PhC acts as the coordinator of care and makes appropriate referrals or follow-up appointments. HCV monoinfection and coinfection clinic Treatment of patients with HIV-HCV coinfection first began in 2005 by an infectious disease (ID) physician with an interest in HCV infection. In 2013, a stand-alone HCV monoinfection and coinfection clinic started with support from nursing and a medical assistant. In 2014, the clinic added a PhC. The goal of the clinic remains to manage and treat patients with HIV-HCV coinfection, including patients with advanced liver disease and decompensated cirrhosis. Patients associated with THS through another clinic, such as the preexposure prophylaxis (PrEP) or transgender or gender nonbinary clinics, who are HIV-negative but infected with HCV can also receive HCV treatment at THS through this clinic. Initial visits are conducted by the interdisciplinary clinic team. During these visits the PhC evaluates the patient for the severity of liver disease; reviews laboratory values, imaging, medical and social history; performs physical examinations; and identifies potential drug interactions. The PhC orders additional laboratory values, imaging, or referrals, provides patient education, modifies any concurrent therapies to minimize drug interactions, and prescribes HCV direct-acting antivirals. Because the PhC is often the prescriber, the prior authorization process, including peer-to-peer discussion, is streamlined to ensure prompt acquisition of medications. Additionally, whereas other states impose restrictions on HCV direct-acting antivirals to either ID or gastroenterology specialists, in NM there are no prescriber restrictions. Follow-up HCV treatment visits and posttreatment visits are generally conducted by the PhC to evaluate laboratory tests, treatment progress, outcomes, and need for post-HCV management of cirrhosis (i.e., endoscopy or ongoing surveillance for hepatocellular carcinoma). The HCV 12-week sustained virologic response (SVR) rate in our HIV/HCV coinfected patients was 98% from January 2015 through December 2017. Treatment protocols and flowsheets were developed by the clinic physician and PhC and are used in the THS HIV-HCV clinic, UNM HCV clinic, and partners of HCV Project ECHO. PrEP clinic At the start of 2015 there was no dedicated PrEP clinic in Bernalillo County, NM. Barriers to providing PrEP include low awareness among providers and lack of provider time to sufficiently initiate and monitor therapy.6-8 As a result, THS created a PhC-run PrEP clinic. The goal of the clinic is to provide PrEP services to individuals at high risk of acquiring HIV. Potential patients are screened by the PrEP nurse over the telephone and are then seen in clinic by the PhC. During the initial clinic appointment, a rapid HIV test, baseline laboratory tests including screening for sexually transmitted infections, and risk assessment are performed. Additional appointment time is dedicated to HIV/PrEP education, PrEP initiation if appropriate, monitoring, and follow-up of therapy. A significant amount of time initially is also spent ensuring access to medication for PrEP, including enlisting patients in co-pay assistance programs if necessary. The clinic originally met 1 half-day every other week and served HIV-negative partners of THS patients. However, as the first dedicated PrEP clinic in the metro area, the need for additional clinic time quickly became apparent. Now the clinic is held 1 half-day a week and serves all individuals interested in PrEP, regardless of THS affiliation. Over 200 patients have been evaluated and received PrEP in the PhC-run clinic. No cases of HIV transmission have been documented while on PrEP in this clinic. HIV primary care and cardiovascular risk reduction clinic Because patients living with HIV are now living longer and mortality due to non-HIV related conditions continues to increase,9-14 a shift in management from palliative care to primary care was necessary. Established in 2013, the THS primary care and cardiovascular (CV) risk reduction clinic assists in the management of chronic disease for patients living with HIV who (1) have risk factors for CV disease, (2) are affected by CV disease, (3) have other chronic diseases that increase their risk of CV disease, and/or (4) have significant primary care needs. The goal of this PhC-run clinic is to decrease CV morbidity and mortality in patients living with HIV at THS by screening for, preventing, and managing patients’ non-HIV chronic diseases. Patients are either referred to the clinic by their HIV PCP or identified by glycosylated hemoglobin (HbA1c) screening report (HbA1c > 7%). The most common reasons for referral include, but are not limited to, prediabetes, obesity, new diagnosis of diabetes, or chronic uncontrolled diabetes, hyperlipidemia, hypertension, and nicotine dependence. In addition to the comanagement of these disease states, the PhC evaluates point-of-care blood glucose levels, estimates atherosclerotic cardiovascular disease risk, conducts diabetic foot examinations, makes referrals for eye examinations, and assesses blood pressure or other physical examinations (e.g., cardiac examination) as needed. The PhC independently adjusts or initiates medications based on medical assessment, laboratory data, and physical examination results as they relate to the patient’s primary care needs. Young adult clinic Young adults, ages 13–24 years old and account for 22% of all new HIV diagnoses, yet this group is the least likely to be linked to care.15 Young adults have different medical and psychosocial needs and often require intensive intervention. In 2008, the young adult clinic (YAC) was established as an interdisciplinary clinic for the care of patients living with HIV between the ages of 15 and 26 years. The goal of YAC is to assist youth living with HIV in reaching their full potential as healthy and well-adjusted individuals by delivering a comprehensive continuum of care prevention, treatment, community support, and transition services such as education, employment, and housing. All young adults diagnosed with HIV at THS are seen, at least initially, in YAC. Currently, and since 2015, the patient care team is led by the PhC and include a NP/PA, a child-adolescent psychiatrist, a counselor, a case manager, registered nurses, a nutritionist, and medical assistants. The team assesses the unique medical, mental health, and social needs of each patient and coordinates care accordingly. The PhC works to optimize patient adherence to ART and clinical outcomes much in the same manner as the AHCCP. PhC responsibilities include HIV education to youth and family, ordering laboratory tests, initiating ART, evaluating ART regimens for appropriateness and drug-drug interactions, anticipating and managing adverse events, assessing need for prophylactic antibiotics, addressing polypharmacy issues, monitoring drug levels, assessing adherence, identifying adherence barriers, and implementing adherence solution strategies. In 2017 YAC was recognized by HRSA for its achievement of high HIV viral suppression (97%; top 10 clinics in the nation) in this age group. Perinatal care A THS PhC is involved in essential duties related to the care coordination and management of pregnant women living with HIV and neonates exposed to HIV. Currently, however, there is no dedicated perinatal clinic due to the low number of pregnant women living with HIV within NM. For women followed at THS, the PhC will ensure appropriate therapeutic response to ART with an undetectable viral load at the time of delivery, coordinate medication supply, and manage adverse effects and drug interactions. The PhC also contacts the hospital where delivery will occur to confirm that appropriate medications are available for both mother and baby during and after delivery. In all women living with HIV who deliver at UNM hospital, the PhC prescribes home HIV prophylaxis zidovudine for the neonate and ensures that the family has the medication prior to discharge from the hospital. The PhC provides education and consultation to providers throughout NM on appropriate perinatal care, including laboratory monitoring and therapeutic management. Since the PhC’s involvement in perinatal care, there has been no documented case of perinatal transmission in NM. Pediatric care Pediatric patients living with HIV throughout the state of NM are followed by the UNM pediatric ID specialty clinic. A PhC funded through THS also provides clinical pharmacy services to the pediatric clinic to optimize clinical outcomes. The PhC works in collaboration with a pediatric ID physician. Clinical interventions of the PhC are similar to that of the AHCCP. Those interventions include ART selection, dose and formulations adjustment based on weight and response, medication supply coordination, adverse effect monitoring, and drug interaction management. As of 2017, all pediatric patients achieved complete viral suppression. The care of pediatric patients living with HIV is complicated by the paucity of data for new antiretrovirals, the limited number of approved antiretroviral agents in this population, and the need for oral solutions for weight-based dosing. Funding Establishing a means of funding for PhCs at THS is crucial for the sustainability and expansion of this model. PhCs looking to start their own clinic must first understand their practice site. With current reimbursement rates for medication therapy management (MTM) services, it is not feasible in our system to have billing reimbursement be the sole justification for a PhC’s employment. Grants and dual appointments may be ways to subsidize the overhead cost of a PhC. In our experience, initial PhC contributions to the clinic led to recognition by THS administration and health care staff that PhCs were integral team members and resulted in expansion of PhC hiring and scope of practice. The college of pharmacy partners with THS in sharing the salary cost of the faculty. The salary cost is also subsidized by additional grants. In addition, select health plans throughout the state of NM recognize PhCs as providers for billing. In 2015 PhCs at THS submitted billing for 304 patients for 774 unique encounters. The PhCs billed for $188,425, which is roughly equivalent to the FTE PhCs devoted to THS in 2015. Of note, the amount billed may not represent the amount collected, which is dependent on the insurance, clinic structure, and services provided. Overall, PhCs billed for 39 different Current Procedural Terminology (CPT) codes; 73.9% of 2015 billing was for MTM CPT codes 99605–99607. Table 3 lists common services billed for by THS PhCs in 2015. Table 3. Services Pharmacist Billed for in 2015 by CPT Codesa CPT Code CPT Description 2015 Frequency (%) 99607 Additional 15 minutes MTM services 675 (35.4) 99606 Established patient, initial 15 minutes MTM services 617 (32.3) 36415 Routine venipuncture 126 (6.6) 99605 New patient, initial 15 minutes MTM services 118 (6.2) 82948 Blood glucose test 116 (6.1) 90471 Vaccine administration 49 (2.6) 99367 Medical team conference 42 (2.2) 81015 Urinalysis 22 (1.2) 90649 HPV vaccine 17 (0.9) 90670 Pneumococcal vaccine (PCV13) 17 (0.9) Misc. Misc. CPT codes 157 (5.6) CPT Code CPT Description 2015 Frequency (%) 99607 Additional 15 minutes MTM services 675 (35.4) 99606 Established patient, initial 15 minutes MTM services 617 (32.3) 36415 Routine venipuncture 126 (6.6) 99605 New patient, initial 15 minutes MTM services 118 (6.2) 82948 Blood glucose test 116 (6.1) 90471 Vaccine administration 49 (2.6) 99367 Medical team conference 42 (2.2) 81015 Urinalysis 22 (1.2) 90649 HPV vaccine 17 (0.9) 90670 Pneumococcal vaccine (PCV13) 17 (0.9) Misc. Misc. CPT codes 157 (5.6) aCPT = current procedural terminology, MTM = medication therapy management, HPV = human papillomavirus. View Large Table 3. Services Pharmacist Billed for in 2015 by CPT Codesa CPT Code CPT Description 2015 Frequency (%) 99607 Additional 15 minutes MTM services 675 (35.4) 99606 Established patient, initial 15 minutes MTM services 617 (32.3) 36415 Routine venipuncture 126 (6.6) 99605 New patient, initial 15 minutes MTM services 118 (6.2) 82948 Blood glucose test 116 (6.1) 90471 Vaccine administration 49 (2.6) 99367 Medical team conference 42 (2.2) 81015 Urinalysis 22 (1.2) 90649 HPV vaccine 17 (0.9) 90670 Pneumococcal vaccine (PCV13) 17 (0.9) Misc. Misc. CPT codes 157 (5.6) CPT Code CPT Description 2015 Frequency (%) 99607 Additional 15 minutes MTM services 675 (35.4) 99606 Established patient, initial 15 minutes MTM services 617 (32.3) 36415 Routine venipuncture 126 (6.6) 99605 New patient, initial 15 minutes MTM services 118 (6.2) 82948 Blood glucose test 116 (6.1) 90471 Vaccine administration 49 (2.6) 99367 Medical team conference 42 (2.2) 81015 Urinalysis 22 (1.2) 90649 HPV vaccine 17 (0.9) 90670 Pneumococcal vaccine (PCV13) 17 (0.9) Misc. Misc. CPT codes 157 (5.6) aCPT = current procedural terminology, MTM = medication therapy management, HPV = human papillomavirus. View Large Clinic challenges While the PhCs have been able to implement numerous clinical initiatives, this model is not without limitations. Most problematic is the lack of recognition nationally of pharmacists as providers. Despite NM’s extensive PhC laws, pharmacists are still often restricted by the Centers for Medicare and Medicaid Services regulations which limit what CPT codes pharmacists are capable of billing, further limiting the reimbursement rate of each clinic. Moreover, pharmacists do not receive extensive training in billing, and in some cases pharmacists do not learn how to properly submit for billing until after the opportunity for reimbursement passes. This issue is compounded by the interprofessional clinics in which multiple providers are seeing the same patient and the encounter is usually billed to the highest-level provider, often the physician. A close relationship with coders within the clinic, who may not be aware of pharmacist billing, is a necessity to maximize the amount of reimbursement a pharmacist can claim. If pharmacists gain provider status it will become essential for pharmacists to understand the intricacies of medical billing. Discussion Pharmacists’ role in HIV is not well defined in the current DHHS guidelines.16 Pharmacists are mentioned briefly in regards to therapeutic drug monitoring, adherence counseling, and cost evaluation despite the fact that pharmacists have repeatedly demonstrated their positive impact on patient outcomes through their interventions.17,-21 This narrow scope of practice is a limited view of the potential involvement and impact pharmacists can have in the management of people living with or at risk of HIV and/or HCV infection. At THS, PhCs have identified and established new roles to address evolving patient care needs beyond the previously limited scope of practice. The guideline published by the American Society of Health-System Pharmacists (ASHP) provides a framework for pharmacist involvement in HIV.22 The aspects of HIV prevention, care, and treatment outlined in this guideline are currently addressed at THS through a number of the specialized PhC clinics. However, the ASHP guideline is intended for HIV pharmacists in general but it does not cover advanced practice or collaborative practice models. Pharmacists, with their specialized training and expertise in pharmacotherapy, provide a unique skillset to the HIV management team. Additional advantages of the PhC are that the licensure (1) allows our specialized and highly trained pharmacists the ability to make clinical decisions and interventions, not only recommendations, in real time, which is often required in HIV care, especially when many patient cases do not clearly follow protocol; (2) increases opportunities for billing and reimbursement; and (3) increases the number and diversity of possible prescriber clinics with the expansion of PhC-run clinics. This is especially important in light of the continued decrease in the number of PCPs available and perhaps most evident in the subspecialty of infectious diseases, the most common specialty in HIV primary care.23-26 Moving forward, the number of HIV-trained providers will decrease while the life expectancy of individuals living with HIV increases. 26-29 NPs and PAs have taken an important role in health care delivery in this practice area.23,26 PhCs are also well-positioned and trained to provide comprehensive health care to patients living with HIV and HCV. It is not uncommon for THS patients to have significant delays between available appointments with their PCP. PhCs bridge care for complex patients that require routine monitoring and long-term adherence. The triaging and management of patient needs allows for a more efficient medical home. The addition of PhCs should not be perceived as a replacement of PCPs; instead PhCs should be considered specialists to enhance and augment patient care. In our clinic, and NM overall, the advancement of pharmacy practice has come from a close relationship with providers. The THS-PhC model of pharmaceutical care has been successful in part due to (1) the advanced training of the PhC providers (i.e., fellowship or 2 years of postgraduate residency training in HIV or ambulatory care); (2) the shared faculty appointments between the UNM College of Pharmacy and THS; and (3) the ability to bill for clinical services. Conclusion Pharmacists with the PhC license are able to provide high-quality medical care to patients living with or at risk of HIV and/or HCV infections within an interprofessional medical home model. Disclosures Dr. Ryan has served on an advisory panel for Theravance BioPharma but has no other potential conflicts of interest. Dr. Deming has served on an advisory committee for Gilead Science but has no other potential conflicts of interest. Dr. Mercier has served on an advisory panel for Paratek Pharmaceuticals but has no other potential conflicts of interest. The other authors have declared no potential conflicts of interest. References 1. Pharmacist Prescriptive Authority Act , Section 61- llB-3 NMSA 1978. http://www.nmpharmacy.org/Resources/Documents/PhC/BOP_PHARMACIST%20PRESCRIPTION%20AUTHORITY.pdf (accessed 2018 Jan 19 ). 2. Dole EJ , Murawski MM , Adolphe AB et al. Provision of pain management by a pharmacist with prescribing authority . Am J Health-Syst Pharm. 2007 ; 64 : 85 – 9 . Google Scholar Crossref Search ADS PubMed 3. Health Resources and Services Administration . About the Ryan White HIV/AIDS Program. https://hab.hrsa.gov/about-ryan-white-hivaids-program/about-ryan-white-hivaids-program (accessed 2018 Aug 30 ). 4. Newsome C , Colip L , Sharon N , Conklin J . 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TI - Treatment of patients with HIV or hepatitis C by pharmacist clinicians in a patient-centered medical home
JF - American Journal of Health-System Pharmacy
DO - 10.1093/ajhp/zxz059
DA - 2019-05-17
UR - https://www.deepdyve.com/lp/oxford-university-press/treatment-of-patients-with-hiv-or-hepatitis-c-by-pharmacist-clinicians-LMBg7kSK6I
SP - 821
VL - 76
IS - 11
DP - DeepDyve
ER -