Talking LTC at Home Reimbursement with GeriMed’s Susan Rhodus

The opportunities in long-term care (LTC) at home and how to overcome the challenges of being reimbursed accordingly.

In this interview, Pharmacy Technology & Management Review’s Maggie Lockwood talks with GeriMed Senior Vice President of Contracts and Advocacy Susan Rhodus about the opportunities in long-term care (LTC) at home and how to overcome the challenges of being reimbursed accordingly. GeriMed is a group purchasing organization that offers contracts and pharmacy services to long-term care.

Pharmacy Technology & Management Review: Susan, outline the current state of reimbursement for LTC at home services.

Susan Rhodus: The majority of pharmacy benefit managers (PBMs) are not paying for LTC at home, or not adequately paying for it. There are a couple that don't pay at all.

PTMR: What has GeriMed done to counter this reluctance to pay?

Rhodus: First, GeriMed has created the medical codes to bill for the LTC at home. The genesis of this was a large pharmacy member of ours in North Carolina that was using a courier service to deliver prescriptions to patients. I visited the pharmacy with a colleague and we realized the pharmacy wasn’t doing just “retail” services. This was actually long-term care. They were doing all the things they were supposed to do, even though they didn't realize it until we came in there and said, well, you know, as long as you do all these things, technically you're in long-term care.

PTMR: But at that point there wasn’t a way to bill for these services provided outside of LTC facilities?

Rhodus: Right. At that point there was no coding under the NCPDP [National Council for Prescription Drug Programs] telecom standard to identify these claims as being long-term care pharmacy services provided to patients at home. That's when GeriMed proposed submitting a data element request form (DERF). As it turned out, the industry felt there was a code for this situation already, so we developed a service level code instead.

PTMR: And what’s been the result of that effort?

Rhodus: The Medicare Part D plans, PBMs, and NCPDP have to recognize the codes but they must contract with the pharmacies or PSAO/GPO to get appropriate payments. We tell customers that if they have a patient who is LTC at home, they have to put the PRC [patient residence code] as 1; the pharmacy service type as 5, because the pharmacy is providing long term care services; and then you put a level of service of 7, which identifies the patient being given services is equal to a long-term care pharmacy in their home.

First,  the PBM, especially the bigger PBMs, must change their software, to accept those codes and agree to pay higher reimbursement for providing these additional services. And then pharmacists were concerned about audits. How will you confirm the person qualifies for these services?

PTMR: I’m sure that’s a real concern given how aggressive PBMs are with audits.

Rhodus: We came up with an attestation form, which has evolved. This is where pharmacies document that the patient can't leave their home; that they need assistance with ADLs [activities of daily living], like banking, and medication administration, going shopping, household maintenance, or toileting, showering, and eating.

If a patient needs help with two or more of these ADLs they become eligible for admission to a nursing home. But the patient may prefer to remain at home or it may be out of their financial range to move into an assisted living facility, which costs $30,000 to $50,000 on average annually. It’s important to note that there has to be a real need for assistance with ADLs. It’s not just a matter of convenience. They also need to have three or more chronic medical conditions and be taking multiple maintenance medications as well as being unable to leave their home without assistance.

PTMR: What are the services pharmacies provide then?

Rhodus: You can’t just do compliance packaging and delivery. You have to do additional services like coordination of care, medication management, and reconciliation if the patient goes into the hospital. The pharmacist has to do all those on a clinical level or it's not a long-term care pharmacy at home. What’s amazing is that at this point, independent retail pharmacies often already do all of this.

PTMR: What other considerations are there?

Rhodus: Pharmacies that have both retail and LTC businesses need to keep two separate inventories, because they are buying medications at a reduced rate that is only applicable to patients receiving LTC-level services, either at home or in a facility. These pharmacies must have  separate NCPDP and NPI [National Provider Identifier] numbers, as well as a separate account with their wholesaler to buy these products.

PTMR: Let’s talk about the opportunity afforded by LTC at home.

Rhodus: I think pharmacists are being hit so hard on the retail side with horrible reimbursement that they are seeing LTC at home as a mechanism to stay in business. But NCPA [The National Community Pharmacists Association] does a survey every year and it estimates that 11,000 of its 19,000 members are doing long-term care. Not long-term care at home necessarily, but long-term care — general group homes or small assisted living group homes and even skilled facilities, depending on if they're in a rural area. And the key is getting more pharmacies to recognize that it may be worth it for them to really take a look at long-term care as a piece of their business. The population is aging — we will have the most people in the United States over the age of eighty (80) years old in the year 2040.  There is not enough room in nursing homes or assisted living for all people that need care to get it in a facility. So if you can live at home and receive pharmacy services that are the same as what you would receive if you lived in a facility, we can save healthcare dollars (our tax dollars) and provide a better quality of life for these aging vulnerable people.

PTMR: And so the landscape is changing?

Rhodus: The big thing pharmacists need is education to know what’s allowed and not allowed in LTC pharmacy at home. You have to do it the right way. And then, when we can get some of these PBMs to pay money for this service for doing it the right way, it will go far.

Check out the Long-term Care at Home Alliance “Who Is Eligible?” Fact Sheet

PTMR: Tell us more about how GeriMed supports its members

Rhodus: GeriMed offers business consulting and guidance on LTC programs. We also recommend pharmacies take a look at other organizations such as the LTC@Home Network and the Alliance for Long-term Care at Home, which includes 16 organizations such as NCPA, ASCP [the American Society of Consultant Pharmacist], and three LTC-specific group purchasing organizations [GPOs], including GeriMed. This is a great way to learn how to properly run a program and get on-going support.

We know pharmacists are all very busy. What’s important is you can't cut corners. You cannot just dial this in. You have to be really committed to it and understand it and make sure you are doing this the right way. PTMR