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Pharmacogenomics in the Community Pharmacy

It's no secret that pharmacies are going to have to diversify their revenue streams and continue to expand on non-dispensing revenue in order to survive. This can take many forms, including boosting front-end sales, adding new services like MTM and chronic care management, and more recently pharmacogenomics.


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With pharmacogenomics being so new, it can be hard to even know how to get started, where it fits in with your existing business model, and where to learn more on the subject.


In the spirit of PharmCompliance, this article won't be discussing the clinical details of pharmacogenomics, but rather how to operationalize and build your genomics business.


OK let's get started!


Where do I learn the clinical side of pharmacogenomics?


Thankfully, pharmacy schools and professional organizations have stepped in and started offering a lot of education in this area. Most people probably got little to no education in genomics in school (I only remember them droning on about VKORC1), so if you decide to get in the business you'll need to get up to speed.


Here are a few to get you started in your search:


University of Florida

University of Colorado-Denver

NACDS

ASHP

Mayo Clinic

Shenandoah University

RxGenomics

ACCP


I'm not advocating one over the other, so do your homework.


OK that's about all I'll say on the clinical side. Now on to how to make it happen, and more importantly, how to grow your business with the service.


Do I need a lab or expensive equipment for this?


Absolutely not. Patients will typically have a genomics test ordered by their provider, and will then go to a commercial lab to have it done. Both Quest Diagnostics and LabCorp are in this business. They then send the results back to the provider's office, just like they would any other test.


Should everyone get tested?


It's not really cost-effective to test everyone, because there are going to be many patients on just a few meds that have not had any genes identified that affect response. Because of this, you're going to need an efficient way to screen patients that might benefit from the service.


There are actually genomics software platforms that integrate with your pharmacy dispensing system to help you risk-stratify and determine who will benefit the most from the service. Examples include Rxight and MedTek21.



How can I make money doing this?


Now for the million-dollar question (OK it's probably not that much). The bad news is, most insurance companies are not currently going to pay for the service.


HOWEVER


That isn't a reason not to launch the business. After all, if you can get patients who are willing to pay cash to have it done, is that not better than dealing with billing?


Here is how you can do it, in a few broad categories:

  1. Work with a provider's office

  2. Contracting directly with a facility or company

  3. Hiring a provider or provider service

Now let's break each of these down:


1. Working with a provider's office


Billing for Chronic Care Management (CCM)


Regardless, with providers being the ones to order the test, you'll need to develop a good relationship with a provider. However, this relationship can go deeper to allow pharmacists to actually bill for their services under the provider. This is done using specific CPT codes for Chronic Care Management. You can take a look at the guide here.


CPT Code 99490, for example, requires this:


"Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements:

  • Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient

  • Chronic conditions place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline

  • Comprehensive care plan established, implemented, revised, or monitored Assumes 15 minutes of work by the billing practitioner per month."

"Clinical staff time" could encompass numerous things, including pharmacogenomics; while there are service elements to meet in order to bill under these CPT codes (see page 11 of the guide), that's required for basically all services, including disease-state management, so this is no different. You just need to learn what's required and do it, but it can be done.


PROS:

  • Billing Medicare allows a patient to participate with either no out-of-pocket or only their copay

  • Working with the doctor's office will give you a good patient base

  • Because CCM can encompass more than genomics, you can incorporate MTM and disease-state management into the model to fill out your appointments for the day

  • Can be done with no out of pocket costs to the provider

CONS:

  • You'll need a lot of enrolled patients for this service to significantly add to your bottom line; reimbursement from CMS is around $40 per 20 minute visit (you can search for reimbursement by CPT code here)

  • CCM only allows Medicare patients to receive the service, meaning you miss commercial patients

  • The patient will still have to pay for the lab; only the pharmacist's time is covered under this CPT code

Offering it as a cash-only service at the provider's office


To capture the non-Medicare patients, why not offer genomics at a cash rate too? Again, working with the provider, you both can create a 'packaged deal' that includes the lab test, the pharmacist review, and then final physician review of the pharmacist recommendations.


If we look at the same 20-minute review from a pharmacist, the physician's order and final acceptance/rejection of recommendations, and lab test, you could still offer it to patients for a price many patients would pay and make money doing it.


Don't believe me? Here's a paper I found describing pharmacists that did just that.


PROS:

  • Cash only means no hassle about billing or getting paid, and no complicated contracts to sign with insurance companies

  • Allows you to expand past the Medicare population to people

  • Probably the easiest way to get the business started

CONS:

  • Many patients still won't pay (or be able to pay) cash for the service

2. Contracting directly with a facility or company


Long term care facilities


Many of you reading this are probably already in the long-term care business, considering it's a staple of many community pharmacies. If you are, you know that consultant pharmacists are required to do monthly reviews of patient charts anyway; why not distinguish your service by adding pharmacogenomics?


You would likely be the only one in town doing it, and if you can demonstrate cost-savings or improved quality to the facility through either national data or case studies it could help you land the contract over the next guy. That alone could be worth a lot of money, regardless of what you make providing the pharmacogenomics services to the facility.


If you look at Medicare's Quality Measures, for example, for nursing homes, you'll see a lot of quality scores related to medications. Many of these could be affected by genomics; for example, if a patient is not responsive to clopidogrel they would be more likely to be admitted to the hospital. Making a strong case statement to the facility, with examples such as these, could help you land the contract. For that matter, making a case like that could help you land a deal under any of these models.


PROS:

  • Even one contract with an LTC could provide