CMS Mega Rule: Pharmacy Recommendations

by Flora Bessey, Pharm.D., CGP

As we continue to strive to assist our facilities in implementing the Mega Rule, it is helpful to break down this often-intimidating set of regulations in steps. As a consultant pharmacist, I will deal with the role of the pharmacy and consultants.

As has been mentioned, Phase 1 went "live" on November 28th, 2016. The success and pace of implementation has been mixed, but there are now certain "best-practices" that can be followed, or adjusted as needed to fit each facility's unique situation.

The Phase 1 "Final Rule" on pharmacist recommendations is quite explicit: it requires physicians to "report on pharmacist recommendations," which is to include reasoning as to why a physician decides to follow, or decides to reject, the pharmacist recommendations.

What does this mean to our facilities? Ultimately, the buck stops with the medical director. It is helpful if each facility requests that the medical director sign the monthly report of the consultant pharmacist saying "I have received and reviewed the pharmacist's medication regimen review report." This should be done even if the medical director is not the attending physician for a particular patient or group of patient (the Kaiser system is a particularly obvious example of this). However, it should be noted that if individual physicians refuse to complete this documentation, the facility could still be written up during survey. It is also worth noting that starting this year, nursing home’s performance on certain quality measures will be collected, and published online. Starting in 2018, facilities will begin receiving payment based upon performance on these measures.  View The CMS Skilled Nursing Facility Value-Based Purchasing Program (SNFVBP).

Starting this year, physicians will have performance on certain quality measures collected and published, and payment will be affected beginning in 2018 as per the Merit-based Incentive Payment System (MIPS), or the Advanced Alternative Payment Methods (APM). (MACRA: MIPS & APMs - Centers for Medicare & Medicaid Services) So it is in the best interest of both physicians and SNF's to ensure that all of the required documentation is completed.

The medication reconciliation aspect is something that will hopefully be part of each facility's medication management program. It is important to work with your pharmacy to ensure that this is properly documented.

Another part of the Mega Rule that has led to some questions and concerns is the requirement for a drug regimen review (DRR) for each resident at least once a month. If a facility has internet-based charting the DRR requirement is less onerous, but it still comes with a cost. Due to laws against inducement, this is a service which cannot be performed by a pharmacy pro bono. In the past, some LTC pharmacies charged very high fees to perform these reviews, even if it was being completed by a bench pharmacist. How is this being done at your facility? Do you have a good relationship with your consultant pharmacist? Can you ask them what is a reasonable charge for this service? Can you contract with them individually to perform this service? In addition, DON's should ensure that not only the attending physician but also the medical director receive a copy of these DRR's.

If you are a regular reader of "The Wave," chances are that you are already well ahead of your colleagues in implementing and complying with the requirements of the Mega Rule. Don't be shy about reaching out to others and assisting them in doing the same. We are all working toward the same goal: the quality care of our residents.