Please send some peer-reviewed (preferred) articles that demonstrate financial and clinical impacts of clinical pharmacists providing Comprehensive Medication Management (CMM) or medication therapy management (MTM) in ambulatory clinics. Issues that could be included:

Comment by InpharmD Researcher

There is an extensive body of ambulatory care literature evaluating the impact of clinical pharmacists providing comprehensive medication management (CMM) or medication therapy management (MTM), although reported economic and utilization outcomes are heterogeneous. Pharmacist-led medication review in ambulatory clinics is consistently associated with improved identification and resolution of drug-related problems, reductions in potentially inappropriate medications, and modest decreases in total medication counts, supporting a role in deprescribing among older adults; however, effects on hospitalizations and quality of life are more variable. Economic analyses suggest potential reductions in downstream healthcare and pharmaceutical costs, with some studies demonstrating favorable cost-effectiveness and return on investment depending on the payment model. Within value-based and population health frameworks, integration of pharmacists into team-based ambulatory care is associated with improved chronic disease control and, in some cohorts, reduced acute care utilization. Although direct comparative evidence between pharmacists and advanced practice providers (APPs) on CMM and MTM outcomes is limited, collaborative care models indicate that pharmacists can deliver effective medication management and may reduce primary care workload, supporting a complementary and potentially cost-efficient role. Please refer to the accompanying tables and summaries for detailed quantitative clinical and economic outcomes.

We graded the evidence as insufficient for most outcomes because of inconsistency and imprecision that stem in part from underlying heterogeneity in populations and interventions. Medication therapy management interventions may reduce the frequency of some medication-related problems, including nonadherence, and lower some health care use and costs, but the evidence is insufficient with respect to improvement in health outcomes.

Background

A 2019 review evaluates health economics evidence based on 11 randomized controlled trials of pharmacist-led medication review in pharmacotherapy managed cardiovascular disease risk factors, specifically hypertension, type-2 diabetes mellitus, and dyslipidemia, in ambulatory settings. Among 5 US-based studies conducted from 2001 to 2016, pharmacist-led interventions primarily consisted of a medication review with adherence counseling and a face-to-face interview with patients during follow-ups. Economic evaluations included cost-effectiveness, third payer, societal, and cost-utility. All studies conducted in the US reported favorable outcomes in blood pressure improvements, life years gained, quality-adjusted life year (QALY), or refill adherence, with life year incremental costs from individual studies ranging from $49.73 per patient to $432.1 per patient. The corresponding incremental cost-effectiveness ratio was determined to be $59.76 per QALY (one study), $1.66 per mmHg to $48.6 per mmHg for systolic blood pressure, $3.53 per mmHg to $105.4 per mmHg for diastolic blood pressure, and $1,964.1 (men) and $2,274.2 (women) per life year gained (one study). The wide span of years in which studies were conducted could have contributed to the considerable variations in monetary outcomes across studies. [1]

A 2015 meta-analysis assessed the effects of medication therapy management (MTM) services among outpatients with chronic illnesses. A total of 44 studies (21 randomized controlled trials, four non-randomized controlled trials, and 19 cohort studies) were included for analysis, all of which used pharmacists to deliver MTM services, specifically medication review, patient-directed education, care coordination, and opportunity for follow-up. Although the studies reported wide confidence intervals (CI), medication therapy management interventions reduced health plan expenditures on medication costs. After MTM interventions, patients with diabetes mellitus or heart failure had lowered odds of hospitalization (diabetes: odds ratio 0.91 to 0.93 based on the type of insurance; adjusted hazard rate for heart failure: 0.55; 95% CI 0.39 to 0.77) and hospitalization costs (mean differences ranged from -$363.45 to -$398.98). [2]

A 2021 systematic review of pharmacist-led interventions in ambulatory care settings included 31 studies (27 controlled trials and 4 observational studies) evaluating clinical, behavioural, economic, and humanistic outcomes. Clinical medication review was the most frequently studied intervention (61.29%), followed by adherence review (19.3%). Clinical medication review demonstrated favorable effects on clinical outcomes, particularly management of drug-related problems and adverse events, and contributed most to reductions in healthcare costs. Adherence review was most effective for improving medication adherence. In observational studies, adherence review was associated with 2% higher adherence (34.3% vs 32.3%), 1.8% fewer hospitalizations, 2.7% fewer emergency room visits, and lower total healthcare costs (−$226.07; all p<0.0001), and medication therapy management reduced plan-paid healthcare costs by 10.3% compared with a 0.7% increase in controls (p<0.05). In interventional studies, correction of identified drug-related problems reached 78.7% in intervention groups versus 0% in controls (p<0.001), and inappropriate medications decreased from 27.2% to 8.9% with pharmacist review (p<0.001). Collaborative pharmacist interventions also improved medication adherence and medication appropriateness index scores (median 8.0 vs 20.0; p= 0.001). However, effects on hospital admissions and quality of life were inconsistent or not significant. The authors concluded that clinical medication review can play a major role in managing drug-related problems and economic issues, while larger, standardized, and rigorously designed intervention studies are needed to support decision-making and confirm meaningful improvements in patient care. [3]

A 2024 qualitative systematic review and meta-synthesis included 9 qualitative studies involving 235 stakeholders (general practitioners, specialist physicians, pharmacists, nurse practitioners, patients, carers, and clinic staff) examining perspectives on pharmacist involvement in deprescribing in ambulatory care settings. Four overarching themes were identified: therapeutic impetus and status quo mentality, role and responsibility, multidisciplinary care, and conflicting interests in pharmacy practice. Stakeholders generally supported pharmacist involvement in deprescribing but reported multiple barriers, including unclear role responsibility, prescriber authority concerns, limited communication and care fragmentation, lack of access to clinical information, insufficient guidelines or deprescribing resources, patient resistance to medication changes, and lack of reimbursement or time for deprescribing activities. Enablers included collaborative relationships with prescribers, embedding pharmacists within clinics, regular medication review processes, improved communication and shared decision-making, and increased access to deprescribing resources. Overall, pharmacists were viewed as a valuable but underutilized contributor to deprescribing in ambulatory care; improving accessibility, communication with pharmacists, and trust in their professional role were identified as key strategies to support safe and successful deprescribing and improve patient outcomes. [4]

Literature Review

A search of the published medical literature revealed 10 studies investigating the researchable question:

Level of evidence

A - Multiple high-quality studies with consistent results Read more→

Please see Tables 1-10 for your response.

Cost-Saving Medication Therapy Management for Outpatients
Design	Prospective cohort study N= 20,281 outpatient prescriptions
Objective	To evaluate the causes and monetary value of cost-saving prescription interventions made by clinical pharmacists in outpatient pharmacy
Study Groups	N/A
Inclusion Criteria	Not specified.
Exclusion Criteria	Not specified.
Methods	Outpatient prescriptions were randomly audited using a customized outpatient prescription audit tool integrated with computerized physician order entry. Drug-related problems were communicated to respective prescribers, and their response to each intervention was documented. Both unit dose cost and anticipated dose cost savings were calculated to evaluate the monetary benefit for patients.
Duration	Between August 2017 and June 2018
Outcome Measures	Monetary value of cost-saving
Baseline Characteristics	General data of the reviewed prescriptions	Medication errors, n (%)	Cost-effective intervention, n (%)	p-value
	Gender Male Female	123 (39.6%) 187 (60.3%)	49 (43.7%) 63 (56.2%)	0.452
	Age group 1-20 21-40 41-60 61-80 81-100	29 (9.03%) 106 (34.1%) 95 (30.6%) 78 (24.8%) 2 (0.64%)	6 (5.3%) 31 (27.6%) 35 (31.2%) 38 (33.9%) 2 (1.7%)	< 0.001
Results Anticipated and unit dose cost saved for drug-related problems	Primary domain	Causes (%)	Unit dose cost saved (International normalized ratio [INR])	Anticipated dose cost saved (INR)	p-value
	Drug selection	Inappropriate drug (within guidelines but otherwise contraindicated) (1.8%)	54.26	401.2	< 0.001
		No indication for drug (3.5%)	1,503.14	2,404.39
		Inappropriate combination of drugs or drugs and herbal medication (25.7%)	583.81	3,694.78
		Inappropriate duplication of therapeutic group or active ingredient (43.4%)	1,313.94	14,117.87
	Dose selection	Drug dose low (0.9%)	1,075	1,075	< 0.001
		Drug dose high (12.4%)	162.4	2,764.17
		Dosage regimen too frequent (8.8%)	134.89	2,028.27
		Dose-timing instructions wrong, unclear, or missing (0.9%)	23.63	94.52
	Treatment duration	Duration of treatment too short (0%)	0	0	< 0.001
	Treatment duration	Duration of treatment too long (1.8%)	24.66	310.6	< 0.001
	Unit dose cost of INR 4875.73 and anticipated dose cost of INR 26890.8 were saved from outpatients. Major contributory drug classes that reduced the cost of therapy were antibiotics (24.23%), proton-pump inhibitors (13.27%), and analgesics (12.34%). Prescribers' response to pharmacist intervention varied; 53% responded to stop the drug, 21% responded to change the brand, and 20% changed the frequency of administration.
Adverse Events	N/A
Study Author Conclusions	As clinical pharmacist has the expertise to detect, resolve, and prevent medication errors, the development of clinical pharmacy practice in a hospital outpatient pharmacy will have a significant impact on reducing prescription errors and health-care cost also.
Critique	The presented data only represents a single institution's experience. The study took place in India, in which presented cost savings may not be as relevant in the US outpatient settings

Table 1 References:
[4] Priya K, Sreshta M, Philip S. Cost-saving medication therapy management for outpatients. Perspect Clin Res. 2021;12(1):14-20. doi:10.4103/picr.PICR_164_1

Improving the Economic and Humanistic Outcomes for Diabetic Patients: Making a Case for Employer-Sponsored Medication Therapy Management
Design	Prospective, single-center, pre-post longitudinal study N= 101
Objective	To determine the cost savings of a pharmacist-led, employer-sponsored medication therapy management (MTM) program for diabetic patients and to assess for any changes in patient satisfaction and self-reported medication adherence for enrollees
Study Groups	Pre-joining: Office visit (n= 54) Emergency room visit (n= 23) Inpatient visits (n= 10) Post-joining Office visit (n= 67) Emergency room visit (n= 12) Inpatient visits (n= 3)
Inclusion Criteria	Employees, their spouses, and dependents whose primary provider of medical insurance and prescription coverage was the City of Toledo; diagnosed with type 2 diabetes; have been on medication or been administered a new prescription for the treatment; had appropriate means of transport to a participating site; be able to read and understand English.
Exclusion Criteria	Any patient not meeting any one of the inclusion criteria.
Methods	Patient visits and counseling sessions with pharmacists for the study period were staggered to take place at 2–4 weeks, and 3, 6, 9, and 12 months following the baseline visit. Economic costs were analyzed for patients whose data were available for the one-year study period. The pre-joining costs were calculated by obtaining all utilization costs for one year before entering the program. All post-costs were calculated for one year following enrollment. Utilization and associated costs were identified by the number and cost of physician office visits, emergency room visits, and inpatient visits or hospitalizations. Total costs were defined as the sum of the aforementioned three different forms of health care utilization.
Duration	January 15, 2008, to September 1, 2010 Follow up: 12 months
Outcome Measures	Average cost and overall costs post-joining, patient self-reported adherence
Baseline Characteristics		Office visit (n = 54)	Emergency room visit (n = 23)	Inpatient visits (n = 10)
	Pre-joining costs Average costs Overall costs	$47.70 $22,946.45	$1,378.33 $56,381.80	$16,002.16 $222,522.42
	Pre-joining average number of visits	10.22	1.87	1.60
Results	Endpoint	Office visit (n= 67)	Emergency room visit (n= 12)	Inpatient visits (n= 3)
	Post-joining costs Average costs Overall costs	$66.41 $34,722.91	$1,722.08 $32,167.63	$17,016.19 $55,911.58
	Post-joining average number of visits	7.07	1.33	1.33
	Office visit costs were found to increase by $11,776.41, but cost savings of $24,214.17 and $166,610.84 were realized for emergency room visits and inpatient visits. A substantial cost savings of $179,047.80 was found when the total costs for the employees, their spouses, and dependants were taken into account. Adherence was found to decrease marginally for the study population at six months but improved at 12 months. The overall improvement in adherence was found to be statistically significant (p= 0.003).
Adverse Events	N/A
Study Author Conclusions	This MTM program had numerous positive outcomes for both employers and employees. Employers realized overall cost savings of $179,047.80, while employees showed a significant increase in patient satisfaction and self-reported adherence with medication. The positive economic and humanistic results of this study provide supporting evidence for implementation of employer-sponsored, pharmacist-led MTM programs.
Critique	The study can be subject to selection bias since the participants were excluded if they were not related to medical insurance and prescription coverage of the City of Toledo. Recall bias is also likely due to the self-reported nature of outcomes that may underestimate the adherence.

Table 2 References:
[5] Pinto SL, Kumar J, Partha G, et al. Improving the economic and humanistic outcomes for diabetic patients: making a case for employer-sponsored medication therapy management. Clinicoecon Outcomes Res. 2013;5:153-159. doi:10.2147/CEOR.S40735

The Evaluation of Comprehensive Medication Management for Chronic Diseases in Primary Care Clinics, A Texas Delivery System Reform Incentive Payment Program
Design	Retrospective, observational study N= 3,280
Objective	To evaluate the effectiveness of this Comprehensive Medication Management (CMM) program in decreasing drug therapy problems and related medical costs
Study Groups	Patients (N= 3,280)
Inclusion Criteria	Age > 18 years, taking 4 or more prescribed medications diagnosed with at least one of the chronic diseases: hypertension, congestive heart failure, chronic obstructive pulmonary disease, asthma, or diabetes
Exclusion Criteria	N/A
Methods	Patient charts during the study period were reviewed by clinical pharmacists to manage polypharmacy patients. Pharmacist's recommendations could be 'accepted', 'partial', or 'declined'. The cost benefits were analyzed using local institutional data.
Duration	Study period: October 2015 to September 2016
Outcome Measures	Number of drug therapy problems, 'accepted' and 'partial' implementation rates, cost-savings based on potential services avoided
Baseline Characteristics		Patients (N= 3,280)
	Age, years 18 to 39 40 to 64 65 to 79 80+ years	211 (6.43%) 1,559 (47.53%) 1,161 (35.40%) 349 (10.64%)
	Women	2,022 (61.65%)
	White Black Other	1,961 (59.79%) 605 (18.45%) 714 (21.77%)
	Number of chronic diseases 1 2 3 4 5	1,704 (51.95%) 1,283 (39.12%) 253 (7.71%) 38 (1.16%) 2 (0.06%)
	Number of drug therapy problems 0 1 2 3	3,000 (91.46%) 260 (7.93%) 19 (0.58%) 1 (0.03%)
Results	Endpoint	Patients (N= 3,280)
	Number of drug therapy problems 'Accepted' implementation rates 'partial' implementation rates	301 151 (49.8%) 129 (42.8%)
		Estimated cost per event (2016 US dollars)	Total savings
	Estimated cost-savings based on potential services avoided Clinic outpatient visit Specialty visit Emergency room visit Hospital admission Reduce/Increase drug product	$206 $264 $1021 $17,263 Varied, calculated based on average wholesale price of drugs	$26,986 $2904 $67,386 $1,070,306 $18,028
Adverse Events	N/A
Study Author Conclusions	By reviewing electronic health records of 3,280 patients, the pharmacist identified 301 drug therapy problems and resolved 49.8% of these problems with collaboration from the patient’s primary care physician or care team. The most commonly identified drug problems were related to potentially adverse drug reactions or inappropriate drug dosage. The CMM program resulted in potential cost savings of $1,143,015.
Critique	This was one of the more recent data showing the interventions of a pharmacist in an outpatient setting. However, the study period ranged from October 2015 to September 2016, nearly 5 years ago which may not reflect the current economic climate of the COVID-19 pandemic.

Table 3 References:
[6] Chung TH, Hernandez RJ, Libaud-moal A, et al. The evaluation of comprehensive medication management for chronic diseases in primary care clinics, a Texas delivery system reform incentive payment program. BMC Health Serv Res. 2020;20(1):671.

Postdischarge pharmacist medication reconciliation: Impact on readmission rates and financial savings
Design	Retrospective, cohort, comparison and quality improvement analysis N= 494
Objective	To assess the impact of ambulatory clinical pharmacist medication therapy assessment and reconciliation for patients postdischarge in terms of hospital readmission rates, financial savings, and medication discrepancies
Study Groups	Medication review group (n= 243) Comparison group (n= 251)
Inclusion Criteria	All patients identified as high risk for readmission were followed by Group Health care management
Exclusion Criteria	Patients discharged to a location other than home or home with home health services
Methods	Patients with a higher risk of readmission who needed transition care management were identified by the hospital care team at a Group Health rapid process improvement workshop with our sources and references used. One to two days postdischarge nurses called the patients in the care management to inform them of the upcoming phone calls from the pharmacists for a more comprehensive medication review. Pharmacists would contact the patients 72 hours postdischarge to go over their medication lists, including medication omissions, therapeutic duplicates, dose changes, discontinued medications, and drug-drug interactions. All encounters were documented on the electronic medical records and the time spent for each case. The 14-day readmission data was used to calculate financial savings.
Duration	September 2009 to February 2010
Outcome Measures	Readmission rates, financial savings, and medication discrepancies
Baseline Characteristics		Medication review (n= 243)	Comparison (n= 251)	p-value
	Mean age, years	67	67	0.69
	Age ≥ 85 years	41 (16.9%)	42 (16.7%)	0.99
	Female	134 (55%)	128 (51%)	0.60
	Mean No. medical encounters Inpatient admits within 12 months of hospitalization ED visits within 12 months of hospitalization	4.4 1.5	5 1.5	0.99 0.99
	Medicare status at hospitalization	125 (51%)	146 (58%)	0.16
	Patients aged >65 years on HRME*	21 (9%)	29 (12%)	0.36
	Primary care physician at time of hospitalization	213 (88%)	235 (94%)	0.03
	Number of medications Prescription Over-the-counter	7 2	7 2	0.33 0.87
	*high-risk medication in the elderly Most frequent discharge diagnoses included chest pain, pneumonia, GI hemorrhage, syncope and collapse, general symptoms, atrial fibrillation, acute pancreatitis, congestive heart failure, abdominal pain, acute myocardial infarction. No significant p-values were noted between the two groups.
	Abbreviations used: ED, emergency department; GI, gastrointestinal; HRME, high-risk medication in the elderly9; PCP, primary care physician.
Results	Endpoint	Medication review (n= 243)	Comparison (n= 251)	p-value
	No. of readmitted patients 7-day 14-day 30-day	2 (0.8%) 11 (4.5%) 28 (11.5%)	11 (4.4%) 22 (8.8%) 34 (13.5%)	0.01 0.04 0.29
	Most frequent admission diagnoses Congestive heart failure	4	0	0.02
		Patients with ≥1 discrepancies	Total no. of discrepancies in medication review
	Medication discrepancies Discontinued medications Omissions Dose changes Therapeutic duplications Drug-drug interactions	48% 46% 44% 18% 8%	264 250 186 69 24
	Other frequent admission diagnoses included chest pain, GI hemorrhage, syncope and collapse, abdominal pain, chronic airway obstruction, intestinal obstruction, pancreatic cancer, pneumonia, and shortness of breath (p-values not significant). A labor cost of $45.22 per medication reconciliation translates to $4,522 for each 100 patients receiving medication reconciliation. The number needed to treat of 25 corresponds to four readmissions prevented per 100 patients. With the cost of readmission estimated at $10,000, this equals a gross savings of $40,000 per 100 medication reconciliation services. Subtracting the cost for pharmacist labor ($40,000 – $4,522) results in a net savings per 100 patients of $35,478.
Adverse Events	N/A
Study Author Conclusions	Most literature on medication reconciliation evaluates inpatient processes, whereas data on medication reconciliation postdischarge are limited. Our data support the hypothesis that medication assessment and reconciliation by pharmacists 3 to 7 days popostdischargean decrease readmissions and provide cost savings.
Critique	This retrospective cohort study has its inherent limitations in design. Researchers did not formally evaluate if the admissions or readmissions were medication-related. Overall, the data regarding pharmacist interventions in post-discharge medication management is promising.

Table 4 References:
[7] Kilcup M, Schultz D, Carlson J, Wilson B. Postdischarge pharmacist medication reconciliation: impact on readmission rates and financial savings. J Am Pharm Assoc (2003). 2013;53(1):78-84. doi:10.1331/JAPhA.2013.11250

Clinical and Economic Benefits of Pharmacist Involvement in a Community Hospital-Affiliated Patient-Centered Medical Home
Design	Single-center, retrospective, quality improvement study N= 63
Objective	To exhibit the clinical and economic benefit of pharmacist involvement in accountable care organization (ACOs) and patient-centered medical homes (PCMHs) as documented by clinical interventions (CIs) and drug cost reductions
Study Groups	Participants (N= 63)
Inclusion Criteria	Any adult patient with an eligible insurance plan who was let by a pharmacist with a documented clinical intervention
Exclusion Criteria	N/A
Methods	Documented cases of patient interventions by pharmacists were analyzed. Pharmacists were consulted by providers for patient medication management through follow-up MTMs. Any cost management CIs were defined as a direct cost savings from switching one medication to another.
Duration	Study period: October 2016 to March 2017
Outcome Measures	Documented clinical interventions and recommendations to a cheaper therapy with calculated cost-savings
Baseline Characteristics		Participants (N= 63)
	Age, years	68
	Women	50 (79%)
Results	Endpoint	Participants (N= 63)
	Number of documented CIs	283
	MTM interventions cost management interventions patient/provider education intervention Transition of care medication reconciliations collaborative drug therapy management interventions	94 (33.2%) 88 (31.1%) 37 (13.1%) 36 (12.7%) 28 (9.9%)
	Recommendations to switch to a less expensive alternative Extrapolated cost savings	16 $118,409
Adverse Events	N/A
Study Author Conclusions	Clinical benefit of pharmacy services was demonstrated through documented CIs. Pharmacists can have a dramatic and quantitative effect on reducing drug costs by recommending less expensive generic or therapeutic alternatives. Documenting CIs allows pharmacists to provide valuable evidence of avoided drug misadventures and identification of medication discrepancies. Such evidence supports an elevated quality of care.
Critique	Although a small patient population, this reflects a recent attempt at measuring cost management in an outpatient setting.

Table 5 References:
[8] Tate ML, Hopper S, Bergeron SP. Clinical and economic benefits of pharmacist involvement in a community hospital-affiliated patient-centered medical home. J Manag Care Spec Pharm. 2018;24(2):160-164.

Return-On-Investment for Billable Pharmacist-Provided Services in the Primary Care Setting
Design	Prospective study N= 39 practice sites
Objective	To describe pharmacist-delivered billable and non-billable patient-centered care services and assess the impact of various billing methods on an ambulatory care pharmacy department’s return-on-investment (ROI) for billable services
Methods	Data sources included electronic health records, pharmacist flowsheets, and internal financial reports. Potentially billable services comprised hospital-based fee codes (G0463) and/or chronic care management codes. Total expenses, including benefits, for a full-time equivalent pharmacist was calculated as $170,898. The number of pharmacist hours devoted to billable services was calculated by multiplying the number of annual encounters by time spent for encounters.
Duration	September 1, 2016, to August 31, 2017
Outcome Measures	ROI for potentially billable services
Results	Summary of Return-On-Investment (ROI) for Billed Services and Billed Services Plus Missed Billing Opportunities
	----	Total hours (FTE)	Total revenue (cost of pharmacist services)	ROI^a on billed services	Billed services plus missed billing opportunities (cost of pharmacist services)	ROI^a on billed services plus missed billing opportunities
	Billed	948.3 hours	$173,638.66	-	-	-
	Services	(0.46 FTE)	($78,613.08)	1.2:1	-	-
	Missing billing	158.1 hours	$68,268.37	-	$241,907.03	-
	Opportunities	(0.08 FTE)	($13,671.84)	-	($92,284.92)	1.6:1
	948.3 total hours for all encounters = 0.46 FTE
	FTE: Full-time equivalent, 2,080 Hours ^a1.0 FTE pharmacist salary and benefits for ROI calculation was estimated to be $170,898
	Type and Total Avenue of Encounters From September 2016 to August 2017
	Encounter type			Total revenue
	Annual Wellness Visits^b			$138,595.21
	Immunizations			$20,550.46
	Screenings (alcohol, smoking cessation, and depression)			$8,625.27
	Transitions of Care^c			$3,600.00
	Comprehensive Medication Review			$750.00
	Total			$173,638.66
	^bPharmacists received an incentive payment from a commercial payer for completing initial annual wellness visits. ^cPharmacists were part of the team that provided transitions of care services. The pharmacist’s role was to perform a comprehensive medication review (CMR), and $50 of the payment was allocated for provision of the CMR during a transition of care encounter.
Study Author Conclusions	Study findings indicate that the integration of billable methods, such as incident to and Medicare Annual Wellness Visits (AWVs), to finance pharmacist-provided clinical services in the primary care setting resulted in a positive ROI for billable services. However, the majority of the time was spent performing non-billable services, which did not result in an overall positive ROI. To realize a sustainable business model, pharmacists should be performing a high volume of billable services. Billing G0463 (encounters eligible for the hospital-based facility) and chronic care management (CCM) codes, when applicable, are revenue sources that have the potential to increase ROI yet may be underutilized. Pharmacists should work with their organizational leadership to maximize billing opportunities in the outpatient setting.
Critique	Only 17% of clinical time was spent addressing billable services, which did not translate into a positive ROI. Implementing a minimum number of daily visits (similar to physician models) may increase efficiency and ensure proper revenue. Pharmacists may also bring value to a team via non-billable services that are still important, such as drug information responses, work on committees, and development of protocols.

Table 6 References:
[9] Tran T, Moczygemba LR, Musselman KT. Return-On-Investment for Billable Pharmacist-Provided Services in the Primary Care Setting [published online ahead of print, 2021 May 26]. J Pharm Pract. 2021;8971900211013194. doi:10.1177/08971900211013194

Billing for pharmacists’ cognitive services in physicians’ offices: Multiple methods of reimbursement
Design	Retrospective, observational analysis N= 6,930
Objective	To (1) evaluate charges and reimbursement for pharmacist services in an outpatient family health center recognized as a patient-centered medical home (PCMH) and (2) determine the number of patients that must be managed by a pharmacist to cover the cost of salary and fringe benefits
Methods	This study was a retrospective analysis of financial data during a 4-year period (2006–10) in three ambulatory care practices with well-established clinical pharmacy services in North Carolina. Data were collected from monthly and annual internal financial reports and an electronic medical record and included annual charges and collections, clinic capacity, number of patients seen (monthly and annually), and patient no-show rates. Four different clinics were managed by the pharmacists, including anticoagulation, pharmacotherapy, osteoporosis, and wellness clinics. “Incident to” level 1 billing was used for the anticoagulation and pharmacotherapy clinics, whereas level 4 codes were used for the osteoporosis clinic. The wellness clinic utilized a negotiated fee-for-service model.
Duration	2006 to 2010
Outcome Measures	Encounters, total charges, total reimbursement
Baseline Characteristics	Problems	Time involved, minutes	Level of visit	North Carolina Medicare reimbursement
	Minimal	5	“Level 1” or nurse visit	$19.06
	Self-limited to minor	10	“Level 2” visit	$40.04
	Low to moderate severity	15	“Level 3” visit	$66.83
	Moderate to high severity	25	“Level 4” visit	$99.21
	Moderate to high severity	40	“Level 5” visit- typically involves full examination	$133.56
Results	Fiscal year	Encounters	Charges using level 1 billing	Reimbursement (reimbursement rate)
	2007-08	1,142	$36,036	$24,201 (67%)
	2008-09	1,515	$41,131	Not reported (N/A)
	2009-10	2,025	$70,925	$20,387 (29%)
	2010-11	1,953	$57,195	$25,432 (45%)
	Mean	1,658	$51,322	$23,340 (47%)
	The mean annual charges were $65,022, and the mean reimbursement rate was 47%. The mean charge and collection per encounter were $41 and $19, respectively. Eleven encounters per day were necessary to generate enough charges to pay for the cost of the pharmacist. Considering actual reimbursement rates, the number of patient encounters necessary increased to 24 per day.
Study Author Conclusions	Unique opportunities for pharmacists to provide direct patient care in the ambulatory setting continue to develop. The use of a combination of billing methods resulted in sustainable reimbursement. The ability to bill at the level of service provided instead of a level 1 visit would decrease the number of patients needed to pay for a pharmacist.
Critique	This study used real-world data, but assumptions had to be made to allow for predictions.

Table 7 References:
[10] Scott MA, Hitch WJ, Wilson CG, Lugo AM. Billing for pharmacists' cognitive services in physicians' offices: multiple methods of reimbursement. J Am Pharm Assoc (2003). 2012;52(2):175-180. doi:10.1331/JAPhA.2012.11218

Outcomes of annual wellness visits provided by pharmacists in an accountable care organization associated with a federally qualified health center
Design	Retrospective, single-center, chart review N= 300
Objective	To evaluate the financial outcomes of annual wellness visits (AWVs) conducted by clinical pharmacists working as part of an accountable care organization (ACO) in a federally qualified health center in Arizona
Study Groups	All patients (N= 300)
Inclusion Criteria	Patients met criteria for Medicare AWV and were seen by clinical pharmacists
Exclusion Criteria	Patients seen by other healthcare providers or for whom charts were not available
Methods	Data collected from patient charts included revenues collected from AWV and preventive screenings.
Duration	October 2013 to December 2013
Outcome Measures	Revenue from AWVs and services provided
Baseline Characteristics		All patients (N= 300)
	Age, years	64.4 ± 4.6
	Female	172 (57%)
	Body-mass index, kg/m²	29.5 ± 2.4
	Chronic diseases Hypertension Dyslipidemia Diabetes mellitus Chronic kidney disease Depression	190 (63%) 150 (50%) 148 (49%) 89 (30%) 48 (16%)
Results	Endpoint	Total charges	Contract-allowed amount	Total revenue
	Month and year October 2013 November 2013 December 2013 Total	$19,178 $23,731 $19,820 $62,729	$8,626 $12,038 $9,994 $30,659	$6,937 $9,151 $6,252 $22,340
	Service	Number of orders	Unit price	Total revenue
	Mammogram Laboratory testing Hemoglobin A_1c Lipid panel Other Vaccination Pneumococcal Tetanus, diphtheria, and pertussis Influenza Total	40 - 100 52 249 - 37 40 72 -	$361.00 - $48.50 $68.50 Varied - $64.00 $44.00 $30 -	$14,440.00 - $4,850.00 $3,562.00 $7,239.00 - $2,368.00 $1,760.00 $2,160.00 $36,379.00
Adverse Events	N/A
Study Author Conclusions	Recommendations made by pharmacists during AWVs in an ACO associated with a federally qualified health center had a high acceptance rate and generated substantial revenue.
Critique	The short study duration used in this analysis limits the conclusions regarding long-term revenue generated. According to the authors, data on net financial benefit could not be calculated and included after calculating all other expenses

Table 8 References:
[11] Alhossan A, Kennedy A, Leal S. Outcomes of annual wellness visits provided by pharmacists in an accountable care organization associated with a federally qualified health center. Am J Health Syst Pharm. 2016;73(4):225-228. doi:10.2146/ajhp150343

Outcomes of systematic anticoagulation management in pharmacist and nurse-specialized clinics
Design	Retrospective, observational, cohort study N= 200
Objective	To compare the quality of anticoagulation-related outcomes via two models of care, pharmacist-managed anticoagulation clinic (PMAC) and nurse-managed anticoagulation clinic (NMAC).
Study Groups	PMAC (n= 100) NMAC (n= 100)
Inclusion Criteria	Age > 18 years, treated with warfarin at UI health for a minimum of 1 months.
Exclusion Criteria	N/A
Methods	Patient data from the outpatient pharmacist-run, clinic where warfarin patients received management therapy was collected. This data was compared with the NAMC, who also received warfarin patients from the same location. Based on the institutional collaborative practice agreement, pharmacists and nurses independently dosed and managed warfarin.
Duration	15-month period
Outcome Measures	Secondary outcome: Warfarin-related hospitalizations and emergency department (ED) visits.
Baseline Characteristics		PMAC (n= 100)	NMAC (n= 100)
	Age, years	58.7 ± 15.5	64.2 ± 13.2
	Female	65%	52%
	White African American Hispanic Other	14% 58% 25% 3%	26% 41% 29% 4%
	Indication for warfarin Venous thromboembolism Peripheral vascular disease stroke Atrial fibrillation Mechanical valve replacement (MVR) Other	66% 12% 11% 9% 2% 0	3% 1% 2% 53% 39% 2%
	Goal INR range 2-3 2.5-3.5	84% 11%	63% 32%
	Greater than 3 missed monitor meeting	78%	33%
	Include relevant baseline characteristics that will provide a general (big picture) view of the patients in the study.
Results	Endpoint	NMAC (n= 100)	PMAC (n= 100)
	Hospitalization/ED visits: Hemorrhages Charge due to hemorrhage	14 $773,522	13 $718,270
	Hospitalization/ED visits: Embolisms Charge due to embolism	1 $59,100	2 $188,199
	Hospitalization/ED visits: Non-therapeutic INR Charge due to non-therapeutic INR	22 $553,445	1 $24,247
	Total cost Cost avoided by PMAC	$1,366,066 $505,349	$860,717 -
Adverse Events	N/A
Study Author Conclusions	The quality of warfarin anticoagulation did not differ between pharmacist and nurse-managed models of anticoagulation care; however, PMACs decreased the odds of warfarin-related hospitalizations/ED visits and their associated costs.
Critique	Aside from the retrospective nature of the study introducing bias, baseline characteristics were significantly different between groups. The authors did not attempt to correct for differences in hospitalization and ED visits. Lastly, the study focuses on warfarin anticoagulation.

Table 9 References:
[12] Manzoor BS, Bauman J, Shapiro NL, Stamos T, Galanter W, Nutescu EA. Outcomes of systematic anticoagulation management in pharmacist and nurse specialized clinics. J Am Coll Clin Pharm. 2018;1(2):68-73.

Cost and Effectiveness of Pharmacist-Led Group Medical Visits for Type-2 Diabetes: A Multicenter Randomized Controlled Trial
Design	Multisite, randomized, controlled, parallel design trial N= 250
Objective	To determine the impact of a pharmacist-led group medical visit intervention added to standard care compared to standard care alone for patients with Type-2 DM on glycemia, blood pressure, lipids, health status, and healthcare system costs
Study Groups	Pharmacist-led group visit (n= 117) Standard care (n= 113)
Inclusion Criteria	All patients over the age of 18 with documented Type-2 DM in the medical record, a last recorded hemoglobin A1c of >7.0%, and at least one of the following: 1. Smoker (any cigarette smoking < 30 days) 2. An LDL >100 mg/dl in the last blood draw 3. A blood pressure >130/80 mm Hg documented on at least two occasions within the last 6 months
Exclusion Criteria	Pregnancy, psychiatric instability, NYHA class 3 or 4 heart failure, liver cirrhosis, end-stage renal disease, dialysis, end-stage cancer, or organic brain injury
Methods	Patients were randomly assigned to receive either a clinical pharmacist-led group medical visits in addition to standard primary care or receive standard primary care alone. The clinical pharmacist-led group medical visit consisted of American Diabetes Association Standards of Diabetes Self-Management education on diabetes self-care during the first hour, followed by behavioral counseling and comprehensive medication management for hyperglycemia, hypoglycemia, hypertension, and dyslipidemia during the second hour. The clinical pharmacists who delivered these group medical visits were required to have at least one year of postgraduate residency training or equivalent in outpatient clinical care. Each visit consisted of 4–6 participants and lasted around 120 minutes. Group medical visits were held once weekly for over 4 weeks, followed by 4 booster sessions held once every 3 months. The standard care group regularly visited primary care and specialty care providers. The patients received an average of 4 visits per year with their primary care provider, with additional visits scheduled on an as-needed basis determined by the physician.
Duration	13 months
Outcome Measures	The mean change in the UKPDS risk score, which consists of change from baseline in A1c, systolic blood pressure, and LDL-cholesterol Change in cost
Baseline Characteristics		Pharmacist-led Group Visit (n= 117)	Standard Care (n= 133)
	Age, years	65.8 ± 8.7	65 ± 9.8
	Male	95.7%	96.2%
	Duration of diabetes, years	13.5 ± 9.4	12.4 ± 9.9
	Hypertension	92.3%	85%
	Hyperlipidemia	87.2%	91%
	Coronary Heart Disease	39.3%	43.6%
	Stroke	10.3%	3.8%
	Congestive Heart Failure	10.3%	9.8%
	Chronic Obstructive Pulmonary Disease	11.1%	15.8%
	Active smoker	21.4%	27.1%
	Systolic blood pressure, mmHg	136.5 ± 19.0	136.2 ± 17.4
	Diastolic blood pressure, mmHg	75.1 ± 11.4	75.3 ± 10.5
	Total Cholesterol, mg/dL	155.2 ± 33.5	165.3 ± 39.7
	HDL Cholesterol, mg/dL	37.8 ± 10.9	38.1 ± 9.5
	LDL Cholesterol, mg/dL	87.6 ± 29.8	93.7 ± 33.7
	Hemoglobin A1c	8.2% ± 1.5%	8.2% ± 1.3%
Results	Endpoint	Pharmacist-led Group Visit (n= 117)	Standard Care (n= 133)	p-value
	Mean change in UKPDS risk score	-0.02 ± 0.09	-0.04 ±0.09	0.45
	Mean change in hemoglobin A1c	-0.27 ± 1.25%	-0.14 ± 1.23%	0.30
	Mean change in systolic blood pressure, mmHg	-6.9 ±19.7	-8.9 ± 17.4	0.12
	Mean change in low-density lipoprotein, mg/dL	-5.4 ± 30.1	-14.2 ± 30.0	0.12
	Mean change in cost 13 months after Study period minus 13 months of Study period, $	-1575 ± 30774	2360 ± 23708	< 0.01
Study Author Conclusions	The addition of pharmacist-led group medical visits in T2DM achieved similar improvements in cardiovascular risk factors to usual care, while outpatient care costs decreased. Furthermore, thirteen months after the completion of the intervention, healthcare costs in group medical visits decreased to below baseline levels compared to the steady rise in cost of usual care. Future studies should be conducted in the non-VHA setting to assess the generalizability of the results.
Critique	Only about 40% of individuals contacted agreed to participate in the study. This suggests that group visits may not fit all patients with type 2 diabetes. Only patients who sought care in VHA hospitals were included in the study. as a result, the patients in this selection are primarily male.

Table 10 References:
[13] Wu WC, Taveira TH, Jeffery S, et al. Costs and effectiveness of pharmacist-led group medical visits for type-2 diabetes: A multi-center randomized controlled trial. PLoS One. 2018;13(4):e0195898. Published 2018 Apr 19. doi:10.1371/journal.pone.0195898