(Management Case Study) Improved Outcomes, Revenue, and Access in a Migraine Clinic

Purpose: A patient contacted neurology clinic stating that she was on her way to the emergency room for treatment of a 4-day migraine that was unresponsive to abortive medications. This case describes an unmet patient need that lead to implementation of neurology clinical pharmacist program and migraine treatment cocktails. The program’s goal was to optimize the management of migraines and prevent emergency room visits thus reducing overall healthcare costs as well as increase patient access and physician revenue.

Methods: Cedars-Sinai Medical Network developed a novel, team-based approach using lean process methodology in utilizing a neurology clinical pharmacist embedded within neurology offices to co-manage migraine patients with neurologists. The need for implementation of neurology clinical pharmacist was discussed with neurology and pharmacy leadership and pilot phase was implemented. Pilot phase included involvement of one neurologist, neurology clinical pharmacist, and office staff who participated in program design. With the help of pharmacy and operations management, nursing and office staff, as well as physician leadership, standard work for scheduling, rooming, and documentation in electronic health record was adapted from primary care but modified for neurology needs. Best practices for establishing provider and patient buy-in, patient hand-off, and agenda setting were also created. Specific plan and co-visit scheduling workflows for all patients who needed an office visit for migraine cocktail administration were designed and implemented. Productivity goals and outcomes reporting were developed as well. The pilot was used as a proof of concept and further refinement and development of standard work and best practices. Training and onboarding sessions were organized, and 30-day, 60-day, and 90-day check meetings were held to finetune and adjust workflows. Due to the success of the pilot, the co-visit model was expanded to all neurologists in the department.

Results: A total of 87 migraine cocktails were ordered by the pharmacist between 1/2022 and 12/31/2022, with average of 7 treatments per month. So far in Q1 2023 36 migraine cocktails have been ordered by the pharmacist (average of 12 treatments per month). Each treatment is a potential preventable emergency department visit, thus saving total healthcare costs. Neurology clinical pharmacist and neurologists see migraine patients utilizing co-visits. Co-visits with pharmacists allow physicians to see more patients and increase revenue by generating additional RVUs for services provided by the neurology clinical pharmacist. The majority of Co-visits were overbooked on the physician’s schedule (85% of the time) thus allowing additional revenue. Physicians were able to bill at a level of 99214 for 49% of Co-visit appointments, 99213 for 37% of Co-visit appointments, and 99215 for 11% of Co-visit appointments compared to billing at a level of 99211 as traditionally done when the pharmacist has a solo visit with the patient.

Conclusion: Implementing a neurology clinical pharmacist in migraine program imbedded in neurology offices optimizes patient care, increases patient access, prevents emergency room visits, and increases revenue.