CCPP Module 21, Section 5: Troubleshooting Early-Stage Barriers
MODULE 21: LAUNCHING YOUR FIRST COLLABORATIVE PRACTICE SITE

Section 21.5: Troubleshooting Early-Stage Barriers

Every new service encounters predictable hurdles. This section prepares you for the most common challenges, including low patient referral rates, physician skepticism, and billing/reimbursement issues, providing proactive strategies to overcome them.

SECTION 21.5

Troubleshooting Early-Stage Barriers

From Problem Solver to Proactive Strategist: Anticipating and Overcoming Implementation Hurdles.

21.5.1 The “Why”: From Inevitable Problems to Predictable Puzzles

There is a dangerous myth that can take hold after a successful pilot program proposal: the myth that the hardest part is over. You have won the arguments, secured the resources, and designed the service. The temptation is to believe that implementation will be a smooth, linear process. The reality is that launching any new clinical service is less like rolling a ball down a perfectly smooth ramp and more like navigating a complex maze filled with predictable, yet challenging, obstacles. Expecting a flawless rollout is unrealistic; preparing for the most common barriers is the hallmark of a savvy and effective program leader.

This is where your mindset must shift from that of a clinical expert to that of a strategic problem-solver. The barriers you will face—physician skepticism, low referral volumes, operational friction, billing complications—are not unique failures of your program. They are the predictable and universal challenges that every new service line in every hospital has faced in some form. They are not signs of failure; they are signs that you are engaged in the real, messy work of innovation within a complex system. Your job is not to avoid these problems, but to anticipate them, diagnose their root causes with precision, and deploy targeted, systematic solutions.

This section is your strategic playbook for that process. We will dissect the most common early-stage barriers you are likely to encounter. But more than just listing the problems, we will provide a deep dive into the underlying causes and, most importantly, a set of proactive, evidence-based strategies to overcome them. As a pharmacist, you are already a master of troubleshooting. You do it every day with complex medication regimens, therapeutic duplications, and insurance rejections. This section will teach you to apply that same diagnostic, solution-oriented skillset to the operational, financial, and interpersonal challenges of program implementation. By mastering this content, you will transform predictable problems from sources of frustration into opportunities to demonstrate your value, build stronger alliances, and create a more resilient and successful clinical service.

Pharmacist Analogy: Troubleshooting a Complex Third-Party Rejection

Imagine a new prescription for a specialty medication arrives at your pharmacy. You process it, and the insurance responds with a hard rejection: “PRIOR AUTHORIZATION REQUIRED.” This is not a simple “refill too soon” error. This is a complex barrier, and as the pharmacist, you are the designated troubleshooter.

Your approach is not random; it is a systematic, multi-step investigation:

  • 1. Diagnose the Root Cause: You don’t just resubmit the claim. You investigate. Is the drug non-formulary? Does the patient have a step-therapy requirement? Is there a specific clinical criterion they haven’t met? This is identical to diagnosing low referral rates. You don’t just complain; you investigate the root cause—is it a lack of awareness, a difficult referral process, or a lack of trust?
  • 2. Communicate with the Prescriber: You call the physician’s office. You don’t say, “Your prescription was rejected.” You say, “The insurance requires a prior authorization for this medication. It looks like they require documentation of failure with drug X and Y first. Has the patient tried those?” This is how you must address physician skepticism. You don’t demand their trust; you present data, align your service with their needs, and communicate in a way that makes their life easier.
  • 3. Engage with the Payer (The “Administrator”): Sometimes, you have to call the insurance helpdesk yourself to clarify a confusing policy or a benefit structure. You have to speak their language, referencing plan details and formulary status. This is the same skill you use when dealing with billing and reimbursement issues. You must learn to speak the language of finance and administration, justifying your service based on value, cost-effectiveness, and alignment with institutional goals.
  • 4. Follow a Standardized Process: You have a workflow for prior authorizations. You know which forms to use, what clinical information to gather, and how to track the status. This is the importance of having your own Policies and Procedures in place to handle operational friction. A predictable process yields a predictable result.
  • 5. Persist and Follow-Up: You know that a PA is not a one-time event. You have to follow up in 3 days, 5 days, a week. You are persistent because you know the patient needs the medication. This is the mindset you must adopt for all early-stage barriers. You must be the persistent, professional, and relentless advocate for your service’s success.

Troubleshooting a PA is not a side task; it is a core competency of a modern pharmacist. Likewise, troubleshooting the barriers to implementing your clinic is not a distraction from your “real” clinical work; it *is* the work of a clinical leader. You already have the skills; now you will apply them on a larger scale.

21.5.2 The First Hurdle: Overcoming Low Patient Referral Rates

Your clinic is open, your schedule is built, and you are ready to see patients. But then, the referrals don’t come. Your beautifully designed appointment slots sit empty. This is perhaps the most common and most demoralizing challenge for a new clinical service. It can feel like a personal rejection of your value, but it is rarely that simple. Low referral volume is a symptom, not the disease itself. Your first job as a program manager is to become a diagnostician and uncover the root cause of the empty schedule. Only then can you apply the correct treatment.

Referrals are the lifeblood of any specialty service. A sustainable patient panel is not built on a handful of complex cases, but on a steady, predictable stream of new patients who meet the criteria for your service. Achieving this requires a proactive, multi-faceted strategy that combines marketing, relationship-building, and the relentless removal of logistical friction. You cannot simply build a great clinic and expect patients to arrive; you must build clear, easy, and compelling pathways that lead them to your door.

Masterclass Table: Diagnosing the Root Cause of a Referral Problem
The Symptom (What You Observe) The Potential Root Cause (The “Why”) Diagnostic Action (How You Investigate) The Targeted Solution
Absolute silence. Virtually no referrals from anyone. Lack of Awareness: The providers literally do not know your service exists, what it does, or that they can refer to it. Go to the clinic you are embedded in. Ask five random providers or MAs, “Have you heard about the new pharmacy clinic?” If the answer is “no,” you have your diagnosis. Deploy an Internal Marketing Campaign. Present at staff meetings, create flyers, send clear and concise emails explaining your “Top 3” use cases.
You get referrals, but they are all “inappropriate” (e.g., patients who need a simple refill authorization, not comprehensive disease management). Lack of Understanding: Providers know you exist, but they don’t understand your specific scope or the type of patient who benefits most from your service. Review the last 10 referrals. If they are consistently outside your defined scope, schedule a brief meeting with the referring providers to clarify your services. Clarify Your “Brand.” Develop a one-page “Who to Refer” guide with clear inclusion/exclusion criteria. Focus your messaging on the complex patients you are best equipped to help.
Providers express interest and say they will refer, but the referrals never materialize. Process Friction: The process of placing a referral is too difficult, time-consuming, or hard to remember. It’s easier for the provider to just manage the patient themselves. Try to place a referral to yourself in the EHR. Is it easy to find? Does it require filling out multiple fields? If it takes you more than 30 seconds, the process is too hard. Make It “Stupidly Easy” to Refer. Work with IT to create a one-click referral order in the EHR. It should be as easy as ordering a TSH. Pre-populate as much information as possible.
Only one or two “early adopter” physicians are sending you patients. The rest of the group is holding back. Lack of Trust / Skepticism: The majority of providers are taking a “wait and see” approach. They need to be convinced of your value and your ability to integrate safely into their workflow. This is a diagnosis of exclusion. If they are aware of you and the process is easy, the remaining barrier is trust. Cultivate a Champion & Share Early Wins. Turn your early adopter into a vocal champion. Track the outcomes of their patients meticulously and ask them to share that success story with their colleagues.
The Pharmacist’s Playbook for Internal Marketing

You must become the chief marketing officer for your own service. This doesn’t require a large budget, but it does require a consistent and targeted effort. Your audience is internal: the providers, nurses, and MAs in your target clinics.

  • The 5-Minute “In-Service”: Ask for 5 minutes on the agenda of the next monthly primary care staff meeting. Do not present a 20-slide PowerPoint. Use one slide that answers three questions: 1. What is the biggest problem I solve for you? (e.g., “I manage your complex, uncontrolled diabetes patients, freeing up your time.”) 2. Who are the 3 perfect patients to refer to me today? (e.g., “A1c >9%, on multiple insulins, recent hypoglycemia.”) 3. How do you refer? (e.g., “Search for ‘PharmD Diabetes’ in the order set.”).
  • The “Donut Drop”: Once a month, bring a box of donuts or bagels to the clinic’s breakroom. Attach a simple flyer that says, “A Treat from Your Friendly Neighborhood CMM Pharmacist! Got questions about managing HTN or CHF? Find me in the team room!” This builds goodwill and visibility.
  • The Hallway Conversation: Your physical presence is your best marketing tool. Be visible. Be approachable. When a provider walks by, make eye contact and say, “Morning, Dr. Smith! I had a great visit with your patient Mrs. Jones yesterday. We got her started on an SGLT2i and her glucose is already looking better.” This plants a seed of value.
  • The “Results-Oriented” Email: After you have a significant positive outcome for a provider’s patient, send them a concise, data-driven EHR message. “FYI: For your patient John Doe, since his referral to my clinic 3 months ago, his A1c has improved from 10.2% to 8.1%, and we were able to discontinue his sulfonylurea, eliminating his hypoglycemia risk. Thanks for the collaboration.”

21.5.3 The Human Hurdle: Overcoming Physician Skepticism

Even with a strong business case and administrative support, you may encounter skepticism from the very physicians you are meant to collaborate with. This can be jarring and feel like a personal critique of your skills. It is crucial that you do not interpret it this way. Physician skepticism is rarely about you personally; it is a natural and often professionally responsible response to a change in the established model of care. They are asking for proof, not a fight. Your job is to provide that proof through competence, communication, and a relentless focus on making their professional lives easier and their patients’ outcomes better.

Overcoming skepticism is a process of trust-building. Trust is not granted; it is earned, one patient encounter and one professional interaction at a time. It is built not on grand gestures, but on the consistent, reliable execution of the small things: answering pages promptly, providing concise and actionable recommendations, closing the communication loop on every single patient, and demonstrating unwavering respect for their role as the ultimate captain of the patient’s care team. Your goal is to transform their perception of you from “another consultant to deal with” to “an indispensable colleague who makes my job easier and my patients healthier.”

Masterclass Table: Translating Physician Concerns into Trust-Building Actions
The Stated Concern (What They Say) The Underlying Fear (What They Might Be Thinking) Your Proactive, Trust-Building Strategy (What You Do)
“I’ve been managing diabetes for 20 years. I’m comfortable with it.” “I’m worried you’ll criticize my current management or make me look bad in front of the patient. I don’t see the value you add.” Frame your service as an extension of their work, not a replacement. Script: “I completely understand. I see my role as being able to spend the extra time on education and titration that I know you don’t have. I can help implement the plan you’ve already started. Let me take on one or two of your most complex cases and see if I can help get them to goal.”
“I’m worried about the liability. Who is ultimately responsible if something goes wrong?” “This feels legally risky. If you make a change and the patient has a bad outcome, will I be held responsible?” Provide clarity and demonstrate safety. Show them the signed CPA and your detailed clinical protocols. Emphasize your communication plan: “Per my protocol, I will be communicating every single change to you through the EHR for your awareness. For any situation outside the protocol, I will page you for guidance before taking any action. You are always in the loop.”
“It’s just going to be more work for me. Another inbox message I have to read.” “This is going to disrupt my workflow and add to my administrative burden.” Promise and deliver a “positive workflow footprint.” Your #1 goal is to make their life easier. Keep your EHR messages incredibly concise (use SBAR format). Handle the prior authorizations. Manage the patient phone calls about side effects. Prove that every minute they spend interacting with you saves them ten minutes of work later.
“My patients don’t want to see another provider. It will just confuse them.” “This will fragment the patient’s care and weaken my relationship with them.” Use inclusive, team-based language. Script for the patient: “Dr. Smith and I work together as a team to manage your medications. He has asked me to see you to focus specifically on your diabetes.” Script for the provider: “I always introduce myself to patients as a pharmacist on *your* team, here to help execute *your* plan of care.”
The Cardinal Sin: Never Contradict or Criticize a Provider to a Patient

This is the fastest and most permanent way to destroy a collaborative relationship. Even if you discover the provider has made a clear error or is not following guidelines, you must never express this to the patient. Your professional obligation is to correct the clinical problem while preserving the integrity of the patient-provider relationship. Wrong way: “Wow, Dr. Smith should have started you on this medication a long time ago.” Right way (to the patient): “Based on the newest guidelines, Dr. Smith and I agree that adding this medication is the best next step for you.” Right way (to the provider, privately): “For Mrs. Jones, I noticed she meets criteria for an SGLT2i based on her heart failure. Per my protocol, I’d like to initiate empagliflozin. Please let me know if you have any objections.” Always present a united front to the patient.

21.5.4 The Financial Hurdle: Navigating Billing and Reimbursement

While your pilot program may have been funded based on a quality improvement argument, the long-term survival and expansion of your service will inevitably depend on its ability to demonstrate financial sustainability. Billing for clinical pharmacy services is a complex, evolving, and often frustrating landscape. It is a significant barrier that can intimidate even the most confident clinician. However, ignoring it is not an option. You must become, at a minimum, fluent in the basic principles of ambulatory care billing and work relentlessly to ensure your documentation and workflow are optimized to support legitimate reimbursement for the valuable cognitive services you provide.

The key is to approach this proactively and collaboratively. Billing is a team sport. You are the clinical expert, but you are not expected to be a certified professional coder. Your primary responsibility is to perform and meticulously document high-quality clinical care. Your secondary responsibility is to partner with your clinic’s practice manager, billing and coding specialists, and compliance department to understand the rules and ensure your work is being translated into the appropriate codes. This collaboration should begin before you see your first patient.

Masterclass Table: Common Pharmacist Billing Mechanisms & Pitfalls
Billing Mechanism How It Works Critical Requirement for Success Common Pitfall to Avoid
“Incident-to” Billing (Medicare Part B) Services are provided by the pharmacist but billed under the physician’s NPI number as if the physician performed them. The practice is reimbursed at 100% of the physician fee schedule. A physician must be physically present in the office suite during the visit. The pharmacist’s service must be part of a plan of care established by the physician. Billing “incident-to” on days when no physician is physically in the suite. This is a major compliance violation. You MUST know the physician’s schedule.
Facility Fee Billing (Hospital-Based Clinics) The hospital charges a separate facility fee (G0463) for services provided in a recognized outpatient department. This is independent of the professional fee. The clinic must be officially registered as a hospital-based outpatient department (which has strict regulatory requirements). Assuming any clinic in the hospital qualifies. This status is formally determined by the finance department. You must confirm your clinic’s status.
Direct Billing (Using Pharmacist’s Own NPI) The pharmacist, as a credentialed provider with specific payers (some state Medicaids, some commercial plans), bills directly for their services using CPT codes. The pharmacist must be individually credentialed with each specific insurance plan, a process that can take months. Payer policies on recognizing pharmacists as providers vary widely. Assuming that having an NPI number automatically means you can bill for services. Credentialing is a separate, payer-by-payer process.
Annual Wellness Visits (AWV) & Chronic Care Management (CCM) Using specific CPT codes for preventative services (AWV) or non-face-to-face care coordination (CCM). Pharmacists can perform many of these tasks. Strict adherence to the time-based and component-based requirements of the specific CPT codes. Meticulous documentation of time spent is essential for CCM. Billing for CCM for a patient who did not consent, or billing for time that is not adequately documented. These services are frequent targets for audits.
Thinking Beyond the Bill: Demonstrating “Cost Avoidance”

Direct reimbursement is important, but for a pilot program, it is often not the most powerful financial argument you can make. Many of your most impactful interventions do not generate revenue; they *avoid* costs. This concept of “cost avoidance” is extremely compelling to health system administrators. You must track these interventions just as carefully as your billable services.

Your QI dashboard should have a section dedicated to Cost Avoidance. Examples include:

  • Prevented Hospital Readmissions: The average cost of a heart failure readmission can be over $15,000. If your data shows you reduced readmissions by even a few patients, the cost avoidance is substantial. Work with your quality department to get this data.
  • Prevented Emergency Department (ED) Visits: By managing a patient’s hypoglycemia or hypertensive urgency in your clinic, you prevent a costly ED visit (average cost ~$2,000). You should track every instance where you believe an ED visit was avoided.
  • Optimizing High-Cost Drugs: By switching a patient from a high-cost branded medication to an equally effective, guideline-recommended generic, you generate direct savings for the health system’s pharmacy budget or the patient’s insurance plan. Track these changes.

When you can go to your director and say, “This quarter, we generated $20,000 in direct billing, and we documented an *additional* $75,000 in cost avoidance from prevented readmissions and ED visits,” you are making an incredibly powerful statement about the total financial value of your service.