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AJMC's ACO and Emerging Healthcare Delivery Coalition: First Live Meeting Coverage | Page 2

Published Online: June 23, 2014
Katie Sullivan
Real-World Best Practices: Financial Structures, Quality Measurement, Medication Management 

Kelly Conroy, Palm Beach Accountable Care Organization (PBA- CO), LLC, provided insight into experience with managing patients at the PBACO. CMS accepted the group on July 1, 2012. As with other accountable care models, PBACO focuses on a triple aim of care, which includes improving the patient experience, improving population health, and decreasing per capita healthcare costs. Additionally, as a member of CMS’s Medicare Shared Savings Program, they are able to be rewarded for achieving specific quality and cost-saving benchmarks.

Ms Conroy noted that initial implementation was difficult. They had to put pressure on the community stakeholders, like hospitals,to buy into the accountable care model. It was difficult to convince providers and doctors that transitioning from the fee-for-service model to and ACO was not only possible, but the financially responsible and logical choice. It was important to reach out to physicians and let them know that their contributions were making a difference once they agreed to join PBACO’s efforts.

“We created this outside component of competition with our community stakeholders pushing on the doctors, and eventually, the doctors started answering the phones, and then eventually, the doctors started to appoint a point of contact in their office to get it,” said Ms Conroy. “And then, after they made $22 million or saved $22 million, then they got really interested in doing things.”

They quickly discovered that patient satisfaction was key to improving outcomes. Even something as a simple as a follow-up call was found to improve the patient experience. As a “low-tech” ACO, PBACO still found ways to engage patients in their care plans. She provided the example of their In-Form‐A‐Doc document which allows the patient to document health concerns and questions in between visits. She noted that it is important to keep track of patients and to treat the same patients prospectively assigned in the beginning of year as at the end of a tracking period. Still, patient engagement and outcomes can be improved, even solutions are low-tech.

“Patient engagement: I see a lot of ACOs went really high-end; patient portals, all kinds of patient engagements. We went very, very low end,” said Ms Conroy. “We used the Medicare opt-out letter that you have to send to patients as a good way to start talking to the patients, and it turns out once the physician had that conversation with the patient, the patient wants to save Medicare, wants to work closer with the doctor, and it made them feel good.”

Achieving Quality in ACOs: Are They Ready to Maximize the Value of Pharmaceuticals in Patient Care?

Kimberly Westrich, MA, director for health services research, National Pharmaceutical Council (NPC), said ACOs intertwine quality and cost-effectiveness like yin-yang.

“We’re moving to an ACO world, a value-based world,” she said, and changing to a different reimbursement model provides the opportunity to develop a strategic framework “where lowering costs and raising quality can really be merged.”

There is also a large opportunity for pharmaceuticals, and the collaboration between the American Medical Group Association, Premier Health Alliance, and NPC has been focusing on just that. These partners seek to develop and implement a framework that will define the role of pharma in ACOs, and how that will aid in the success of meeting financial targets and quality benchmarks. They have considered several recommendations which include a reduction of the “one-size-fits-all” mind-set in medication therapy management.

“We heard about silos this morning, that’s the way the system is currently built,” said Ms Westrich. “One part of really optimizing medication value is getting out of that silo world, thinking about the resources as being a pooled thing that we can access, not silos; medications are something that in many conditions can help cost offsets.”

Aside from de-siloing care systems, Ms Westirch recommended moving away from the one-size-fits-all approach by using composite risk to identify the patients who may require an intervention, and putting into place a system of checks and balances to ensure that patients—especially those with chronic diseases—are receiving optimal care. These quality checks will also certify that there are not incentives that inappropriately lower costs.

Health providers should also assess how “ready” pharmaceutical companies are to enter an ACO arrangement. After identifying existing gaps in care, they can develop a partnership with pharma companies that improve patient outcomes. Pharmacists will ultimately play an important role in many ACOs’ success if the infrastructure can be built.

How to Decrease Cost While Improving Quality and Safety: Medication Therapy Disease Management Program 

As a pharmacist, Michael A. Evans, BS, RPh, said that his organization—Geisigner Health System—has taken a risk by imple- menting pharmacist-run disease management clinics. Mr Evans suggested that clinical pharmacists are the “drug experts” who can teach pharmacology to everyone in a system, including physicians, physician assistants, and nurse practitioners. They also work with physicians and utilize electronic health records (EHRs) to coordinate patient care. He said that while there remains a challenge with coordinating care with retail pharmacies, Geisigner has already begun to explore ways to close that gap.

The organization’s medication therapy disease management program (not to be confused with CMS’s definition of medication therapy management, or MTM) includes 51 pharmacists in 47 locations. It focuses on anemia management, pain therapy, heart failure, geriatrics, and several other conditions.

“In our process—prior to the patients being referred into the program—their adherence to medications was about 50% of the time; the normal population that we see across the country,” said Mr Evans. “But once we start managing the patient, we’re touching them, we get the patient on a therapy that they accept, we get the patient on a therapy that’s not causing them side effects, [and] we get them on a therapy that the patient is willing to accept the burden of the cost. Patients now will become adherent to the therapy 81% of the time.”

Pharmacists can improve adherence rates and increase medication cost savings by having a role in a patient’s continuum of care. For instance, he said, a patient may be prescribed a medication, but there is no way to ensure they are taking it as prescribed. Patient questionnaires and EHR documentation are just some of the ways that pharmacists and providers can monitor patient activity and prevent adverse drug reactions.

“Remember, we’re touching these patients 1.44 times per month. Primary care, they’re not touching that often, or the specialist, they’re not touching the patient that often, nor do we want them to be touching them that often, right? We want the physicians practicing at the top of their license, seeing patients and diagnosing conditions, referring the patient over to the pharmacist for their care. Patients love it; you can see the satisfaction. Satisfaction surveys are greater than 95%,” said Mr Evans.

Overall, Mr Evans said that the pharmacy and the pharmacist are integral resources in accountable care models. Data integration and management, combined with effective communication, will be key as well.

Accountable Care Organization Best Practices in Specialty Pharmacy 

Michael Baldzicki, CRCM, executive vice president of industry relations and advocacy for Armada Health Care, said there are a variety of innovative opportunities for collaboration with new delivery models like ACOs. Specialty pharmacy is a new segment for most participants, but it is quickly becoming an area of strategic focus. Technology has played a large role in boosting the importance of specialty pharmacies, especially as biosimilars may impact cost utilization management techniques.

“Specialty pharmacy has evolved from a more lick-and-stick game to now a service-oriented program initiative, so a lot of these specialty pharmacies are trying to prove their value stake not only to the payer, but also to the manufacturer, and really hone in on key therapeutic areas, saying, ‘I’m going to be good at these 4 things, or maybe 1 thing because I’m a local specialty pharmacy and I’m going to be really good at hep C,” said Mr Baldzicki. “And that’s where they’re sitting, kind of putting their anchor, to really put their stake in the game, not only get into the payer network, but work with local physician groups.”

There are a variety of opportunities for specialty pharmacy. One is that they have the capability to share and integrate data analytics. They also can offer and integrate disease management therapy programs. They can even enter risk-sharing agreement contracts with ACOs. By collaborating, specialty pharmacies can improve outcomes for ACOs, including in hospital readmissions, quality metrics, and overall adherence.

Mr Baldzicki noted that health reform and other shifts in care will impact the exact partnership that specialty pharmacy will have in accountable care models.

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Issue: June 2014
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