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Galvanizing Growth: Value-Based Medication Management Services in Medical Homes and ACOs

Published Online: February 19, 2014
Marie Smith, PharmD; Jeannette Wick, RPh, MBA
A 1-day, state-level invitational conference of key healthcare executives and thought leaders was held to address the platform question, “How can pharmacists collaborate with employers, payers, other healthcare professionals, and patients to improve patient health outcomes, enhance medication adherence, and lower total healthcare costs?”

Nationally recognized speakers who successfully implemented pharmacist-directed programs with demonstrated positive impact on healthcare outcomes addressed participants. All participants engaged in moderated roundtable discussions where they addressed 6 topics—primary care medical home, community pharmacy medication management, ambulatory care medication clinics, regional healthcare models, employer/payer medication management programs, and shared-resource pharmacist programs. Ten key messages were formulated during the conference that can guide healthcare leaders at the state and national levels to address the expansion of pharmacist-provided medication management services (MMSs).

Overall, pharmacists need to share successful models of MMS that can improve healthcare quality and contribute to cost savings with multiple stakeholders—consumers, healthcare clinicians, payers, and policy makers.

Am J Pharm Benefits. 2014;6(1):e18-e23
On October 2, 2012, the University of Connecticut School of Pharmacy hosted the second Harold G. Hewitt Symposium, “The Value of Pharmacists in Medication Management.” The speakers and 50 invited participants addressed the platform question, “How can pharmacists collaborate with employers, payers, other healthcare professionals, and patients to improve patient health outcomes, enhance medication adherence, and lower total healthcare costs?”

The conference convened 50 of Connecticut’s healthcare thought leaders (representatives from state health agencies, payers, providers, employers, academia, consumer organizations, and pharmacist organizations, hereafter called “participants”) to gain knowledge and reach consensus on more effective use of pharmacists as direct patient care providers. The previous session, held in 2008, “Value of Medicines, Value of Pharmacists,”1 laid the groundwork for diverse stakeholders to embrace value-based insurance design and pharmacist-provided patient care services.

Symposium Format

In the morning, 7 speakers addressed participants in plenary and panel sessions. During the afternoon, the speakers facilitated roundtable discussions addressing the primary care medical home, community pharmacy medication management, ambulatory care medication clinics, regional healthcare models, employer/payer medication management programs (MMPs), and shared-resource pharmacist programs. Participants selected topics of interest to them (rather than having topics assigned to them) and switched topics as they wished. Roundtable discussions addressed these questions:

• What are the burning issues or greatest needs related to the roundtable discussion topics?

• What would it take to create change in your organization?

• How can you involve pharmacists in the next 6 to 12 months to create forward movement?

Each roundtable group presented their key messages to the re-convened assembly at the end of the day.

Key Messages

Speakers, panelists, and participants identified 10 key messages.

Message 1: Recent Institute of Medicine (IOM) and Commonwealth Fund (CF) reports indicate team-based care is one mechanism to achieve better healthcare at a lower cost.

At this time, our nation is experimenting with new care delivery and payment models. Discussion about patient-centered medical homes (PCMHs), accountable care organizations (ACOs), integrated care organizations (ICOs), and coordinated care organizations (CCOs) isn’t restricted to healthcare managers or clinicians. As policy makers and payers have become involved in pressing healthcare reform needs, these terms have filtered into everyday news.

Concerns about primary care delivery models are not new. In a 2004 paper, Grumbach and Bodenheimer lamented that multidisciplinary medical teams worked together less effi ciently and effectively than they could.2 Grumbach and Bodenheimer cited 5 needs for optimal teamwork:

• clear goals with measurable outcomes

• clinical and administrative systems

• labor division

• training of all team members, and

• effective communication.

Working relationships and personalities hinder team formation. More cohesive teams generate better clinical outcomes and higher patient satisfaction. Primary care practices that take small steps, like inviting and supporting physician and nonphysician professionals to work together, improve work environments and patient outcomes.2

The IOM’s report, “Best Care at Lower Cost: The Path to Continuously Learning Health Care in America,”3 supports these ideas. Its simple callout drives the message: “Americans would be better served by a more nimble healthcare system that is consistently reliable and that constantly, systematically, and seamlessly improves.” The findings call for aligned patient-clinician relationships; a continuous improvement culture; better incentives and informatics; teamwork and interprofessional communication; and a safer and more efficient healthcare delivery system. Pharmacist-provided medication management services (MMSs) meet these goals.4

A second report—the Commonwealth Fund’s “The Performance Improvement Imperative Utilizing a Coordinated, Community-Based Approach to Enhance Care and Lower Costs for Chronically Ill Patients”5—recommends a comprehensive health reform implementation plan that is specific and time-limited. For example, the report suggests that by 2016, the nation should double annual improvement in quality-of-care metrics and limit per capita increases in health spending to the annual growth in per capita gross domestic product plus 0.5%. This could reduce national spending by $893 billion over 10 years. It further focuses on 50 to 100 voluntary Health Improvement Communities (HICs) for patients with multiple high-cost chronic conditions to save roughly 21% of target expenditures. Pharmacists must be part of these system-level and policy initiatives.

Message 2: MMS, if unfettered by policy or attitude, can be expanded to include a wide range of activities.

This message builds on Grumbach and Bodenheimer’s ideas. In the last few years, numerous authors have reiterated that highly functional healthcare systems allow all healthcare professionals to “practice at the top of their licenses” (or work to the full extent of their training) to create better practice environments, and cut costs.6-10 Some states would have to revise or modify laws to remove practice restrictions and encourage contemporary practice patterns. State regulations vary regarding practice settings, education and training requirements for pharmacists, and clinician or organizational approval processes. Standardizing interstate variations would facilitate inclusion of pharmacists in medical home or accountable care organizations.11

Message 3: Medication management is a “team sport” that engages many healthcare clinicians to produce better outcomes than each clinician can alone.

To fully evaluate a patient’s medication therapy, we must compare and evaluate multiple disparate data sources. Critical medication elements need review (appropriateness, effectiveness, safety, adherence) through QI, care coordination, clinician collaboration, and patient engagement. Pharmacists providing MMSs need to integrate data from patient/caregiver reports, electronic health records (EHRs), and prescription claims. In most community pharmacy retail settings, data access is limited. Limited information can be sufficient for some adherence programs; however, the lack of clinical information from EHR or clinician reports often precludes more comprehensive services. Some community pharmacy adherence programs such as “auto-refill” programs can be dangerous when discontinued medications—especially during care transition—are still dispensed due to fragmented care and lack of interoperable health information systems.12

Message 4: Pharmacist expertise and systematic MMSs are underutilized.

Pharmacists are well trained, highly accessible, community- based healthcare professionals who remain underutilized. Public perception of the pharmacist’s role is largely confined to traditional images of prescription dispensing and occasional medication counseling, usually when patients ask for help.13,14 Few healthcare consumers, patients, policy makers, and primary care clinicians are aware of pharmacists’ deep medication expertise, advanced clinical training, board-certified specialties, or exceptional MMSs.15 Healthcare reform initiatives and our aging population are healthcare system stressors. The United States must redefine and use primary care teams. The Affordable Care Act, particularly sections that focus on community-based interdisciplinary health teams and health homes, mention pharmacists. Newer care models such as medical homes and ACOs often do not include pharmacists. Pharmacists’ utility is implied, however. Pharmacists must become integrated, active primary care and community-based interdisciplinary team members.15,16

Message 5: Healthcare thought leaders need to establish the value equation for MMS within the context of team-based care.

A team-based role for pharmacists is plausible and imperative. Pharmacists’ skills complement physicians’ skills—so pairing physicians and clinically trained pharmacists can achieve QI goals and enhance primary care practice efficiencies. Yet nonphysician clinicians face organizational and reimbursement challenges. Despite clinical pharmacist services’ positive outcomes in grant-funded or short-term pilot projects, the success in scaling or sustaining such initiatives with robust clinical outcomes and cost savings has been sporadic. Two notable barriers face primary care pharmacists: the lack of (1) a workforce model for the integration of pharmacists as direct patient-care providers, and (2) payment models for pharmacist-provided MMSs.

Innovative payment reforms could direct patients with complex medication regimens, care transitions, poor adherence, or lack of desired clinical outcomes to clinically trained pharmacists working with medical homes and ACOs. This could help reduce patients’ total healthcare costs by reducing unnecessary emergency department visits, specialty consultations, hospitalizations, and preventable readmissions as a result of improved medication use, safety, and patient engagement.

Message 6: Pharmacist integration in new care delivery and payment models is needed.

• David Bates, MD, chief quality officer at Brigham and Women’s Hospital in Boston, Massachusetts, reviewed the US healthcare policy and care redesign principles. He cited unsustainable costs, poor quality, and supply-driven economics as barriers to continuing with healthcare as we know it. New models will be, by necessity, driven by reinvented community-based primary care.

In particular, he noted that preventable adverse events account for $16 billion annually (making them primary drivers).17 Hence, adverse events create opportunity for pharmacists skilled in prevention, monitoring, and vigilance. He cited Porter’s definition of value in healthcare (health outcomes achieved per dollar spent) and said value must be patient-centered and unite stakeholders. Improved value benefits all, and increases economic sustainability.18


• Dr Bates discussed 2 clinician tools: interoperable EHRs and disease-specific registries that can be used by multiple providers and researchers. In addition, he advocated studying standardized clinical assessment and shared care management plans that combine elements of clinical guidelines and iterative QI processes. Study results could identify effective ways to organize, deliver, and pay for high-quality care. Dr Bates recommended expanding health information technology (HIT) to support clinical care, yet warned against over-reliance. He reminded participants that HIT doesn’t deliver healthcare; clinicians do.

• Keith T. Kanel, MD, chief medical officer, Pittsburgh Regional Health Initiative, discussed sustainable care and payment reform. In particular, he discussed target areas designated in ACO care design models—readmission reduction, care coordination of complex patients, medication management, medical homes, meaningful use of information technology, long-term care, the integration of medical and behavioral health, and end-of-life care. Dr Kanel described 4 ways pharmacists contribute to high-value MMS—medication reconciliation, discharge counseling, medication therapy management (MTM), and specialized clinical programs. He described a program developed with 7 independent community hospitals in southwest Pennsylvania.19 Using QI methodology and management systems in a payer-agnostic fashion, these hospitals used multidisciplinary teams that included pharmacists to manage patients with multiple chronic diseases. This program is expected to prevent 1445 Medicare admissions per year and save $74 million over 3 years.


Message 7: Pockets of success with innovative pharmacist-provided MMS exist across the United States.

Four speakers presented overviews of pharmacist-led programs that have been successful.


• Joe Moose, PharmD, a community pharmacistentrepreneur, described a Concord, North Carolina, pharmacy practice. Currently, its 5 locations provide innovative adherence programs, embedded clinical pharmacy services, MTM, and care transition medication reviews. After identifying patients who have risk factors or chronic diseases, Moose Pharmacy’s clinical pharmacists work directly with providers. In one employer-sponsored program for patients with diabetes, pharmacists assess medication therapy, offer smoking cessation and hypertension/lipid monitoring, and refer patients who need other professional services (eg, behavioral counselors, dietitians). The US healthcare system spends $55 billion on missed prevention opportunities and wastes $1 of every $3.20 Dr Moose indicates that the approximately 55,000 pharmacies in the United States could contribute $1 million in savings each if they activated their pharmacists to work closely with patients, caregivers, employers, and other healthcare professionals in a more collaborative and team-based manner.

• Craig Logemann, PharmD, BCPS, CDE, presented a practice model from an Iowa Health System comprising Iowa Health Physicians & Clinics, Urbandale Family Physicians, and West Des Moines Family Physicians. This system covers 76 Iowa and Illinois communities and provides 2.5 million patient visits annually. Pharmacists initiate individual patient appointments for warfarin monitoring, smoking cessation sessions, and comprehensive MTM for patients with diabetes, obesity, lipidemias, and asthma. Pharmacists in these practices work under collaborative practice agreements. A 2009-2010 Wellmark Collaboration on Quality pilot project showed that pharmacist-provided care exceeded the Healthcare Effectiveness Data and Information Set national averages for diabetes, hyperlipidemia, asthma, and hypertension measures. 21 With new pay-for-performance measures included in many PCMHs or ACOs, this is an important finding. The pharmacists use 2 reimbursement strategies: for patients with pharmacistonly visits, the pharmacist submits charges under the supervising physician; for patients’ same-day visits with physician and pharmacist, the physician submits appropriate charges for a complex visit.

• Michael Smith, PharmD, BCPS, CACP, pharmacy clinical manager at the 213-bed William W. Backus Hospital in Norwich, Connecticut, described inpatient and ambulatory clinical pharmacy services. Inpatient pharmacists provide formulary management, IV-to-oral dosage conversions, renal dosing, and vancomycin and aminoglycoside pharmacokinetic services. More recently, they initiated an antibiotic stewardship program, with a goal of decreasing antibiotic expenditure by 20% to 25%. The program employs an infectious disease physician and several pharmacists. The program has achieved approximately 20% savings in the antibiotic budget, decreased pneumonia length of stay by 1.3 days, and decreased pneumonia-associated mortality by 20%. More recently, pharmacists have been key team members on a program to address congestive heart failure patients’ readmission and core quality measures. A dedicated team that includes a cardiologist, nurse practitioner, clinical dietitian, and pharmacist follows an average of 950 patients in an outpatient clinic. The cardiologist reviews and approves the pharmacists’ MTM recommendations daily. This clinic has achieved quality scores above published “usual care” scores.

• Sarah M. Westberg, PharmD, BCPS, associate professor, University of Minnesota College of Pharmacy, explained how Minnesota Medicaid has approached MTM since April 2006. In its first year, 34 pharmacists provided care to 259 patients, submitting more than 431 claims that resolved at least 789 drug therapy problems. In addition, 77% of patients with diabetes reached goal hemoglobin A1C values. Of note, 36% of participants reached all State of Minnesota 2006 Quality of Care and Rewarding Excellence benchmark standards (the overall average in 2006 was 6%). Currently, Westberg and her colleagues are involved in an MTM program for university employees and dependents. The MTM benefit includes a face-to-face outpatient consultation with a pharmacist for plan members taking 4 or more prescription/over-the-counter medications for chronic conditions or who are simply referred by their physicians. Patients enrolled in the MTM program had health risk scores that were more than 3 times higher than those of other eligible university employees.


Message 8: Medication management promotes improved efficiency and care coordination within the healthcare system.

Although many participants had questions about billing in successful plans, data demonstrated that the programs improved patient safety, improved patient self-management, achieved better care transitions, decreased waste, and made more efficient use of physician time. Improved efficiency can occur when pharmacists see patients with complex medication management needs that are too time consuming for a primary care physician’s schedule. In addition, pharmacists working closely with primary care clinicians can manage medication adjustments or titrations for patients who may otherwise be referred to a medical specialist for these services.

Message 9: Successful MTM pilot projects need to be leveraged for scalable and sustainable MTM service programs.

Many healthcare leaders who are unfamiliar with pharmacists’ training and clinical capacity often turn to pilot programs despite ample proof that pharmacists’ clinical services can improve patient outcomes and contribute to cost savings. Successful pilot programs should generate larger implementation trials with a strong evaluation component to focus on effectiveness, quality, and costs measures. Then, methods and outcomes need to be disseminated to all stakeholders including patients using publications and local/national presentations. It’s time to encourage healthcare decision makers to take that leap of faith that allows pharmacists to improve quality and safety significantly based on numerous existing initiatives that are well documented.4

Message 10: The key to rapid and appropriate expansion of pharmacist MMS will depend on marketing the existing successes.

To move from isolated or redundant pilot programs to a widespread advancement in pharmacist-provided MMS, pharmacists need to market existing successes. Word-ofmouth praise from satisfied patients and caregivers is a start replete with credibility, but insufficient for real growth. All stakeholders need to know that pharmacists have unrealized potential. Pharmacists, state and national pharmacy organizations, and pharmacist employers need to prepare and distribute simple, straightforward messages that will amplify the messages that some satisfied patients are voicing. It’s time to create a buzz and deliver more widespread MMS, especially in PCMHs and ACOs.

Summary

The symposium communicated the value of innovative pharmacist-led MMPs. The time is here for novel, scalable, and sustainable medication management services as part of new care delivery and payment reform initiatives. Clearly, pharmacists and their representative organizations need to be active participants in established medical home or ACO learning collaboratives that facilitate dialogues on MMP successes, challenges, and practical implementation strategies. Finally, pharmacists who have successful MMPs need to share their stories with multiple stakeholders—consumers, healthcare clinicians, payers, practice administrators and staff, benefit managers, and policy makers—so that pharmacists’ expertise and their impact on care quality and cost savings can be promulgated.


Take-Away Points

Conference attendees learned practical strategies for innovative pharmacist-provided medication management services (MMSs) that can be applied to medical homes and accountable care organizations (ACOs): 
  • Team-based care is crucial for care coordination and quality improvement initiatives to optimize chronic disease medication outcomes, promote medication safety, and assure cost-effective regimens.


  • Pharmacists have the expertise to manage both the clinical and administrative aspects required for appropriate, safe, and cost-effective medication use. 


  • It will be important to experiment with various care delivery and payment models for pharmacist-provided MMSs as medical homes and ACOs evolve.
Author Affiliations: University of Connecticut School of Pharmacy, Storrs, CT (MS, JW).

Funding Source: None reported.

Author Disclosure: The authors (MS, JYW) report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (MS, JYW); acquisition of data (MS, JYW); analysis and interpretation of data (MS, JYW); drafting of the manuscript (MS, JYW); critical revision of the manuscript for important intellectual content (MS, JYW); administrative, technical, or logistic support (MS, JYW); supervision (MS).

Address correspondence to: Marie Smith, PharmD, University of Connecticut School of Pharmacy, Storrs, CT 06269. E-mail: marie.smith@ uconn.edu
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19. Twedt S. Pittsburgh Regional Health Initiative project designed to reduce hospital readmissions. http://www.post-gazette.com/stories/business/news/ pittsburgh-regional-health-initiative-project-designed-to-reduce-hospital-readmissions- 701000/#ixzz2fC7HpjBe. Accessed September 19, 2013.

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Issue: January/February 2014
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