Galvanizing Growth: Value-Based Medication Management Services in Medical Homes and ACOs | Page 1
Published Online: February 19, 2014
Marie Smith, PharmD; Jeannette Wick, RPh, MBA
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.
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.
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.
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