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.
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