Galvanizing Growth: Value-Based Medication Management Services in Medical Homes and ACOs | Page 2

Published Online: February 19, 2014
Marie Smith, PharmD; Jeannette Wick, RPh, MBA
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.

PDF is available on the last page.

Issue: January/February 2014
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