The move away from fee-for-service (FFS) has driven some health plans to embrace value-based care contracts and accountable care organizations (ACOs). During a session at the Academy of Managed Care Pharmacy Annual Meeting, held March 27-30, 2017, in Denver, Colorado, panelists outlined how the marketplace has evolved.
Jeff Taylor, RPh, MS, pharmacy director of Aetna, Inc, explained that Aetna is moving from today’s care—categorized by episodic treatment, independent and detached providers, and a time-consuming experience for consumers—to more holistic care, with shared accountability, more transparency, and more productive and satisfied employees.
Currently, Aetna has more than 800 value-based contracts in place around the country and is involved with more than 80 ACOs.
“We knew we needed to reduce the total cost of care,” Taylor said, but that is very difficult to do with the incentives in place with the FFS system.
Part of the way Aetna reduced cost of care was to reduce the waste and inefficiencies in the system; for instance by using alternative, less experience therapies as necessary. As Aetna moved to value-based care, it was able to reduce the payments in FFS, although it increased payment for care coordination.
He outlined the continuum on which an ACO may land depending on how structured it is or how sophisticated, starting with pay-for-performance, through patient-centered medical homes, ACO attribution, high-performance networks, ACO products, and finally joint ventures.
The joint venture is a partnership that results in a jointly owned health plan. Aetna is involved with a joint venture with Innova Health Systems, which created Innovation Health.
“It’s a long process for all of these joint ventures: establishing them and going along a timeline,” Taylor explained.
The joint venture provides shared capabilities and earnings and a lot more sharing of data, because the plan is jointly owned and there is a legal agreement in place. Innovation Health, which is located in northern Virginia, connects care management at Aetna with the health system and forms multidisciplinary teams to improve quality of care and reduce costs. Innovation Heath also allows the companies to have strength in numbers and leverage technology.
The big key to this is going to be leveraging technology and getting into the [emergency room], and how we can coordinate with the electronic medical record and influence behaviors,” Taylor said.
He added that value-based care models are the future of care in the United States, as has been indicated by goals set by CMS to move 50% of payments into value-based models by the end of 2018.
Aetna’s results are already seeing results, Taylor said, with a 13% reduction in medical costs, a 12% reduction in avoidable inpatient admissions, and an 11% of generic dispensing of the top 4 drug groups.
Dan Dauner, PharmD, MSPH, BCPS-AQ ID, pharmacy care manager of Essentia Health, explained how his health system, mostly based in Minnesota, has focused part of its 2016 and 2017 strategy on pharmacy management to use cost-effective alternatives when available.
Dauner created a preferred drug list for primary care to provide consistency in prescribing and replace high-cost drugs with lower-cost drugs that are equally effective. In 2014, the program started with 4 drugs that created alerts, and that list was updated as needed. When someone tried to prescribe one of those drugs, he or she would receive an alert pop up to switch the prescription to an alternative drug with a reminder that generics save patients the most.
The acceptance rate—when someone accepted the suggested alternative and changed the prescription—varied greatly. For aripiprazole, the acceptance rate was just 0.7%, while the acceptance rate for metformin was 43.9%.
“We were really perplexed as to why our acceptance rate was so low,” Dauner said.
Diving into the data, Dauner found that the majority of orders (80%) were reorders, and prescribers were much less likely to switch medication on a reorder. Among new prescriptions, there was an 18.5% acceptance rate, while alternatives on less than 4% of reorders were accepted. Other barriers to utilization of the system to prescribe alternatives included alert fatigue and time constraints during the visit.
From December 2014-January 2015 to December 2015-January 2016, Essentia did see changes with orders for some drugs down and orders for alternatives up. For example, orders for mometasone were down while orders for the alternative, fluticasone, were up significantly.
So what caused those changes? Dauner speculated that there were a number of reasons, such as prescribers listening to the alerts or learning from the alerts and altering prescribing patterns, new guidelines, or changes in plan or benefit designs.
“We are moving behavior, which is nice to see,” Dauner said.