A collaborative effort between the health system and health plan pharmacists, as well as care managers and prescribers is key to improving clinical, quality outcomes in value-based payment models.
A collaborative effort between the health system and health plan pharmacists, as well as care managers and prescribers, is key to improving clinical and quality outcomes in value-based payment models, said Joseph A. Albright, PharmD, manager of Clinical Pharmacy Programs at Blue Cross Blue Shield of North Carolina.
AJMC®: At this year's AMCP Nexus 2020 virtual meeting, a panel will discuss value-based payment models in managed care pharmacy. What role can pharmacists play in optimally integrating value-based payment models, and what challenges are typically faced?
Albright: Anywhere that a medication is involved, you really should have a pharmacist involved and really kind of leading that charge. I think that's pretty standard. And so in value-based care, we strongly believe in 2 components: We believe the quality of care has to be as equally weighted as the value, or the cost component. So, when we're thinking about the quality aspect, a lot of the population health–type measures that we look at hit upon things like diabetes, it hits upon heart failure, it hits upon depression. A lot of these categories are medication driven.
So, the therapies being driven by medications, it makes sense for pharmacists to be heavily involved in discussing what we want to get out of the use of those medications. So, making sure that we have A1Cs [glycated hemoglobin] under control, making sure blood pressure is managed, and that adherence is a big item when it comes to depression and anxiety. So, having a pharmacist involved for those measures and those discussions about what we want to get out of therapy is crucial.
From the cost component, there's really a lot a pharmacist can do when it comes to items like making sure there are discussions around alignment of the formularies. When it comes to interchanging medications, pharmacists are positioned very well to be able to say, "These 2 are clinically equal. I might be talking with the health system and we can come to an agreement that well, why don't we just align on this one medication if we think they're clinically equal, because this one shows better value from a cost standpoint."
So, really, both sides of the quality and the cost, or the value, are positioned for a pharmacist to address. When it comes to some of the challenges, oftentimes it's really a matter of relationships. I can't commend Brenden [Brenden O'Hara, RPh, BCACP, clinical pharmacist, Provider Engagement Initiatives, Blue Cross Blue Shield of North Carolina] any more than I have about building relationships. Oftentimes there's an adversarial relationship when you first start out, when it comes to a payer and a provider because we're used to kind of butting heads. But under these value arrangements, it can start out as a challenge trying to make sure we're all on the same page. And we've really found that those quality initiatives we can all wrap our hands around because that's what we're looking for.
And once we have that trust established—that challenge of, are we all in it for the same reasons, has been leveled out—that's when we can get into some more of the cost components that people are a little bit more touchy about. So, I'd say that those are the main challenges that we see from a pharmacist perspective.
AJMC®: Do you have any other concluding thoughts on the potential impact of value-based payment models?
Albright: When I first came to Blue Cross of North Carolina, we had some value-based arrangements going on, but pharmacy wasn't heavily involved necessarily. We did some things kind of off the side of our desks, but when the company—I don't want to call it an about-face— [had] this moment where we had some leadership that said, "This is our goal. Value-based arrangements is what we're going to do; 100% of our population in the next so many years will be part of these arrangements," it was a truly remarkable thing to see every corner of our company kind of shift and find that true north.
And that true north is what we're looking for in, let's make care much more affordable for our members through these cost initiatives. It's the only way we're going to be bending this curve. But let's make sure when we pull these cost levers, let's make sure that everyone's on board. It was so much more collaborative to see our major health system say, "Yes, we want to do this with you." And then we're incorporating those elements of, let's make care better as well.
It's such a win-win situation, and to see major health systems and the major payer in North Carolina, which is Blue Cross of North Carolina, kind of come together and find a North Star is really inspiring for at least my career and I think many others within the company.