Safeguarding Patient Health Through Value-Based Systems Integration

Am J Manag Care. 2025;31(Spec. No. 10):SP728-SP732. https://doi.org/10.37765/ajmc.2025.89800

Experts from across Providence Health & Services gathered in Garden Grove, California, on July 9, 2025, for in-depth discussions on topics front and center for small and large health systems alike. The theme for this Institute for Value-Based Medicine^® event was “Population Health Perspectives on Medical and Pharmaceutical Care for Chronic Diseases,” and during the evening panelists discussed the management of heart failure, chronic kidney disease (CKD), and diabetes; ambulatory clinical pharmacy; pharmacy drug analytics and business intelligence; policy and finance as allies, not adversaries; and infusion center management.

Sophia Humphreys, PharmD, MHA, BCBBS, executive director of pharmacy; and Elie M. Bahou, PharmD, MBA, chief pharmacy officer, both with Providence, cochaired the evening in collaboration with The American Journal of Managed Care^®. They were joined by the following speakers:

• Ty Gluckman, MD, MHA, FACC, FAHA, FASPC, medical director, Providence Center for Cardiovascular Analytics, Research + Data Science, Providence Saint Joseph Health
• Caroline Vovan, PharmD, CDE, director, ambulatory care pharmacy, Providence
• Mike Skafi, MSQA, RPh, assistant vice president, pharmacy operations, Providence
• John Ngo, PMP, executive director, strategy and business development, Providence Saint Joseph Health

Heart Failure Management

A cardiologist by training, Gluckman kicked off the evening with a presentation titled “Addressing Underuse of Guideline-Directed Medical Therapy in Heart Failure—Opportunities to Improve Value Across Different Care Settings.” He highlighted both the issues inherent in heart failure care—it remains “a big and costly problem with associated significant morbidity and mortality,” he noted—and potential solutions to improve the use of evidence-based therapies.

Despite proof that evidence-based therapies can reduce cardiovascular risk and tools that can help incorporate risk-reducing therapeutics, such therapies remain significantly underutilized, he explained. Heart failure is a complicated disease classified by both stage and ejection fraction¹ that is becoming a more prevalent—the incidence has risen from 6.7 million annual cases in 2020 to an estimated 8.5 million by 2030, and potentially 11.4 million by 2050²—and expensive epidemic, with a disproportionate cumulative economic impact on Medicare and commercial insurers from inpatient costs, medications, home health needs, and emergency care,³ among others.

The prognosis is grim, Gluckman stated. “The 5-year mortality rate for all types of heart failure is 75%—so three-quarters of patients are not alive at 5 years after hospitalization for heart failure, and this supersedes or exceeds many of the prognoses in a poor way that is comparable or worse than many of our worst malignancies,” he said. In addition, hospitalization correlates with decreased quality of life, worse outcomes, increased mortality risk, and irreversible functional decline, he said.

Therapeutic goals are to slow disease progression, alleviate symptoms, prevent hospitalization, and improve survival. To accomplish these, drug therapy matters, Gluckman emphasized, with meta-analyses showing cumulative benefits from combining multiple evidence-based therapies at target doses,⁴ what he called “35 years of accumulated evidence to support the use of a wide array of therapies.” One of these more well-known examples is what he calls the Fantastic Four core pillars of therapy: mineralocorticoid receptor antagonists, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers/angiotensin receptor–neprilysin inhibitors, sodium-glucose cotransporter 2 (SGLT2) inhibitors, and β-blockers. Rapid titration is also known to reduce mortality and hospitalization.⁵

Yet, he pointed out, the chronic underuse of guideline-directed medical therapy across heart failure subtypes highlights systemic opportunities for innovative solutions that challenge the space to explore implementation of clinical decision support, remote patient monitoring, and patient activation tools to overcome care barriers on the patient, health system, and clinician levels.

“I can assure you, there are gaps in care and tremendous opportunities to move the needle for all these patients,” Gluckman concluded. “And I would argue that multiple approaches that engage and activate our clinicians and our patients and support them by various mechanisms represent potential strategies to move the needle.”

Managing CKD and Diabetes

Humphreys opened her presentation, “CKD Benefits of GLP-1 RA and GIP/GLP-1 RA,” with the news that the latest updates to the American Diabetes Association treatment guidelines now include choice of pharmacotherapy for CKD.⁶ She then focused on how glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and gastric inhibitory polypeptide (GIP) agonists/GLP-1 RAs can benefit patients with diabetes and chronic CKD. She framed her talk around the kidney-specific benefits of these agents, emphasizing the interconnectedness of cardiovascular and kidney health, likening them to a marriage in which dysfunction in one often affects the other.

“I always say that the kidneys and the heart are like love and marriage,” she said. “You cannot have one without the other.”

Globally, she continued, more than 500 million people have some type of diabetes, with projections exceeding 850 million cases by 2050.⁷ Most cases are type 2 diabetes, making prevention and kidney preservation strategies critical; these include exercise, a healthy diet, smoking cessation, and weight management. Poorly controlled diabetes, she explained, can harm the kidneys through osmolarity issues attributed to hyperglycemia, hemodynamic changes, inflammation, oxidative stress, and albuminuria, or protein leakage.

Humphreys reviewed how GLP-1 RAs and dual GIP/GLP-1 RAs protect kidney function. These medications can help to reduce inflammation, oxidative stress, fibrosis, and hyperglycemia, as well as slow gastric emptying and lower appetite.⁸ GIP/GLP-1 RAs, in particular, work through complementary action and are said to be “more potent than pure GLP-1 RAs,” Humphreys noted.⁹ At present, tirzepatide is the only dual GIP/GLP-1 RA, she said.

Key evidence for the medications’ effectiveness came from the SUSTAIN trials (1-7), which evaluated semaglutide’s impact on estimated glomerular filtration rate (eGFR) and urinary albumin-to-creatinine ratio (UACR). SUSTAIN 1 through 5 and 7 evaluated the efficacy and safety of semaglutide, whereas SUSTAIN 6 focused on the cardiovascular safety of the medication.¹⁰ Early reductions in eGFR were observed from baseline to week 12 in all the SUSTAIN trials, with this extending to week 16 in SUSTAIN 6, Humphreys added. UACR reductions persisted throughout all the trials.

Humphreys also highlighted the phase 3 FLOW trial (NCT03819153), which compared semaglutide 1 mg weekly with placebo in patients with type 2 diabetes and CKD. The trial demonstrated a 24% reduction vs placebo in the primary composite outcome of time to first occurrence of persistent eGFR decline of at least 50 percentage points, onset of persistent eGFR less than 15 mL/min/1.73 m², initiation of chronic renal replacement therapy, renal death, and cardiovascular death.¹¹ Benefits were evident as early as weeks 6 through 12 and sustained throughout follow-up, with improvements extended to cardiovascular outcomes and all-cause mortality, she said

She concluded by noting that for patients with type 2 diabetes with CKD, SGLT2 inhibitors remain first-line treatment recommendations, but GLP-1 RAs with demonstrated benefit, particularly semaglutide, are also recommended to reduce cardiovascular and kidney disease risk, especially if the eGFR is below 20 mL/min/1.73 m².

Ambulatory Clinical Pharmacy in Value-Based Care

“Pharmacists’ expertise is necessary to save money,” Vovan said, before beginning her discussion titled “How Ambulatory Clinical Pharmacy Is Essential in a Value-Based Care Health System,” which looked at the diverse and impactful role of ambulatory clinical pharmacy in value-based care and how these critical players enhance care quality.

She addressed how Providence operates with more than 50 full-risk health plans that include commercial and Medicare Advantage coverage, accounting for “about 500 million patients in California alone and counting.” For full-risk patients, these health plans provide lump sum payments up front and then indicate to Providence their financial responsibilities for expenses encompassing doctor visits, outpatient infusion center visits, and office-administered medications. The goal is to keep patients out of the hospital and make sure “we have some money at the end of the year,” Vovan explained.

Pharmacy is involved in every part of this system, she emphasized, playing roles in how the system operates and how money is managed. Among its key roles and contributions are the following:

• Providing ambulatory clinical services: Within primary care, pharmacists help to manage uncontrolled cases of diabetes, hypertension, and congestive heart failure, among others; they also facilitate physician access for acute-care patients and provide patient and staff education.
• Centralizing prescription renewals and prior authorizations: Doing so helps to lighten the burden of these time-consuming tasks for physicians, and Providence incorporates protocols with focused expertise to accomplish both, Vovan noted. As a result, patient access rises, turnaround times quicken, prior authorizations denials are avoided, medication errors are reduced, and treatment adherence is improved by converting 30-day medication fills to 90- or 100-day fills, she said.
• Incorporating quality measures: At Providence, quality measures include hemoglobin A_1c reduction, blood pressure control for diabetic and nondiabetic patients, medication adherence for various drug classes, postdischarge medication reconciliation, and patient satisfaction improvement (via Consumer Assessment of Healthcare Providers and Systems surveys¹²) through enhancing appointment access and care coordination.
• Integrating clinic purchasing: The purchasing department reviews every medication order for cost-effectiveness; for reimbursement potential, “before we even purchase it to the clinics,” Vovan said; to manage shortages; and to identify potential for significant savings. Examples include contract negotiations that saved $2000 per dose for leuprolide (Lupron; AbbVie), a synthetic hormone,¹³ and moving certolizumab pegol (Cimzia; UCB) administration to a 340B facility, which saved one patient $54,000.

Pharmacy’s role remains crucial, even as it continues to evolve, Vovan concluded. “We’re always trying to seek value. We always have lots and lots of opportunities, because it’s ever-changing,” she stated. “Pharmacy can really make an impact because we know our health care system well. We’re here for value-based care.”

Pharmacy Drug Analytics

Pharmacy drug analytics and business intelligence are inextricably intertwined in the present value-based health care landscape, with both being vital to guiding most decisions centered on bringing value and quality to both the patient and the organization, Skafi explained.

“In today’s complex health care environment, pharmacy has its fair share of factors that come into play and impact the cost and reimbursements of medications,” he said, “depending on how big is your spend.”

For Providence and its annual medication spend of $2.4 billion, that means having a robust business intelligence program capable of a proportional level of due diligence to ensure procurement and revenue cycle optimization. Skafi outlined key foundational components necessary to implement a business intelligence program that can function effectively, based on the Healthcare Financial Management Association’s Business of Healthcare manual and Providence’s experiences.

To start, having a data strategy is critical, and within that strategy, there are 3 nonnegotiable items that key players must agree on: what data to gather, what data to measure, and how to protect those data. Also crucial is concordance on the specific metrics that will be monitored, with direction coming from government regulators or private insurers. Next is data availability, or making sure data are available to decision makers when needed. Of particular importance are reviewing patient care quality, which Skafi stressed should be reported as frequently as possible, and establishing a schedule of priorities, “so managers know when to expect information.” Data integrity is another vital component “for maintaining the accuracy and reliability of data,” Skafi noted. It is essential to accurately report clinical data that can influence patient care and evaluate care costs depending on payment methodology. Close monitoring, implementing integrity checks, and working with system users to address errors are necessary tasks.

From Providence’s experience, Skafi spoke about how data processing and data maintenance are important components. The first encompasses what is done with the data—including generating reports, performing analyses, and identifying opportunities—and making sure generated reports are used and understood. Data maintenance covers the data that are generated and safeguarding related processes, including updating reports and delivering them consistently, in addition to monitoring who has report access and who grants that access.

The overall goal, Skafi emphasized, is to create timely, accurate, and actionable tools and reports to optimize pharmacy operations and financial performance.

Policy and Finances

Ngo delivered the evening’s final individual talk, “Policy Headwinds and Financial Challenges in the Current Environment.” He emphasized the significant economic pressures most health care organizations are facing, but he noted that it might help to “weather the storm” by thinking of finance as an opportunity for growth.

“We’ve all heard the horror stories that [the finance department] only cares about lowering your budget or giving you impossible targets to hit,” Ngo said. “But although certain aspects of that narrative may be true, it’s important for us to focus and shift our understanding from seeing finance just as a checkbox, something you do every year like have an annual physical, to actually seeing it as an opportunity to grow professionally.”

The reason behind this shifting of perspectives from adversary to advocate is the need for mandatory engagement because annual budgets, special projects, and workforce optimization necessitate interaction with the finance department. “There’s simply no way of avoiding finance,” Ngo said.

In addition, proactively engaging with the finance department demonstrates a team mentality, helping to safeguard teams during difficult economic times and reductions in force. During Ngo’s 7-year tenure at Providence, for example, there have been at least 3 reductions in force, but the ability to demonstrate through reporting that these moves ultimately will generate value has helped the system to come out on the other side largely unharmed. Cultivating relationships with partners in finance also helps because their support is crucial for quick answers to pressing questions or to kick off new projects, even to offer warnings about upcoming challenges.

It’s also helpful to remember that “finance speaks a completely different language,” Ngo said. To successfully leverage those relationships and bridge that language gap, certain tools are paramount: operational budgets, budget guidance items, reporting, and online dashboards—all of which have been developed and used “day in and day out for the past 5 or 6 years” at Providence, he noted. Income statements are another valuable tool because they provide detailed financial views of each hospital pharmacy to chief financial officers. Looking ahead, having a pipeline of new projects is essential “because those new projects will help you show the value that you’re bringing to the organization.”

Although a leadership team can accomplish much, formal efforts can go a long way as well—for instance, Providence has a Pharmacy Governance Council—in building crucial buy-in, which in turn helps to reduce pushback later. The endgame, Ngo explained, is to implement proper structures for a mutually beneficial relationship with finance that stresses the importance of honesty, transparency, and collaboration.

Management of Intravenous Medications

Closing out the evening was the panel discussion “Management of Long-Acting vs Short-Acting IV Medications,” which brought back Bahou, Humphreys, Skafi, and Vovan to spotlight strategies for optimizing health care that focus on infusion services, patient care, and cost efficiency within large health systems.

Noting that site of care is important, Skafi explained that “there is always a challenge when it comes to infusions,” such as significant delays and long patient wait times, especially for those requiring critical care, such as patients with cancer. This can have a detrimental impact on patient outcomes, he noted. Proposed solutions included fostering improved collaboration among diverse stakeholders—from pharmacy to providers to nurses to scheduling and prior authorization—and exploring alternative sites of care to alleviate bottlenecks, such as pharmacy settings, provider offices, or specialized ambulatory infusion centers.

Specifically for intravenous (IV) iron, Bahou detailed Providence’s unique approach to strategic medication management, which prioritizes patient safety, clinical outcomes, and cost-effectiveness. He underscored the advantages of using long-acting IV iron, explaining, “When we look at our utilization and the fact that you can infuse that drug, get the patient out with a single infusion, instead of 2 to 10 infusions, it’s beautiful because the patient gets treated for that anemia, and then they go home.” This approach significantly reduces the need for multiple patient visits and enhances overall quality of life.

Another crucial strategy discussed was the shifting of medication billing from medical to pharmacy benefits, which can be particularly beneficial for patients under full-risk management plans. Vovan confirmed the advantage of this shift, which works to reallocate financial risk to the health plan and contributes to substantial cost savings. “If we can shift that to pharmacy benefits, that would be great,” she stated. “And with a lot of our offices, like hematology, they do traditionally have some seats to be able to do infusions if that’s needed.”

The panel also addressed the importance of standardizing and protocolizing care, especially for chronic conditions such as heart failure and type 2 diabetes, viewing the move as critical for addressing significant care gaps that contribute to inflated health care costs. Pharmacotherapy clinics managed by pharmacists were presented as innovative and cost-effective alternatives for the ongoing management of stable patients, particularly within 340B-qualified facilities.

The discussion of navigating policy changes, including Medicaid cuts, while adhering to quality measures brought the panel to a close. Panelists called for health care organizations, especially nonprofit organizations, to centralize operations and keep services in-house when they can to provide more affordable, guided, and higher-quality care. The overarching consensus was there is a need for innovative strategies to deliver high-quality, cost-effective, and patient-centered care in a continuously evolving health care landscape.

Author Information: Ms Shaw is an employee of MJH Life Sciences, the parent company of the publisher of Population Health, Equity & Outcomes.

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