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Succeeding in Value-Based Payment Requires Engaging Pharmacists From Health Plans and Systems


Pharmacists have an important role to play in the success of value-based payment models, according to panelists who discussed their health plan’s value initiatives at the Academy of Managed Care Pharmacy Nexus 2020 meeting.

Pharmacists have an important role to play in the success of value-based payment models, according to panelists who discussed their health plan’s value initiatives at the Academy of Managed Care Pharmacy Nexus 2020 meeting.

Showing a slide of the ever-increasing proportion of gross domestic product spent on health care, Joseph Albright, PharmD, manager of clinical pharmacy programs at Blue Cross Blue Shield North Carolina (BCBSNC), said that the question of sustainability is now more of a reality. We need to bend the cost curve, considering the growing field of high-priced drugs, and the solution is a transition away from fee-for-service (FFS) payment toward paying for value and results.

CMS has implemented several value-based models over the past decade that adjust payment by quality and cost measures, and commercial payers are following suit, with more providers moving out of FFS to alternative payment models that incorporate varying levels of risk. The goal is not to get every provider into population-based models like integrated delivery networks, said Albright, but rather to shift accountability to the provider for quality and cost and therefore shrink the number of providers in volume-based FFS models.

Pharmacists have a key role to play in the transition toward alternative payment models. “If a medication’s involved, then a pharmacist is pretty invaluable,” Albright said, as the pharmacist can help support a number of quality improvement initiatives. Whereas preventive care can mitigate downstream costs, pharmacists can have a more immediate impact by targeting patients with high health care utilization for collaborative drug therapy management, as well as identifying gaps in care.

BCBSNC is “all in” on value-based care as part of its goal of transforming health care across the state, Albright explained, as evidenced by its new way of contracting with providers, Blue Premier. This program is anchored on primary care and integrates behavioral health and social determinants of health, and more than 50% of BCBSNC’s membership is now in this program after just 1 year. The program aims to transition to a sustainable per-member-per-month payment model with revenue that is tied to quality outcomes.

Provider engagement is crucial in Blue Premier, and BCBSNC is working with health systems on fostering a bidirectional exchange of information through a suite of data-reporting tools and personalized reports on progress in the journey toward value. Regular engagement with health systems is accomplished via quarterly meetings, but for pharmacy, this is not enough, so they have “ongoing engagement on a monthly basis to share new opportunities and drive those desired outcomes.”

Brenden O’Hara, RPh, BCACP, clinical pharmacist, Provider Engagement Initiatives at BCBSNC, then discussed the opportunities to engage pharmacists in value-based payment models. Quality measures are a smart place to begin when discussing these models, because health systems and plans need to be able to speak a common language to define what success looks like.

In Medicare’s quality measurement Star Rating System, pharmacists have a direct impact on the measures surrounding comprehensive medication reviews and drug adherence, but they also have an indirect effort on measures like osteoporosis management, diabetes, and hospital readmissions. Similarly, for commercial plans, pharmacists directly relate to Healthcare Effectiveness Data and Information Set measures on medication management for asthma and controlling high blood pressure, whereas they can indirectly contribute to postdischarge medication reconciliation and monitoring the appropriateness of therapy.

Pharmacists in both health systems and community pharmacies have an important role to play in collaborating with health plans to communicate opportunities and succeed in value-based models, O’Hara said. In particular, community pharmacists are one of the primary providers that patients interact with on a regular basis, so they need to be included in opportunities to improve outcomes.

O’Hara then gave examples of what high engagement with pharmacists looks like for BCBSNC. As Albright mentioned, there are monthly meetings held with pharmacists and other stakeholders from both the health plan and health systems, in which participants share data and learn more about one another’s work to avoid duplication. When a health system has high engagement, pharmacists will be directly involved in quality improvement efforts and take the lead on making calls to patients to assess adherence. In contrast, low engagement is characterized by ad hoc meetings that only come together when a specific problem must be addressed.

“The success that we tend to see is when we have pharmacist-to-pharmacist conversation and there’s somebody that is actually doing work as a pharmacist within the health system,” O’Hara said.

He illustrated this success with several graphs on quality measure achievement differences between health systems with high and low engagement. There was a significant gap in performance on blood pressure control by engagement, which O’Hara attributed to the accountability that is present when systems are engaged in conversations with the health plan team and pharmacists.

BCBSNC has seen encouraging signs in the 536,000 members served under Blue Premier in 2019, including increasing colorectal cancer screening by 3041 additional members and achieving blood pressure control in 13,412 more members. The program resulted in an estimated $153 million in cost savings that year, and it paid out $85 million in shared savings to the care providers.

O’Hara reiterated the need to transition out of FFS and said that pharmacists are key to this transition. When pharmacists have the opportunity to practice at the highest level of their license, they can work collaboratively to improve the quality of patient care.

The main takeaway is that engagement is a key factor to success, O’Hara said, because participants in value-based payment models “have to have regular meetings, have to hold people accountable, and have to understand that you both are working together toward a shared goal of better outcomes for your patients.”

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