Your pharmacy is an excellent partner for accountable care organizations. ACOs are formed by doctors, hospitals and other healthcare providers to improve health outcomes and lower overall medical expenses for a targeted patient population. Reimbursements are tied to patient outcomes.
ACOs’ highest-risk and highest-cost patients are those managing chronic illnesses and taking multiple medications a day. When your pharmacy can improve and track adherence – a key driver of readmission prevention and overall health – you are a valuable partner to help ACOs prevent unnecessary medical care.
Jamie Hale serves as the Chief Pharmacy Officer for Cornerstone Health Care where he is responsible for the development and integration of pharmaceutical care services in the Accountable Care Organization. He transitioned to Cornerstone in December 2012 after a 15 year career at Wake Forest Baptist Health, where he last served as Director of Pharmacy.
Download the full audio webinar at http://bit.ly/pharmacyACO.
Pharmacy's Emerging Role in Accountable Care Organizations (ACO)
1. The Emerging Role of
Pharmacy in the ACO
Jamie Hale
Chief Pharmacy Officer
Cornerstone Health Care, PA
November 6, 2013
2. Cornerstone Health Care 2013
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•
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•
•
•
•
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1,800 employees
89 locations
230 physicians
185 shareholder physicians
111 advanced practice providers
34 specialties and ancillary services
21 Practices with extended hours
29 Primary Care practices recognized by NCQA as
PCMH Level 3
• Physicians on staff at 15 different hospitals and 6
health systems
4. Accountable Care Organizations
Centers for Medicare and Medicaid
Services (CMS)
• an ACO is "an organization of health care
providers that agrees to be accountable for the
quality, cost, and overall care of Medicare
beneficiaries who are enrolled in the
traditional fee-for-service program who are
assigned to it."
4
5. Prevalence of ACO Activity
Feb. 2013
Health Affairs Blog- D. Muhlestein 021913- accessed April 14 2013
http://healthaffairs.org/blog/2013/02/19/continued-growth-of-public-and-private-accountable-care-organizations/
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6. ACOs in NC
• Triad and Triangle
• Triad Healthcare Network (THN)
• Cornerstone Health Care, PA
• State
• Coastal Carolina
• Wilmington Physicians
• Universal American
• New Bern and Caldwell Co
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9. Negative Impact of Fee for Service
Patients
• Inability to navigate the
system
• Poor health outcomes
• Reduced satisfaction
and engagement
Payers
• Increasing costs= higher
premiums and payment
cuts
• Declining member
satisfaction and increased
attrition
Physicians
• Declining FFS payment
rates
• Inability to fund
coordinated, evidencebased care models
Beneficiaries
• Increasing costs for
poorer benefits
• Disappearing employer
coverage
Employers
• Higher premiums
• Decreased
willingness/ability to
provide high quality
benefits to employees
Society
• Declining health status
• Greater portion of
investment to health
care
10. An Unsustainable Future
$8.0
Expected future trend (6.5% growth)
Sustainable trend (affordability followed by 4.5% growth)
$7.0
$7.1T
(24% of GDP)
Industry spend ($T)
$6.0
$5.0
$4.3T
(21% of GDP)
$4.0
$4.0T
(14% of GDP)
$2.6T
(18% of GDP)
$3.0
Trend reduction
Waste reduction
$2.0
A period of growth below GDP growth
will be necessary to reach affordability
(30% reduction in costs as a percent of
GDP)
$2.8T
(14% of GDP)
After affordability is achieved, longterm growth must be at the same
level of GDP growth to ensure
sustainability
$1.0
2010
2012
2014
2016
2018
2020
2022
2024
Time
The funding gap is widening, creating a need for rapid transformation in the market
Sources: National Health Expenditure data, Bureau of Economic Analysis, Oliver Wyman analysis
2026
11.
12. The Value Proposition
•
Health care cost and utilization trends
are unsustainable for employers and the
system
•
Patients are receiving a lower level of
quality and service for dollars spent
•
Value= higher quality with lower cost
•
Value= Providing well-rounded patient
centered services NOW to prevent cost
in the future
•
Quality= more time with doctor, timely
follow up, increased educational
opportunities about diagnosis, patient
engagement
13. A BRAVE NEW WORLD
Volume
Value
Fee for service model
Value based care model
Patients ―discharged‖
Patients “transitioned”
Disease Management focus
Care Coordination and navigation
Addressing Sickness
Addressing Health
Measuring Mortality/Harm
Measuring Risk of Harm
Vanderbilt University Hospital—2013 Presentation-Group Practice Improvement
Network, Asheville, NC
14. Payment Models in Value World
Pay for Performance – Quality Driven
MA /
Commercial
Gain Share
MSSP
14
Full Risk
PMPM
17. Key Focus Areas to Transform Health Care
Physician and patient
experience
Improved, Triple Aim
More practice resources
and support to improve
quality of care
Improved
populatio
n health
Patient
experience
of care
Reduced
cost of
healthcare
Remove redundancy and
reduce preventable
utilization while achieving
better outcomes
Improvements in patient
satisfaction through tailored
support services
18. “Pharmaceuticals are the most common medical
intervention, and their potential for both help
and harm is enormous. Ensuring that the
American people get the most benefit from
advances in pharmacology is a critical component
of improving the national health care system.”
The Institute of Medicine (IOM)1
1 The Institute of Medicine, National Academy of Sciences. Informing the future: Critical issues in health. Fourth edition, page 13.
http://www.nap.edu/catalog/12014.html
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19. The Facts
4 out of 5
Patients leave with at least one prescription
1 in 3
of all American adults take 5 or more medications
88%
Of all prescriptions filled are for Medicare Beneficiaries with
multiple illnesses 2
72%
Of physician visits are with Medicare beneficiaries who have
multiple illnesses 2
76%
Of all hospital admissions each year involve Medicare
beneficiaries who have more than one illness 2
1
1 The chain pharmacy industry profile. National Association of Chain Drug Stores. 2001 2 Testimony of Gerard F. Anderson, Ph.D., Johns Hopkins Bloomberg School of Public
Health, Health Policy and Management, before the Senate Special Committee on Aging,
2 ―The Future of Medicare: Recognizing the Need for Chronic Care Coordination, Serial No. 110-7, pp. 19-20 (May 9, 2007)
19
20. Medicare Beneficiaries
• See an average of 13
different physicians
• Have 50 different
prescriptions filled each
year
• Are 100 times more likely
to have a preventable
hospitalization than
someone without a chronic
condition2
2 “The Future of Medicare: Recognizing the Need for Chronic Care Coordination, Serial No. 110-7, pp. 19-20
(May 9, 2007)
21. The Cost of Poor Quality
• $290 billion per year in
avoidable medical
spending (13 percent of
total health care
expenditures)!
• Contributes to as many
as 1.1million deaths
annually!1
200+ Biiiiillion Dollars
2 Institute
of Safe Medicine Practice Medication Safety Alert Newsletter: Community/Ambulatory Care Edition Volume 9, Issue 6: June 2010
22. Strategic Vision
Quality
Cornerstone Pharmacy and Resource Management
Practice /
Provider
Support (PILLS)
Pharmacy Care Clinic Services
Comprehensive Medication
Management
Point of Care Driven Services
• Focused outcomes based on POC
testing, with transition to CMM
• Anticoagulation
• Diabetes
• Asthma / COPD
• Hypertension
• Hyperlipidemia
CMM Services
• ―Pharmacy Hub‖ Driven
• Embedded Practice Model
• Centralized Office Model
• Outreach – Video and Telephony
Supported
• Patient stratification proactive
Patient
system and referral based
Experience
• Rx Intelligence
• Drug Information
• Utilization
• Evidence Based
Protocols
• Learning
• Provider
Education
• CME Support
• Logistics Resource
Management
• Spend
Optimization
• Vendor
Consolidation
• 3rd Party Contract
Review
Infusion
Centers
Patient Safety
• Protocol
Development
• Compounding
guidelines
• Order review and
product checking
Optimization
• Scheduling
Efficiency
• Throughput
Product Selection
• Utilization
• Cost Savings
• PO to IV Conversion
Billing and Coding
Optimization
A Journey to Value
Strategic
Growth
Medication
Dispensing
Generic Utilization
• Tied outcome
initiatives
• Gain in $PMPM
• Generic Sampling
Specialty Pharmacy
• IV and Oral
POC Dispensing
Community
Relationships
• Drive continuity
Employee
Pharmacy
Cost
Savings
23. The PCPCC Defines
Comprehensive Medication Management (CMM)
• The PCPCC Guide Defines
comprehensive medication
management in the patient centered
medical home and ACO clinical
settings
• Included in AHRQ Innovation CenterQuality Toolkit
• 2nd Revision with Appendix A“Guidelines for Practice and
Guidelines for Documentation”
PCPCC Resource Guide- Integrating Comprehensive Medication Management to Optimize Patient Outcomes- 2nd revision
http://www.pcpcc.org/guide/patient-health-through-medication-management
25. Estimated Health Care Cost
Clinic outpatient visit avoided
Specialty office visit avoided
Hospital admissions avoided
Laboratory service avoided
Urgent care visit avoided
Home Health Care Visits Avoided
Long term care admission avoided
Emergency department visit
avoided
Employee Work days saved
Drug Cost
Pharmacists utilized the Assurance IT electronic therapeutic record system and training through Medication Management System, Inc.www.medsmanagement.com
26. Business Case: Fee for Value
General Patient Population
• Initial Visit – 60 minutes
• Follow-up Visit 3 months– 30 minutes
• Follow-up Visit 6 months – 15 minutes
• Follow-up Visit as needed by tele-health
• A 1.0 FTE Pharmacist can see approximately 1050
patients per year
• Savings per patient estimated at $387 - $1,000
• Return on Investment = 2.8 :1 – 7:1 + attribution gain
27. Positive “Side Effects”
• For every 10 patient visits to a clinical pharmacists 8.2
physician/prescriber visits are avoided!
• More efficient and effective patient visits
• An accurate medication list
• Recommended drug therapeutic changes to resolve
already identified drug therapy problems
• Engaged and educated patients on their medication
care plan
Pharmacists utilized the Assurance IT electronic therapeutic record system and training through Medication Management System, Inc.www.medsmanagement.com
32. Data to Information
•
Pharmacy
Medical
Claims
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•
Clinical
Outcomes
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Actionable Intelligence
Key to ACO environment is
optimization of resources
How do we ensure focus on right
patients at right times
Predictive analytics (Tee Time)
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Gaps in therapy
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Patient not at goal
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Annual spend
Risk Stratification
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Objective data points discrete
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Coding scores - Charlson
33. 18 of the 33 ACO quality of care metrics depend on
appropriate medication use to achieve goals!
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•
•
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•
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All Condition Readmissions
Ambulatory Sensitive Readmissions—COPD, CHF
Medication Reconciliation- post discharge
Immunizations-- Influenza, Pneumococcal
Hypertension- control
Heart Failure- Beta-blocker for LVSD
Tobacco use assessment and cessation intervention
Diabetes-- HA1c control (<8%), poor control (>9%), LDL (<100), BP
•
Ischemic Vascular Disease -- LDL control (<100), use of Aspirin or
•
Coronary Artery Disease (CAD)-- Drug therapy for LDL
(<140/90), and Aspirin use
another anti-thrombotic
cholesterol, Composite score- ACE or ARB for patients with CAD and
diabetes and/or LVSD
Accountable Care Organization 2012 Program Analysis- http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/sharedsavingsprogram/D ownloads/ACO_QualityMeasures.pdf
34. Community Partnerships
Build, buy, or
partner
34
ACO’s must
determine what
services they
will need and
how to get
them
CHC example –
200,000
patients –
• Would require 200
pharmacists to
provide
comprehensive
medication
management to all
36. Community Pharmacy
Define your value:
what are you going to offer to be a value
added partner?
• Skin in the game – willing to
share risk?
• New business models
‐ Push vs pull - proactive
• Commodity-based retail
business model shift –
Walgreens?
• Separation of church and
state (dispense and clinical)
• Medical neighborhoods
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37. Community Pharmacy’s Role
• Transitions of care – medication reconciliation
• HealthCare Partners – 30% of medications reviewed post
discharge required intervention
‐ Duplicate drugs, change in dose, therapy dc’d, missed refills, patient
education
• CMM – Care Plan Management
•
•
•
•
Accept the handoffs
Establish “extra” touch points
Ability to have P2P continuity and communication
Protocol management assistance
• Adherence – Compliance packaging programs
• Flags for gaps in care
• Consideration of office delivery/point of care dispensing
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38. Community Pharmacy’s Role
• Population Health - Health Coaching
‐ Weight loss, smoking cessation, chronic diseases
• Screening programs, immunizations (gap coverage)
• Trigger points / warning signs – front line avoid ED
• Home visits?
• Data – clearinghouse for Rx’s / OTC
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39. “…working with clinical
Aging
population, increa
sing patient
complexity, report
ing requirements
and demand for
physician time
pharmacists can
enhance patient care by
promoting the
appropriate selection
Patient
safety and
experience
and use of medications
drug
interactions, adve
rse effects, med
adherence and
prescribing of
drugs
inconsiderate of
patient physiology
to optimize therapeutic
outcomes”
Edgar Maldonado MD
Extensivist, Personalized Life
Care Clinic
43. Listen to the full
webinar at
http://bit.ly/pharmacyACO
43
Notes de l'éditeur
We noticed that the standard model was poorly focused, highly fragmented, loosely linked, and highly porous. The status quo model did an “ok” job, but we knew it could be better.In analyzing, we found a structure organized around the needs of the individual elements of care delivery. Medical oncology set up to meet the oncologist’s needs, surgery set up to meet the surgeons preferences, etc.
In transforming the model, we knew that we could achieve more for our patients by shifting the organizational model to encircle the patient--- like spokes on a wheel.
Avoidable Costs in U.S. Healthcare: The $200 Billion Opportunity from Using Medicines More Responsibly – examines six areas that contribute to unnecessary costs: medication nonadherence, delayed evidence-based treatment practice, misuse of antibiotics, medication errors, suboptimal use of generics and mismanaged polypharmacy in older adults. Together, these areas lead to unnecessary utilization of healthcare resources involving an estimated 10 million hospital admissions, 78 million outpatient treatments, 246 million prescriptions and four million emergency room visits annually. The study found significant opportunities for improvement – to ensure that patients receive the right medicines at the right time, and take them in the right way.
Of the 33 metrics, 18 rely on the appropriate use of medications directly or indirectly to achieve goals of therapy