With their unique roles, pharmacists are moving away from being drug dispensers to becoming consultants in ACO models
Mari Edlin is a freelance writer based in Sonoma, Calif.
A typical ACO with 10,000 Medicare beneficiaries might save up to $1.1 million annually in emergency room and hospitalization costs by improving medication adherence for patients with diabetes, according to Health Affairs. The shift toward accountable care is opening the door for the convergence of pharmacist expertise.
More than 250 organizations have contracted with the Centers for Medicare and Medicaid Services (CMS) under an ACO model for Medicare beneficiaries, and the private market is keeping up a similar pace in accountable care contracts. With their unique roles, pharmacists are moving away from being only drug dispensers to becoming consultants and medication managers in the coordinated care environment of ACOs. The role is already accepted in the Medicare space under the Medication Therapy Management (MTM) program.
Edith Rosato, CEO of the Academy of Managed Care Pharmacy, says that pharmacists can document improvements in care and costs, information, which benefits ACOs by contributing to measures that earn shared savings. The emerging role encompasses:
• Fine tuning risk stratification criteria;
• Prioritizing pharmacy services to identify and manage high-risk patients;
• Making sure that electronic health records include pharmacist interventions, such as MTM; and
• Broadening current performance metrics and cost data.
AMCP is actively defining quality metrics to be used by MTM programs.
“Managed care pharmacists and insurers will need to reassess their programs and make sure their workforces can be nimble in addressing the planning and coordination that are needed to help ACOs reach their targets,” Rosato says.
Although pharmacists are not designated as eligible ACO participants by themselves, the Department of Health and Human Services allows the contracted ACO organizations to use their discretion in inviting pharmacists as participants in the big picture. Specifically, only providers billing under Medicare Part A and Part B can participate directly in shared savings, however, the ACOs themselves can choose to reward pharmacists a portion of the additional payments received from Medicare.
Transition to an ACO is proving to be less complicated than might be expected for organizations that previously embraced an integrated care model. Joe Manganelli, director of pharmacy, Montefiore Care Management Organization in Yonkers, N.Y., the only Pioneer ACO in the state, says his organization is “fully in the door” of involvement with pharmacists in coordinated care.
Stratifying members, Manganelli says, makes it possible for care managers to turn to pharmacists for drug utilization review and for recommendations on optimizing drug therapy. Pharmacy partners have access to the experience of Montefiore’s programs that identify high-risk patients and enroll them in intensive care management programs.
In the general risk population for Montefiore’s accountable care organization, pharmacists work closely with nurses and other healthcare providers to enroll patients in case and disease management programs, conduct drug use evaluation to identify duplications in pharmacotherapy, make recommendations about treatments and counsel members about proper medication use. The result is fewer admissions and readmissions, Manganelli says.
He says the organization relies on pharmacists’ expertise in the hospital and the discharge environments, especially in medication reconciliation, as well as on their ability to promote discussion with patients.
His primary concern is when patients use outside providers. Medicare beneficiaries assigned to an ACO-which is done retrospectively-can choose their providers without regard to either a network or differential cost. Outside physicians probably will not have access to an ACO’s electronic health records and can miss historical patient data.
In time, the hope is that patients will seek out their ACO providers exclusively and providers within extended communities will have far-reaching access to patient data.
Coordinated care is nothing new to HealthCare Partners, a mixed model medical group employing 13 full-time pharmacists and serving 740,000 lives in Southern California. Although it is a Pioneer ACO, Mark Shinmato, director, pharmacy services, says the integrated group has always leveraged the expertise of pharmacists so that it is “business as usual.”
Shinmato agrees that one of the biggest challenges is that under the ACO infrastructure, it is difficult for clinicians to completely perform care coordination when Medicare patients choose outside providers.
“That makes it hard to manage patients during admissions and readmissions, two of the largest cost drivers,” he says.
HealthCare Partners is currently conducting two pilots to rein in some control. One is a telephonic reconciliation program for high-risk patients after discharge to minimize readmissions attributed to inappropriate use of medications. Thirty percent of medications reviewed post discharge required intervention for a variety of reasons, including duplicate drugs, change in dose or frequency, end of therapy, missed refills, drug additions and patient education.
Shinmato says the study indicates the potential role of the pharmacist to bridge the gap in medication reconciliation between the hospital and home and thus, provide physicians with an accurate medication list for each of their discharged patients.
The other program identifies patients who are not achieving therapy goals, such as appropriate HbA1c levels, and then initiates and titrates medical therapy based on physician protocols.
Kelsey-Seybold in Texas has the distinction of becoming the first healthcare provider to be accredited as an ACO by the National Committee for Quality Assurance (NCQA).
The system operated as a team model prior to becoming an accredited ACO. It is a multi-specialty group practice with 370 physicians in 20 locations, 12 of which house pharmacies.
Pharmacists are responsible for typical MTM services for Medicare patients, and the clinics are expanding the services to a commercial population, offering medication reconciliation post-discharge. Cathy Salinas, director of pharmacy, says Kelsey-Seybold pharmacists might eventually offer their services to persons who are not patients of its medical staff.
In addition, pharmacists in the clinics can conduct therapeutic interchange for drug categories, outlined in advance by physicians, without having to gain approval. Kelsey-Seybold also includes a managed care department for which pharmacists assist physicians with medication adherence issues.
“Pharmacists see patients much more often than physicians do,” Salinas says. “We are the last connection in the chain to touch patients.”
SelectHealth based in Salt Lake City operates on what Eric Cannon, chief of pharmacy, considers a shared accountability model rather than an ACO. The insurance arm of Intermountain Healthcare, it is integrated with 22 hospitals and a medical group with more than 185 clinics that employ pharmacists to manage drug utilization and polypharmacy issues.
Cannon says that the pharmacists conduct MTM services and practice collaboratively with physicians and care managers. Some of the clinics specialize in specific conditions, such as diabetes and hypertension as well as polypharmacy and management of certain blood thinners.
Clinics rely on pharmacists to follow up with patients who have problems with their medications and can change doses and make changes if necessary-often freeing up physicians from those duties. Cannon says that the results have been positive, increasing generic dispensing, improving hypertension, reducing the number of bleeds by patients on blood thinners and decreasing side effects.
While Salina Wong, director, clinical pharmacy program for Blue Shield of California, acknowledges that the role of the pharmacist is changing, she says that their capabilities have always been in place, encouraging them to practice at the top of their licenses. The health plan has 10 ACO arrangements.
“While is it uncommon for pharmacists to practice in a primary care physician office, they serve as a natural extension in an ACO,” she says.
The ACO model forges new relationships with retail pharmacists, who are moving from dispensing to consulting roles. Wong foresees more participation of pharmacists on the administrative side, such as promoting technology, including eprescribing, and performing data analyses.
The National Community Pharmacist Association (NCPA) highlights pharmacist expertise as an ACO partner: optimizing appropriate medication use, reducing medication-related problems, reconciling medication after hospitalization, managing diabetes and improving health outcomes.
Kurt Proctor, senior vice president, strategic initiative for NCPA, emphasizes pharmacists’ close relationships with providers and patients.
“In some cases, they can be utilized as physician extenders,” Proctor says.
Although some ACOs are not at a point to integrate pharmacists yet, Proctor is confident that with time, ACOs will recognize what pharmacists can bring to the patient-care experience. Proctor says medication management remains a critical issue for providers.
Although the ACO is an evolving model, Anne Burns, vice president of professional affairs for the American Pharmacists Assn., is optimistic that pharmacists will be integrated into ACOs.
“The ACO is responsible for the overall health of their members-a population-based management strategy-which encompasses measures for evaluating medication utilization.” she says. “The whole focus now is on team-based care.”
Burns, however, recognizes some of the challenges of pharmacist integration.
“Pharmacists have to get their foot in the door, highlight their efficiencies and break down barriers by establishing agreements that clearly outline a pharmacist’s role,” Burns says. “The ACO provides that opportunity.”
She notes that more opportunities exist in rural and smaller communities with fewer providers, enabling pharmacists to assume more responsibility based on their scope of practice.