The Affordable Care Act (ACA) has changed the ways we envision, provide, evaluate, and pay for healthcare. Pharmacists are conducting annual wellness visits for patients, managing chronic care, and providing transitional care management and other services they could only imagine in 2010. And they are getting paid for services not directly related to dispensing.
An era of accountability
“We are entering an era of accountable medication use,” said Brian Isetts, RPh, PhD, BCPS, pharmacy professor at the University of Minnesota College of Pharmacy in Minneapolis. “For the first time ever, providers who don’t help patients manage their medications and then have patients readmitted or suffer less-than-optimal outcomes are being penalized. The kind of pharmaceutical care that used to be derided as ivory tower fantasy is becoming reality.”
The ACA doesn’t endorse pharmaceutical care. Pharmacy-related strategies such as medication therapy management (MTM) are barely mentioned. Instead, the ACA creates a concept of value-based care that focuses on improvement of patient outcomes rather than on simple provision of services.
The shift in FFS
In January, CMS announced that it will move 30% of all provider fee-for-service (FFS) payments to value-based programs such as accountable care organizations (ACOs) by the end of 2016. Half of FFS will move to value-based programs by 2018.
One reason for the shift is the recognition that drug-related morbidity and mortality have reached crisis proportions. Medication harm has been the single largest category of hospital acquired conditions and the most common cause of readmissions, Isetts noted.
Roughly 10 people die from preventable medication-related harm in the United States every hour of every day. As health systems, practices, and providers are held accountable for medication-related adverse events and ineffective drug therapies, it makes sense to bring in the medication experts to help improve outcomes — and reimbursement.
“Pharmacists are now being included in care teams wherever outcomes are being tracked,” said Jennifer Costello, PharmD, BCPS, BC-ADM, assistant director of clinical services for Barnabas Health in Livingston, N.J. “One of the major goals of the ACA was to join forces at the provider level to improve outcomes and resource utilization. It is a dramatic change to be sought out as a needed member of the care team.”
Breaking down silos
Most of the ACA’s new patient-care-related programs debuted at the health-system level. ACOs and other value-based delivery models are intended to improve population health using quality measures such as readmission rates and medication adherence rates.
Measures from groups such as the Pharmacy Quality Alliance feed directly into quality metrics used by CMS to evaluate provider Star Ratings and other quality scores, Costello said. About a third of CMS quality metrics involve medication-related measures such as adherence rates, use of indicated drug interventions, medication regimen reviews, and the like.
“We built our business around the MTM requirement,” said Kevin Boesen, PharmD, chief executive officer of SinfoniaRx, an MTM provider in Tucson, Ariz. “We support more than 300 Part D plans, more than five million lives. But that kind of MTM only touches 10% to 15% of the population. The Star Ratings and other quality-based programs that came with the ACA have to touch as many patients as possible. For the first time, providers and plans are responsible for outcomes.”
Providers aren’t just responsible for outcomes; they get paid for outcomes. Better outcomes get better reimbursement. Where Part D reinforced existing siloes by carving out drug spend, the ACA breaks down some of those silo walls by making providers responsible for the entire cost of care as well as for outcomes.
“You can’t think cheap any longer and prosper,” said Randy McDonough, PharmD, MS, CGP, BCPS, co-owner and director of clinical services for Towncrest and Medical Plaza Pharmacies in Iowa City, Iowa. “You have to think outcome and performance. Payers are shifting their dollars to providers and networks that can provide and document quality.”