Joan Vos MacDonald is a freelance writer living in upstate New York.
How pharmacists are becoming key members of the ACO model.
More than 900 public and private accountable care organizations (ACOs) in the United States manage the healthcare costs of around 32 million Americans, according to healthcare consultancy Leavitt Partners. As that number grows, so does the number of pharmacists these organizations employ to optimize medication use.
ACOs are a reimbursement model where healthcare organizations strive to meet cost and quality targets. If successful, they receive higher reimbursement.
“While underutilized in early ACO models, pharmacists today are playing an increasingly important role in the success of these organizations, and more and more pharmacists are being hired on staff to oversee medication management and optimization,” says Susan A. Cantrell, RPh, CAE, CEO of the Academy of Managed Care Pharmacy (AMCP).
Half of all Americans take at least one prescription drug per-month, whereas almost a quarter take at least three prescription drugs per-month, according to the CDC. Without managing medication costs, which are expected to rise faster than any other medical expenses, ACOs will find it increasingly difficult to deliver cost-effective quality healthcare.
According to a recent study in the ACMP’s Journal of Managed Care and Specialty Pharmacy, ACOs that employ or contract pharmacists are better at managing medication costs while delivering value.
“That’s because pharmacists are uniquely positioned to help optimize appropriate medication use, reduce medication-related problems, and improve health outcomes,” Cantrell says. “As a clinical expert working as part of an interdisciplinary team, pharmacists can assess whether medication use is contributing to unwanted effects and can help achieve desired outcomes from medication use.”
Pharmacists in ACOs
A key aspect of a pharmacist’s work in an ACO is counseling patients. Pharmacists counsel them in drug therapy management clinics, such as anticoagulation clinics; transplant programs; and HIV, hepatitis C, psychiatric and lipid management clinics, to ensure that patients take their medications correctly and that drug-related problems are identified and managed.
They also play a key role in transitional care: counseling post-discharge patients on the proper use of any medications prescribed during their hospital stay. Not taking medications properly and/or not recognizing a side effect or symptom can land the newly discharged patient back in the hospital.
“ACOs currently working with pharmacists have seen positive results in reducing hospital readmission and ER utilization, particularly when they integrate pharmacists in their transitions of care teams,” says Stephanie Gernant, PharmD, MS, assistant professor at the University of Connecticut School of Pharmacy in Storrs.
“I think we’re going to see a greater surge of pharmacist integration in outpatient and primary care settings in the upcoming years. No matter your political ideology, payment based on value is never going away-the cat is out of the bag,” she says.
Currently, the percentage of ACOs working with pharmacists is 63% and that is likely to grow, says Gernant.
“An ounce of prevention is worth a pound of cure, and ACOs working with pharmacists-especially in primary care, preventative care, and risk management settings-see the return. For every adverse drug reaction a pharmacist discovers, for every omission of care she/he corrects, there’s a downstream positive patient outcome, and for ACOs that means dollars.”
Pharmacists can help identify gaps in medication use or red flags that may not be as readily apparent to other providers, says Cantrell. “A pharmacist engaged in therapeutic drug monitoring knows if a patient is not filling a prescription or is taking multiple medications that have been prescribed by different doctors.”
Pharmacists can offer solutions to some of the challenges that patients face in taking medication. They can inform patients about what to expect during treatment, what side effects are common, or how long it might take for a medication to work. They can also help with the challenge of prohibitive costs by suggesting less costly generic alternatives.
Pharmacists Expand Skills
Interdisciplinary care in ACOs is growing because not only are today’s healthcare professionals being trained this way, but government organizations like the Agency for Healthcare Research and Quality (AHRQ) is investing in tools that maximize the role of each team-member, like its TeamSTEPPS, says Gernant. This program is a teamwork system developed jointly by the Department of Defense and AHRQ to improve institutional collaboration and communication relating to patient safety.
College pharmacy courses are also providing skills that enable ACOs to make the most of future pharmacists as team members. “Students within the PharmD curriculum are introduced to managing costs throughout their coursework, both while in class and on experiential rotations,” says Alexandra Watson, PharmD, BCACP, assistant professor at Albany College of Pharmacy and Health Sciences. “Students are required to take Pharmacy Administration and Pharmacoeconomics during their professional coursework.” They learn about the healthcare system as well as techniques to assess economic outcomes, including cost-benefit analysis and cost minimization. In other courses, they have opportunities to apply cost management within real world scenarios and discuss ethical questions surrounding access to medication.
Students are given patient cases in which pharmacoeconomic barriers are addressed and resources including lower cost alternatives, coupons, or patient assistance programs are reviewed. They also conduct mock pharmacy and therapeutic meetings to reduce costs through appropriate deprescribing or determining lower cost alternative therapies.
Training in pharmacology, pharmacokinetics, and pharmacoeconomics enables pharmacists to assess medication use in ways other healthcare practitioners might not be prepared to.
“Since healthcare is moving away from fee-for-service and toward value-based care payment structures, pharmacists now have opportunities to further assist the team by helping meet quality markers,” says Watson.
Specialty Pharmacy Fuels Momentum
One reason pharmacists will play a larger future role in ACOs is the growing number of specialty pharmacy products on the market-medications that are often prohibitively expensive, need special administration, or require extensive monitoring to manage side effects.
“Patterns of care are shifting specifically to focus more on overall drug management due to more specialty pharmaceutical products becoming available in the market,” says Jane Lutz, executive director of the Pharmacy Benefit Management Institute (PBMI). “As a result, the clinical expertise of a pharmacist becomes more and more critical.”
Pharmacists can assist in managing costs in all settings, from managing formularies in the hospital to creating criteria for the use of new biologic agents in managed care, says Watson.
“Community pharmacists are often on the front line and can offer opportunities for interchange or decrease barriers to adherence concerns due to costs,” she says. “Within the ambulatory care setting, pharmacists are becoming integrated both at the patient care and administrative levels to combat rising prescription costs.”
Joan Vos MacDonald is a healthcare journalist and a regular contributing editor.