ACOs, pharmacists, and value-based healthcare


A rural hospital's director of pharmacy tells how ACO membership cut ER visits and healthcare costs - and improved patient care.

At the recent 2015 ASHP mid-year meeting, presenter Herb Hunter PharmD, BCPS, director of pharmacy services at Margaret Mary Health (MMH), delivered a key message linking pharmacy expertise, ACO membership, and improved facility outcomes. In his talk, Hunter explained why he urged MMH, a critical-access facility located midway between Indianapolis and Cincinnati, to join the National Rural Health Accountable Care Organization (NRACO) in 2013.

Herb Hunter“An ACO is comprised of groups of hospitals and healthcare providers that voluntarily coordinate care to ensure that patients, especially the chronically ill, receive high-quality care. Although our membership helps meet the challenges, posed by the Affordable Care Act, of delivering value-based medicine, our primary reason at MMH was to meet the goals of our hospital mission statement: To improve the health of our community.”

ACOs, he said, are designed to help facilities transition from a volume-based to a value-based system for management of population health, and one way that member facilities can benefit is by enrolling in the Medicare Shared Savings Program (MSSP). The MSSP, said Hunter, “will reimburse a facility whose practices in delivering high-quality care and wiser spending of healthcare dollars for ACO-member Medicare patients are realized.”

The ACO facility must first designate a target goal, Hunter said. “For example, when you decrease hospital admissions or reduce emergency-care visits, as a member of the ACO you are paid a portion of savings back from Medicare.”

See also: "Pharmacists are the drug experts. Call us first!"

The team approach

“We knew by joining the ACO it would force us to change our mindset and look at how we could improve our outcomes. We have a lot of people who were using the emergency room [ER] as a primary care physician [PCP] service, so our target was to reduce these emergency visits by better coordinating care, therapies, and treatments through medication therapy management.”

To help identify goals and a strategy of implementation, MMH formed a multidisciplinary committee, said Hunter. The committee comprised an ACO coordinator, a representative from the MMH administration, a nurse practitioner, home-care services, and Hunter, who eventually became the ACO coordinator.

“What we did was identify those patients who were high frequenters of ER services. By reviewing records, we flagged patients who had been in the ER more than three times in two months. The patients were contacted and asked whether they wanted to join this ACO program, a required step, and if they agreed, we assigned them to a PCP. Then a nurse would contact me to do the medication management and meet with the patient to optimize the meds they were taking.”

See also: Pharmacist-driven MTM could save ACOs a bundle


The pharmacy angle

Case studies have found that patients over the age of 60 who take a long list of medications are high frequenters of ERs, said Hunter. So after each patient is enrolled, one of the first steps “is to compare their drug list with that of the Beers list of medications that should be avoided in the elderly if at all possible.”

A letter recommending a change in therapy is then sent to the patient’s physician. “In every case, they would act on our recommendation to discontinue that medicine. We also discussed therapy with the patient, directly or on the phone, or through the ACO coordinator.”


Although gains were modest- due perhaps in part to the fact that transportation, “getting people to the facility,” especially for their free ACO wellness exam, “was a big problem” - the review of enrolled ACO patients showed an overall drop from 90 ER visits per month in 2014 to 60 ER visits per month in 2015.

Among the target patients, total costs per patient per month (PPPM) dropped from $900 to $850, and total PPPM costs dropped from $680 to $630.

To sell hospital decision-makers on joining an ACO, hospital pharmacists should emphasize their expertise in medication management, said Hunter.

“It’s a little like building from scratch, because each facility has different goals, but use your expertise and take that to your administration to demonstrate that pharmacy services can be the starting point of positive change for quality, outcomes, and costs.”

Barbara Hesselgrave is a freelance writer based in Baltimore.

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