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Pharmacists are becoming consultants, medication managers, and more in the coordinated care environment of ACOs
UP FRONT IN DEPTH
By Mari Edlin
A typical accountable care organization (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 to greater reference to 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, RPh, CEO of the Academy of Managed Care Pharmacy, said that pharmacists can document improvements in care and costs information, which benefits ACOs by contributing to measures that earn shared savings. Their 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
• 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 said.
Although pharmacists by themselves are not designated as eligible ACO participants, the Department of Health and Human Services allows the contracted ACO organizations to use their discretion in including 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 award 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. Joseph Manganelli, PharmD, MPA, director of pharmacy, Montefiore Care Management Organization in Yonkers, N.Y., the only Pioneer ACO in the state, said that his organization is “fully in the door” of involvement with pharmacists in coordinated care.
Member stratification, Manganelli said, 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 data from Montefiore programs that identify high-risk patients and enroll them in intensive care management programs.
In the general risk population for Montefiore’s ACO, 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 said.
T organization relies on pharmacists’ expertise in the hospital and the discharge environments, Manganelli continued, especially for medication reconciliation, and depends as well as on their ability to promote discussion with patients.
Manganelli’s primary concern has to do with patient use of outside providers. Medicare beneficiaries assigned to an ACO - assignment is made 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.
The hope is that in time patients will seek out their ACO providers exclusively and that providers within extended communities will have far-reaching access to patient data.
Business as usual
Coordinated care is nothing new to HealthCare Partners, a mixed-model medical group employing 13 full-time pharmacists and serving 740,000 patients in Southern California. Although it is a Pioneer ACO, Mark Shinmoto, PharmD, director, pharmacy services, said the integrated group has always leveraged the expertise of pharmacists; for this organization, pharmacist participation it is “business as usual.”
Shinmoto agreed 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 said.
HealthCare Partners is currently conducting two pilots designed to introduce some control over the process. One is a telephonic reconciliation program after discharge for high-risk patients 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, changes in dose or frequency, termination of therapy, missed refills, drug additions, and patient education.
Shinmoto said the study indicates the potential role of the pharmacist to bridge the gap in medication reconciliation between the hospital and home, and thus to 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 before 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 services to a commercial population, offering medication reconciliation post-discharge.
Cathy C. Salinas, RPh, director of pharmacy, said that 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 obtain 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 said. “We are the last connection in the chain to touch patients.”
SelectHealth, based in Salt Lake City, operates on what Eric Cannon, PharmD, FAMCP, chief of pharmacy and director of health and wellness, considers a shared accountability model rather than an ACO. The insurance arm of Intermountain Healthcare, SelectHealth is integrated with 22 hospitals and a medical group comprising more than 185 clinics that employ pharmacists to manage drug utilization and polypharmacy issues.
Cannon said that the organization’s 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; pharmacists can change doses and make medication changes if necessary - often freeing physicians from those duties. Positive results, Cannon said, include increased dispensing of generics, improved hypertension, reduction in the number of bleeds by patients on blood thinners, and decreases in side effects.
While Salina Wong, director of clinical pharmacy programs for Blue Shield of California, acknowledged that the role of pharmacists is changing, their capabilities have always been in place, she said, 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 said.
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 in technology promotion, including e-prescribing, and performance of data analyses.
The National Community Pharmacists Association (NCPA) highlights expertise of pharmacists as ACO partners, outlining natural pharmacist contributions such as optimization of appropriate medication use, reduction of medication-related problems, medication reconciliation after hospitalization, diabetes management, and improvement of health outcomes.
Kurt Proctor, BS Pharm, PhD, senior vice president, strategic initiatives, NCPA, emphasized pharmacists’ close relationships with providers and patients.
“In some cases, they can be utilized as physician extenders,” Proctor said.
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. Medication management, Proctor said, remains a critical issue for providers.
Although the ACO is an evolving model, Anne Burns, RPh, vice president of professional affairs for the American Pharmacists Association, is optimistic about the integration of pharmacists into ACOs.
“The ACO is responsible for the overall health of its members - a population-based management strategy - which encompasses measures for evaluating medication utilization,” she said. “The whole focus now is on team-based care.”
Burns, however, recognizes some of the challenges connected with that process of 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 said. “The ACO provides that opportunity.”
She noted that more opportunities exist in rural areas and in smaller communities with fewer providers, where pharmacists can assume more responsibility based on the scope of their practice.
Editor’s note: A version of this article was first published April 1, 2013, in Managed Healthcare Executive under the title “Pharmacists offer MTM services to support ACOs.”
Mari Edlinis a freelance writer based in Sonoma, Calif.