The Centers for Medicare & Medicaid Services (CMS) designed a quality payment incentive program, the Quality Payment Program, to encourage health care providers to improve performance. One of these payment models, the Merit-based Incentive Payment System (MIPS), rewards providers for performance under four categories: quality, promoting interoperability, improvement activities and cost.1 This year was the first year that payment adjustments were made based on data submitted to CMS in 2017. Eligible MIPS providers that chose not to submit data or submitted poor data are now seeing negative adjustments to all payments from Medicare. Many health plans have adopted similar payment models, and although these incentives may enhance performance, they also put additional pressure on providers to meet quality requirements.
The results of studies in the United States show that more than half of physicians are experiencing burnout, with symptoms including exhaustion, fatigue and disengagement. Researchers also found a correlation between provider burnout and decreased patient safety, quality of care and provider satisfaction.2 In a 2011 survey, 87% of physicians identified paperwork and administration as the leading cause of work-related stress and burnout. For these reasons, the widely accepted triple aim that focused on enhancing the patient experience, improving population health and reducing cost was expanded to include a fourth aim: improving the care team experience.3 The goal: Focus on reducing burnout and maintaining job satisfaction.
Changes in the health care system that focus on value-based care also put more pressure on the pharmacy industry for continuous quality improvement. As an example, in the community pharmacy setting, CMS designed the Medicare Part D star ratings to measure pharmacy performance with standard metrics. Many community pharmacies struggle to integrate these services into workflow and feel added pressure to perform. Some pharmacies elevate the roles of their current staff members to allow everyone to perform at the top of their license. In a study, Moore and colleagues concluded that integrating technicians into processes that affect quality performance had a positive impact on medication therapy management (MTM) outcomes.4
These models have been replicated in community pharmacies across the country as pharmacists begin to rely on technicians for more than dispensing services. In a study conducted at an independent pharmacy in Charlotte, North Carolina, researchers concluded that clinical technician involvement increased the number of MTM cases completed by 55%.5
Providers and pharmacists alike are working within models that focus on increasing quality of care and must fully use all members of the health care team to work toward improving the fourth aim. This achievement becomes even more difficult when independent pharmacies and practices are taken into consideration. Within the community pharmacy setting, as one solution, pharmacists have elevated the role of technicians, which also reduces the stress to improve quality metrics on their own. Similarly, pharmacists have the opportunity to serve as solutions for independent providers experiencing burnout. Findings from several studies assessing pharmacist-provider collaboration, such as the Asheville Project, demonstrate that pharmacist collaboration on the care team is associated with better patient outcomes.6,7 Much as pharmacists are using technicians to improve workflow and efficiency with MTM, pharmacists can serve as a solution for providers struggling to meet the requirements of value-based care.
Independent community pharmacists and independent providers share several similarities, which can serve as a talking point to help providers understand both the challenges that pharmacists face and the challenges that pharmacists can help them overcome. Connecting on common ground helps establish a relationship. Independent providers have likely received offers to sell to chains or large hospital systems, much like the offers made to independent pharmacies. These similarities are also reflected in the quality performance models on which practices and pharmacies are measured. Additionally, both practice settings experience the increased workload that often accompanies these models. Once a connection is established, providers may be more likely to listen to the solutions that pharmacists can offer.
Many providers have not collaborated with pharmacists before and may not fully understand the enhanced clinical services that a pharmacy can provide. Furthermore, providers may not be aware of the intensive counseling services that the community pharmacy setting offers patients every day. Pharmacists have grown accustomed to providing such services for free, and if not properly documented, those interventions can be forgotten. By quantifying the number of interventions and their impact on patients’ lives, pharmacists build a stronger case for provider-pharmacist collaborations can make a difference. The Pharmacist eCare Plan reflects the trend to improve documentation of pharmacist activities. The plan was developed to serve as a standard for capturing these activities, improving patient care, and enhancing communication between pharmacists and other members of the health care team.8
In a study, Sinclair and colleagues concluded that pharmacist-provided clinical services improved achievement of quality measures within a value-based payment model, supporting the pharmacist-provider relationship.9 This creates a strong case for collaboration, and with the goal of realizing the fourth aim, marketing the role of pharmacists becomes increasingly important. Pharmacies seeking referrals for new or collaborative services should consider how they can affect the quadruple aim. The connection between the service and one of the four aims should be considered. Will this service enhance the patient experience, affect population health, help lower cost or reduce the burden placed on members of the health care team? By acting on lessons learned in the community pharmacy setting by elevating the role of technicians, pharmacists can also provide solutions for primary care providers, allowing them to practice at the top of their license.
About the Authors
Amina Abubakar, Pharm.D., is a board-certified HIV pharmacist who graduated from the Philadelphia College of Pharmacy. Her passion is to bring innovation to clinical practices in order to thrive in a pay-for-performance environment. She is the CEO of Rx Clinic Pharmacy and founder of the Avant Institute, where she shares her methods for expanding enhanced clinical services within the community pharmacy and collaborative settings.
Jessica Sinclair, Pharm.D., graduated from the Purdue University College of Pharmacy. She completed her post-graduate training as a resident of the University of North Carolina PGY1 Community-Based Pharmacy Residency with Rx Clinic Pharmacy in Charlotte. She now works as a clinical pharmacist with Rx Clinic Pharmacy and serves an instructor for the Avant Institute, where she provides insight to pharmacists interested in expanding clinical services and collaborating with providers.