Pharmacy's Emerging Role in Accountable Care Organizations (ACO)

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Your pharmacy is an excellent partner for accountable care organizations. ACOs are formed by doctors, hospitals and other healthcare providers to improve health outcomes and lower overall medical expenses for a targeted patient population. Reimbursements are tied to patient outcomes.

ACOs’ highest-risk and highest-cost patients are those managing chronic illnesses and taking multiple medications a day. When your pharmacy can improve and track adherence – a key driver of readmission prevention and overall health – you are a valuable partner to help ACOs prevent unnecessary medical care.

Jamie Hale serves as the Chief Pharmacy Officer for Cornerstone Health Care where he is responsible for the development and integration of pharmaceutical care services in the Accountable Care Organization. He transitioned to Cornerstone in December 2012 after a 15 year career at Wake Forest Baptist Health, where he last served as Director of Pharmacy.

Download the full audio webinar at http://bit.ly/pharmacyACO.

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  • We noticed that the standard model was poorly focused, highly fragmented, loosely linked, and highly porous. The status quo model did an “ok” job, but we knew it could be better.In analyzing, we found a structure organized around the needs of the individual elements of care delivery. Medical oncology set up to meet the oncologist’s needs, surgery set up to meet the surgeons preferences, etc.
  • In transforming the model, we knew that we could achieve more for our patients by shifting the organizational model to encircle the patient--- like spokes on a wheel.
  • Avoidable Costs in U.S. Healthcare: The $200 Billion Opportunity from Using Medicines More Responsibly – examines six areas that contribute to unnecessary costs: medication nonadherence, delayed evidence-based treatment practice, misuse of antibiotics, medication errors, suboptimal use of generics and mismanaged polypharmacy in older adults. Together, these areas lead to unnecessary utilization of healthcare resources involving an estimated 10 million hospital admissions, 78 million outpatient treatments, 246 million prescriptions and four million emergency room visits annually. The study found significant opportunities for improvement – to ensure that patients receive the right medicines at the right time, and take them in the right way.
  • Of the 33 metrics, 18 rely on the appropriate use of medications directly or indirectly to achieve goals of therapy
  • Pharmacy's Emerging Role in Accountable Care Organizations (ACO)

    1. 1. The Emerging Role of Pharmacy in the ACO Jamie Hale Chief Pharmacy Officer Cornerstone Health Care, PA November 6, 2013
    2. 2. Cornerstone Health Care 2013 • • • • • • • • 1,800 employees 89 locations 230 physicians 185 shareholder physicians 111 advanced practice providers 34 specialties and ancillary services 21 Practices with extended hours 29 Primary Care practices recognized by NCQA as PCMH Level 3 • Physicians on staff at 15 different hospitals and 6 health systems
    3. 3. North Carolina Archdale Asheboro Advance Claremont Conover Elkin Granite Falls Greensboro Hickory High Point Jamestown Jonesville Kernersville Lexington Reidsville Summerfield Taylorsville Thomasville Trinity Winston Salem
    4. 4. Accountable Care Organizations Centers for Medicare and Medicaid Services (CMS) • an ACO is "an organization of health care providers that agrees to be accountable for the quality, cost, and overall care of Medicare beneficiaries who are enrolled in the traditional fee-for-service program who are assigned to it." 4
    5. 5. Prevalence of ACO Activity Feb. 2013 Health Affairs Blog- D. Muhlestein 021913- accessed April 14 2013 http://healthaffairs.org/blog/2013/02/19/continued-growth-of-public-and-private-accountable-care-organizations/ 5
    6. 6. ACOs in NC • Triad and Triangle • Triad Healthcare Network (THN) • Cornerstone Health Care, PA • State • Coastal Carolina • Wilmington Physicians • Universal American • New Bern and Caldwell Co 6
    7. 7. North Carolina Archdale Asheboro Advance Claremont Conover Elkin Granite Falls Greensboro Hickory High Point ©Cornerstone Health Care 2013 Jamestown Jonesville Kernersville Lexington Reidsville Summerfield Taylorsville Thomasville Trinity Winston Salem
    8. 8. Negative Impact of Fee for Service Patients • Inability to navigate the system • Poor health outcomes • Reduced satisfaction and engagement Payers • Increasing costs= higher premiums and payment cuts • Declining member satisfaction and increased attrition Physicians • Declining FFS payment rates • Inability to fund coordinated, evidencebased care models Beneficiaries • Increasing costs for poorer benefits • Disappearing employer coverage Employers • Higher premiums • Decreased willingness/ability to provide high quality benefits to employees Society • Declining health status • Greater portion of investment to health care
    9. 9. An Unsustainable Future $8.0 Expected future trend (6.5% growth) Sustainable trend (affordability followed by 4.5% growth) $7.0 $7.1T (24% of GDP) Industry spend ($T) $6.0 $5.0 $4.3T (21% of GDP) $4.0 $4.0T (14% of GDP) $2.6T (18% of GDP) $3.0 Trend reduction Waste reduction $2.0 A period of growth below GDP growth will be necessary to reach affordability (30% reduction in costs as a percent of GDP) $2.8T (14% of GDP) After affordability is achieved, longterm growth must be at the same level of GDP growth to ensure sustainability $1.0 2010 2012 2014 2016 2018 2020 2022 2024 Time The funding gap is widening, creating a need for rapid transformation in the market Sources: National Health Expenditure data, Bureau of Economic Analysis, Oliver Wyman analysis 2026
    10. 10. The Value Proposition • Health care cost and utilization trends are unsustainable for employers and the system • Patients are receiving a lower level of quality and service for dollars spent • Value= higher quality with lower cost • Value= Providing well-rounded patient centered services NOW to prevent cost in the future • Quality= more time with doctor, timely follow up, increased educational opportunities about diagnosis, patient engagement
    11. 11. A BRAVE NEW WORLD Volume Value Fee for service model Value based care model Patients ―discharged‖ Patients “transitioned” Disease Management focus Care Coordination and navigation Addressing Sickness Addressing Health Measuring Mortality/Harm Measuring Risk of Harm Vanderbilt University Hospital—2013 Presentation-Group Practice Improvement Network, Asheville, NC
    12. 12. Payment Models in Value World Pay for Performance – Quality Driven MA / Commercial Gain Share MSSP 14 Full Risk PMPM
    13. 13. What does it mean for the patient?
    14. 14. Key Focus Areas to Transform Health Care Physician and patient experience Improved, Triple Aim More practice resources and support to improve quality of care Improved populatio n health Patient experience of care Reduced cost of healthcare Remove redundancy and reduce preventable utilization while achieving better outcomes Improvements in patient satisfaction through tailored support services
    15. 15. “Pharmaceuticals are the most common medical intervention, and their potential for both help and harm is enormous. Ensuring that the American people get the most benefit from advances in pharmacology is a critical component of improving the national health care system.” The Institute of Medicine (IOM)1 1 The Institute of Medicine, National Academy of Sciences. Informing the future: Critical issues in health. Fourth edition, page 13. http://www.nap.edu/catalog/12014.html 18
    16. 16. The Facts 4 out of 5 Patients leave with at least one prescription 1 in 3 of all American adults take 5 or more medications 88% Of all prescriptions filled are for Medicare Beneficiaries with multiple illnesses 2 72% Of physician visits are with Medicare beneficiaries who have multiple illnesses 2 76% Of all hospital admissions each year involve Medicare beneficiaries who have more than one illness 2 1 1 The chain pharmacy industry profile. National Association of Chain Drug Stores. 2001 2 Testimony of Gerard F. Anderson, Ph.D., Johns Hopkins Bloomberg School of Public Health, Health Policy and Management, before the Senate Special Committee on Aging, 2 ―The Future of Medicare: Recognizing the Need for Chronic Care Coordination, Serial No. 110-7, pp. 19-20 (May 9, 2007) 19
    17. 17. Medicare Beneficiaries • See an average of 13 different physicians • Have 50 different prescriptions filled each year • Are 100 times more likely to have a preventable hospitalization than someone without a chronic condition2 2 “The Future of Medicare: Recognizing the Need for Chronic Care Coordination, Serial No. 110-7, pp. 19-20 (May 9, 2007)
    18. 18. The Cost of Poor Quality • $290 billion per year in avoidable medical spending (13 percent of total health care expenditures)! • Contributes to as many as 1.1million deaths annually!1 200+ Biiiiillion Dollars 2 Institute of Safe Medicine Practice Medication Safety Alert Newsletter: Community/Ambulatory Care Edition Volume 9, Issue 6: June 2010
    19. 19. Strategic Vision Quality Cornerstone Pharmacy and Resource Management Practice / Provider Support (PILLS) Pharmacy Care Clinic Services Comprehensive Medication Management Point of Care Driven Services • Focused outcomes based on POC testing, with transition to CMM • Anticoagulation • Diabetes • Asthma / COPD • Hypertension • Hyperlipidemia CMM Services • ―Pharmacy Hub‖ Driven • Embedded Practice Model • Centralized Office Model • Outreach – Video and Telephony Supported • Patient stratification proactive Patient system and referral based Experience • Rx Intelligence • Drug Information • Utilization • Evidence Based Protocols • Learning • Provider Education • CME Support • Logistics Resource Management • Spend Optimization • Vendor Consolidation • 3rd Party Contract Review Infusion Centers Patient Safety • Protocol Development • Compounding guidelines • Order review and product checking Optimization • Scheduling Efficiency • Throughput Product Selection • Utilization • Cost Savings • PO to IV Conversion Billing and Coding Optimization A Journey to Value Strategic Growth Medication Dispensing Generic Utilization • Tied outcome initiatives • Gain in $PMPM • Generic Sampling Specialty Pharmacy • IV and Oral POC Dispensing Community Relationships • Drive continuity Employee Pharmacy Cost Savings
    20. 20. The PCPCC Defines Comprehensive Medication Management (CMM) • The PCPCC Guide Defines comprehensive medication management in the patient centered medical home and ACO clinical settings • Included in AHRQ Innovation CenterQuality Toolkit • 2nd Revision with Appendix A“Guidelines for Practice and Guidelines for Documentation” PCPCC Resource Guide- Integrating Comprehensive Medication Management to Optimize Patient Outcomes- 2nd revision http://www.pcpcc.org/guide/patient-health-through-medication-management
    21. 21. 1) Identify patients 10) Reiterativ e process 9) Evaluation s 8) Document steps 2) Understan d patient perspectiv e 10 Steps to Achieve Comprehensive Medication Management 7) Patient Agreemen t 6) Develop a care plan 5) Identify drug therapy problems 3) Identify use patterns 4) Assess medicatio ns
    22. 22. Estimated Health Care Cost Clinic outpatient visit avoided Specialty office visit avoided Hospital admissions avoided Laboratory service avoided Urgent care visit avoided Home Health Care Visits Avoided Long term care admission avoided Emergency department visit avoided Employee Work days saved Drug Cost Pharmacists utilized the Assurance IT electronic therapeutic record system and training through Medication Management System, Inc.www.medsmanagement.com
    23. 23. Business Case: Fee for Value General Patient Population • Initial Visit – 60 minutes • Follow-up Visit 3 months– 30 minutes • Follow-up Visit 6 months – 15 minutes • Follow-up Visit as needed by tele-health • A 1.0 FTE Pharmacist can see approximately 1050 patients per year • Savings per patient estimated at $387 - $1,000 • Return on Investment = 2.8 :1 – 7:1 + attribution gain
    24. 24. Positive “Side Effects” • For every 10 patient visits to a clinical pharmacists 8.2 physician/prescriber visits are avoided! • More efficient and effective patient visits • An accurate medication list • Recommended drug therapeutic changes to resolve already identified drug therapy problems • Engaged and educated patients on their medication care plan Pharmacists utilized the Assurance IT electronic therapeutic record system and training through Medication Management System, Inc.www.medsmanagement.com
    25. 25. High Tech and High Touch
    26. 26. Outreach Capabilities
    27. 27. Right Patients at the Right Time 30
    28. 28. Patient-centered population managers unlock significant value in today’s upside down pyramid
    29. 29. Data to Information • Pharmacy Medical Claims • • Clinical Outcomes • Actionable Intelligence Key to ACO environment is optimization of resources How do we ensure focus on right patients at right times Predictive analytics (Tee Time) • Gaps in therapy • Patient not at goal • Annual spend Risk Stratification • Objective data points discrete • Coding scores - Charlson
    30. 30. 18 of the 33 ACO quality of care metrics depend on appropriate medication use to achieve goals! • • • • • • • • All Condition Readmissions Ambulatory Sensitive Readmissions—COPD, CHF Medication Reconciliation- post discharge Immunizations-- Influenza, Pneumococcal Hypertension- control Heart Failure- Beta-blocker for LVSD Tobacco use assessment and cessation intervention Diabetes-- HA1c control (<8%), poor control (>9%), LDL (<100), BP • Ischemic Vascular Disease -- LDL control (<100), use of Aspirin or • Coronary Artery Disease (CAD)-- Drug therapy for LDL (<140/90), and Aspirin use another anti-thrombotic cholesterol, Composite score- ACE or ARB for patients with CAD and diabetes and/or LVSD Accountable Care Organization 2012 Program Analysis- http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/sharedsavingsprogram/D ownloads/ACO_QualityMeasures.pdf
    31. 31. Community Partnerships Build, buy, or partner 34 ACO’s must determine what services they will need and how to get them CHC example – 200,000 patients – • Would require 200 pharmacists to provide comprehensive medication management to all
    32. 32. How do you get your foot in the door? 35
    33. 33. Community Pharmacy Define your value: what are you going to offer to be a value added partner? • Skin in the game – willing to share risk? • New business models ‐ Push vs pull - proactive • Commodity-based retail business model shift – Walgreens? • Separation of church and state (dispense and clinical) • Medical neighborhoods 36
    34. 34. Community Pharmacy’s Role • Transitions of care – medication reconciliation • HealthCare Partners – 30% of medications reviewed post discharge required intervention ‐ Duplicate drugs, change in dose, therapy dc’d, missed refills, patient education • CMM – Care Plan Management • • • • Accept the handoffs Establish “extra” touch points Ability to have P2P continuity and communication Protocol management assistance • Adherence – Compliance packaging programs • Flags for gaps in care • Consideration of office delivery/point of care dispensing 37
    35. 35. Community Pharmacy’s Role • Population Health - Health Coaching ‐ Weight loss, smoking cessation, chronic diseases • Screening programs, immunizations (gap coverage) • Trigger points / warning signs – front line avoid ED • Home visits? • Data – clearinghouse for Rx’s / OTC 38
    36. 36. “…working with clinical Aging population, increa sing patient complexity, report ing requirements and demand for physician time pharmacists can enhance patient care by promoting the appropriate selection Patient safety and experience and use of medications drug interactions, adve rse effects, med adherence and prescribing of drugs inconsiderate of patient physiology to optimize therapeutic outcomes” Edgar Maldonado MD Extensivist, Personalized Life Care Clinic
    37. 37. A Thousand Words
    38. 38. Over 30 medications down to 12
    39. 39. Listen to the full webinar at http://bit.ly/pharmacyACO 43

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