Pharmacy services can help accountable care organizations (ACOs) improve patient care and outcomes. A 1-page proposal should identify pharmacy services like chronic disease management, medication reconciliation after discharge, or annual wellness visits. These services help with benchmarks like readmissions, adherence to preventive screenings, and management of chronic conditions. Pharmacists can enhance care coordination, patient education, and medication optimization within ACOs.

1. Pharmacy Services and Accountable Care Organizations Discussion
Pharmacy Services and Accountable Care Organizations Discussion ON Pharmacy Services
and Accountable Care Organizations DiscussionWrite a 1-page business proposal for
developing pharmacy services within an ACO/MSO. Review the self-study lecture handout
to get an idea of the pharmacy services you may want to implement. You can focus on all,
some or one service that has been presented to you.RubricYou will get full credit upon
submission of a completed proposal if it includes: 1) the pharmacy service(s) you want to
implement within an ACO/MSO; 2) an explanation of how this/these service(s) will improve
patient care within the ACO/MSOPharmacy Services and Accountable Care Organizations
Discussionattachment_1Unformatted Attachment Preview2/15/2021 Learning Objectives
1. Compare and contrast the services provided by different healthcare outlets 2. Describe
the responsibilities of pharmacy/pharmacist at each site or model of care 3. Compare and
contrast the characteristics of emerging health care models • Define accountable care
organization (ACO) and management services organization (MSO) • Differentiate between
fee-for-service/performance-based healthcare models • Identify the role of each member of
the healthcare team plays in enhancing the quality of care 2 2 2/15/2021 The Current State
of Affairs Percentage of Adults Ages 45-64 and 65 and over with 2+ Chronic Conditions
http://www.cdc.gov/nchs/data/databriefs/db100.htm 3 3 2/15/2021 The Current State of
Affairs https://www.apha.org/topics-and-issues/generation-public-health/health-rankings
4 4 2/15/2021 The Current State of Affairs Total Health Expenditure per Capita, Select
Countries, 2008 http://facts.kff.org/chart.aspx?ch=1952 5 5 2/15/2021 The Current State
of Affairs 2009 National Health Expenditures by Category (%) Centers for Medicare and
Medicaid Services (CMS), Office of the Actuary. (CMS, nd., PD-US, CC BY-NC-SA 3.0) 6 6
2/15/2021 Healthcare Costs • ~$25 to $45 billion per year wasteful spending in 2011 •
50% had no follow-up visit to their primary care provider between hospitalizations Health
Affairs. 2012; 31: 939-947 N Engl J Med. 2009; 360:1418-1428 7 7 2/15/2021 Fee-for-
Service (FFS) Healthcare Model • A method in which doctors and other health care
providers are paid for each service performed • Tests (e.g., laboratory tests) • Office visits
https://www.healthcare.gov/glossary/fee-for-service/ 8 8 2/15/2021 Everyone is
demanding better quality at lower cost 9 9 2/15/2021 The Affordable Care Act Better
Individual Care ACA – Accountable Care Act ACO – Accountable Care Organization Triple
AimACA & ACOs Lower Growth in Expenditures Better Population Health Patient Protection
and Affordable Care Act; Public Law 111-148, Section 3022, 124 STAT 395 10 10
2/15/2021 Performance-based Healthcare Model • An umbrella term for initiatives aimed

2. at improving the quality, efficiency, and overall value of health care • These arrangements
provide financial incentives to hospitals, physicians, and other health care providers to
carry out such improvements and achieve optimal outcomes for patients
http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=78 11 11 2/15/2021
Performance-based Healthcare Model • The typical pay-for-performance (P4P) program
provides a bonus to health care providers if they meet or exceed agreed-upon quality or
performance measures (e.g., reductions in hemoglobin A1c in diabetic patients) • Programs
may also reward improvement in performance over time (i.e., year-to-year decreases in rate
of avoidable hospital readmissions)
http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=78 12 12 2/15/2021
Management Services Organization (MSO) In healthcare, a MSO is an organization owned by
a group of physicians, a hospital and physician group, or business investors with a physician
group Managed Care Contracting Wendy Knight Aspen Publications; 1997 13 13 2/15/2021
Managed Care • An organized health care delivery system designed to improve both the
quality and the accessibility of health care, while containing costs • Has evolved due to
different factors: • • • • • Historical Economic Technological Social Government Navarro RP.
Managed Care Pharmacy Practice. 2nd ed. Sudbury, MA. Jones and Bartlett Publishers. 2009.
14 14 2/15/2021 History Behind Managed Care: HMO Act of 1973 • Federal government
gave $375 million over 5 years for the development of HMOs using a Fee-For-Service
payment • Pharmacy Services and Accountable Care Organizations DiscussionAlso required
employers to offer a federally qualified HMO option in their health benefits plan • HMOs
now must satisfy a series of requirements: • • • • • Meeting minimum benefit package
standards Adequate provider networks Quality assurance system Employee grievance
system Complying with standards of financial stability Navarro RP. Managed Care Pharmacy
Practice. 2nd ed. Sudbury, MA. Jones and Bartlett Publishers. 2009. 15 15 2/15/2021
History Behind Managed Care: Medicare Modernization Act of 2003 • An act to provide for a
voluntary prescription drug benefit under the Medicare program and to
strengthen/improve the Medicare program • Was designed to address this problem that
patients, particularly senior citizens at whom Medicare was targeted, have found
prescriptions harder to afford • Created Medicare Advantage plans Navarro RP. Managed
Care Pharmacy Practice. 2nd ed. Sudbury, MA. Jones and Bartlett Publishers. 2009. 16 16
2/15/2021 Basic Functions of MSO • Provides administrative and business services to
individual physicians and group practices • Cost savings provide negotiating power with
health plans and healthcare purchasers • Relieves physicians of non-medical business
functions so that they can concentrate on the clinical aspects of their practice Managed Care
Contracting Wendy Knight Aspen Publications. 1997 Advanced IPA Contracting, Direct
Contracting William J De Marco. 1999 Physician Driven Health Plans William De Marco MA
CMC. 1998 17 17 2/15/2021 Accountable Care Organization (ACO) Network of healthcare
providers consisting of many stakeholders- payers, physician groups, hospitalsthat receives
reimbursement based on metrics of Quality Care, Patient Satisfaction, and Reductions in
Cost of Care https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/ACO/index.html?redirect=/ACO/ 18 18 2/15/2021 History Behind Accountable
Care 2007 • Elliott Fisher (Dartmouth Medical School) publishes “Creating Accountable

3. Care Organizations: The Extended Hospital Medical Staff” 2010 • Patient Protection and
Affordable Care Act (PPACA) signed into law • Outlines a “Shared Savings Program” 2011
2014 • CMS releases its proposed rules for the “Shared Savings Program: inviting
commentary before rules are finalized” • All first year ACOs will have reached the shared
risk stage, if they have continued with the Shared Savings program Fisher ES, et al. Health
Aff (Millwood) 2007;26:w44-w57 19 19 2/15/2021 Components of ACOs • A legal entity •
Composed of a group of providers • That assume responsibility (are accountable) to manage
and coordinate care • For a defined group of patients • In an effective (high quality) and
efficient (low cost) manner
https://www.acponline.org/system/files/documents/about_acp/chapters/md/kirschner.p
df 20 20 2/15/2021 Basic Functions of ACOs • Coordinate clinical efforts among all
participating providers (e.g., primary care physicians, specialists, hospitals) • Facilitate the
delivery of more effective and efficient care through increased care access, population
management, care management and care selfmanagement education • Facilitate the ability
to translate patient clinical and service use data to promote more effective care • Establish
clinical guidelines to more effectively care for these patients
https://www.acponline.org/system/files/documents/about_acp/chapters/md/kirschner.p
df 21 21 2/15/2021 ACO Quality Measures ACO Quality Measures Domains
Patient/Caregiver Experience Care coordination/Patient Safety Preventive Health At-Risk
Population https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/sharedsavingsprogram/Downloads/2018-reporting-yearnarrative-
specifications.pdf 22 22 2/15/2021 ACO Benchmark Measures • Benchmark measures the
rate of performance achieved to earn the quality points for each measure (example below)
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/sharedsavingsprogram/Downloads/2018-reporting-yearnarrative-
specifications.pdf 23 23 2/15/2021 Advantages of the Current Models • Performance
measurements • Fostering local organizational accountability for capacity • Intervening to
improve quality and lower costs Fisher ES, et al. Health Affairs. 2007;26(1):w44-w57 24 24
2/15/2021 Challenges of the Current Models • Reversing the current market • Changing the
physician practice culture • Legal obstacles • Variability in the degree of alignment •
Pharmacy Services and Accountable Care Organizations DiscussionPractical challenges
Fisher ES, et al. Health Affairs. 2007;26(1):w44-w57 25 25 2/15/2021 Evolving Healthcare
Workforce Roles Care coordination Manage chronic conditions Patient Education /Self-care
Wellness 26 26 2/15/2021 Evolving Healthcare Workforce Roles • Physician Nutritionists •
Team leader • Mid-level practitioners Health coaches Pharmacists • Establish patient goals
Physician • Initiate referrals to specialists Mental health workers Social workers Nurses 27
27 2/15/2021 Evolving Healthcare Workforce Roles • Social workers/Care Nutritionists
coordinators • Address socioeconomic and psychosocial issues Health coaches Pharmacists
Physician • Patient access • Promote communication among care team Mental health
workers Social workers Nurses 28 28 2/15/2021 Evolving Healthcare Workforce Roles •
Nurses • May serve as care coordinators Nutritionists Health coaches • Communicate with
patients/families • Quality Improvement Pharmacists Physician Mental health workers
Social workers Nurses 29 29 2/15/2021 Evolving Healthcare Workforce Roles • Mental

4. health workers • Aid in identifying patients with social, neurocognitive disorders or mental
health concerns • Tools to address depression, anxiety, substance abuse, etc. Nutritionists
Health coaches Pharmacists Physician Mental health workers Social workers Nurses 30 30
2/15/2021 Evolving Healthcare Workforce Roles • Health coaches • Frequent patient
follow-up • Aid patients one-onone to attain treatment goals Nutritionists Health coaches
Pharmacists Physician Mental health workers Social workers Nurses 31 31 2/15/2021
Evolving Healthcare Workforce Roles • Nutritionists/Dieticians • Nutrition/lifestyle often at
the core of many chronic conditions (i.e., diabetes, hypertension, heart failure) Health
coaches • Individualized counseling Mental health workers • Encourage behavior change
Nutritionists Pharmacists Physician Social workers Nurses 32 32 2/15/2021 Evolving
Healthcare Workforce Roles Nutritionists Health coaches Pharmacists Physician Mental
health workers Social workers Nurses 33 33 2/15/2021 Role of the Pharmacist •
Medication expert • Experiences coordinating with physicians, nursing staff and other staff
members • Prevent hospitalizations, comorbidities, adverse events, and decrease health
costs • Determining appropriate and cost-effective therapies to include in formularies
www.ashp.org/DocLibrary/Advocacy/PolicyAlert/ACO-Policy-Analysis.aspx 34 34
2/15/2021 What Does the Literature Show? Study Methods Result Conclusion Brummell et
al. Retrospective chart review 2,780 medicationrelated problems Developing an MTM
program to manage and optimize pharmaceuticals will be a cornerstone to managing the
health of a population Best practices: improving patient outcomes and costs in an ACO
through comprehensive medication therapy management 23 MTM pharmacists (~18 FTE)
working in 30 locations n= 670 ACO patients 12:1 ROI ? $11,965 to $8,197 per person in
total health cost MTM – Medication therapy management; ROI – Return on investment J
Manag Care Pharm. 2014;20:1152-1158 35 35 2/15/2021 Benefits of Medication Therapy
Management • Reduces prescription costs • Identifies eligible patients • Direct interaction
with patients • Role of protocols for pharmacists to change prescriptions • Communication
from pharmacist to physician 36 36 2/15/2021 What Does the Literature Show? Study
Alhossan A, et al. Methods Results Conclusion Retrospective 1608 interventions single-
center (~5.4 per pt) chart review Outcomes of 272 referrals made AWV n = 300 provided by
patient 183 DM/Lipid pharmacists records in an ACO 370 vaccinations associated offered
with a federally 24 dosage changes qualified health Total revenue > center $22,000
Pharmacists recommendations during AWV for ACO had a high acceptance rate and
generated substantial revenue AWV – Annual wellness visit; ACO – Accountable care
organization Am J Health Syst Pharm. 2016;73:225-228 37 37 2/15/2021 Benefits of
Annual Wellness Visits • New opportunity for pharmacists • • Recommendations had a high
acceptance rate by patients and healthcare providers • • Financially viable patient care
services Pharmacists preferred to schedule follow up appointments Pharmacists provide
medications related services • Gives healthcare providers more time for specialty care 38
38 2/15/2021 Alternative Pharmacy Services • Chronic disease state management • •
Chronic care management • • Asthma, diabetes, heart failure, hypertension, etc. Medicare
patients with >2 chronic conditions 20 minutes/month of non-face-to-face care Transitions
of care • • • • Medication reconciliation Advise over the counter selection Immunizations
Perform transition of care within 5 days of discharge • Prevent readmissions 39 39

5. 2/15/2021 Benchmarks Impacted by Pharmacist: Patient/Caregiver Experience Domain
Measure Number Description ACO-1 Getting Timely Care, Appointments, and Information
ACO-2 How Well Your Providers Communicate ACO-3 Patients’ Rating of Provider ACO-4
Access to Specialists ACO-5 Health Promotion and Education ACO-6 Shared Decision Making
ACO-7 Health Status/Functional Status ACO-34 Stewardship of Patient Resources
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/sharedsavingsprogram/Downloads/2018-and-2019-qualitybenchmarks-
guidance.pdf 40 40 2/15/2021 Benchmarks Impacted by Pharmacist: Care
Coordination/Patient Safety Domain Measure Number Description ACO-8 Risk-
Standardized, All Condition Readmission ACO-35 Skilled Nursing Facility 30- Day All-Cause
Readmission Measure ACO-36 All-Cause Unplanned Admissions for Patients with Diabetes
ACO-43 All-Cause Unplanned Admissions for Patients with Heart Failure All-Cause
Unplanned Admissions for Patients with Multiple Chronic Conditions Ambulatory Sensitive
Condition Acute Composite ACO-11 Use of Certified Electrical Health Record Technology
ACO-12 Medication Reconciliation Post-Discharge ACO-13 Falls: Screening for Future Fall
Risk ACO-44 Use of Imaging Studies for Low Back Pain ACO-37 ACO-38
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/sharedsavingsprogram/Downloads/2018-and-2019-qualitybenchmarks-
guidance.pdf 41 41 2/15/2021 Benchmarks Impacted by Pharmacist: Preventive Health
Domain Measure Number Description ACO-14 Preventive Care and Screening: Influenza
Immunization ACO-15 Pneumonia Vaccination Status for Older Adults ACO-16 Preventive
Care and Screening: Body Mass Index (BMI) Screening and Follow Up ACO-17 ACO-18 ACO-
19 ACO-20 ACO-42 Preventive Care and Screening: Tobacco Use: Screening and Cessation
Intervention Preventive Care and Screening: Screening for Clinical Depression and Follow-
up Plan Colorectal Cancer Screening Breast Cancer Screening Statin Therapy for the
Prevention and Treatment of Cardiovascular Disease
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/sharedsavingsprogram/Downloads/2018-and-2019-qualitybenchmarks-
guidance.pdf 42 42 2/15/2021 Benchmarks Impacted by Pharmacist: AtRisk Population
Domain Measure Number Description ACO-40 Depression Remission at Twelve Months
ACO-27 & -41 (Diabetes Composite) ACO-27: Diabetes Mellitus: Hemoglobin A1c Poor
Control ACO-41: Diabetes: Eye Exam ACO-28 Hypertension: Controlling High Blood
Pressure ACO-30 Ischemic Vascular Disease: Use of Aspirin or Another Antithrombotic
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/sharedsavingsprogram/Downloads/2018-and-2019-qualitybenchmarks-
guidance.pdf 43 43 2/15/2021 Summary • In the FFS model providers are paid for each
service performed whereas P4P model aims to improve the quality, efficiency, and overall
value of health care • An MSO is an organization owned by a group of physicians, a hospital
and physician group, or business investors with a physician group to provide management
and administrative for practicing providers • An ACO is a group of providers that are held
accountable a defined group of patients (i.e., Medicare patients) through high quality care at
a low cost • The pharmacist can play a vital role in the current health care models,
especially regarding enhancing quality for the patient and the healthcare team 44 44

6. 2/15/2021 QUESTIONS? 45 4Pharmacy Services and Accountable Care Organizations
Discussion