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Other Sites and Models of Care
Genevieve Hale, PharmD, BCPS, BCCP, CPh
Associate Professor of Pharmacy Practice
Nova Southeastern University College of Pharmacy
Essentials of Pharmacy Practice IV
gh341@nova.edu
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
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
The Current State of Affairs
https://www.apha.org/topics-and-issues/generation-public-health/health-rankings
The Current State of Affairs
Total Health Expenditure per Capita, Select Countries, 2008
http://facts.kff.org/chart.aspx?ch=1952
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)
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
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/
Everyone is demanding
better quality at lower cost
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
Performance-based Healthcare Model
• An umbrella term for initiatives aimed 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
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
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
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.
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
• Also 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.
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.
Basic Functions of MSO
• Provides administrative support 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
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/
History Behind Accountable Care
2007
• Elliott Fisher (Dartmouth Medical School) publishes
“Creating Accountable 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
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.pdf
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.pdf
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
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
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
Challenges of the Current Models
• Reversing the current market
• Changing the physician practice culture
• Legal obstacles
• Variability in the degree of alignment
• Practical challenges
Fisher ES, et al. Health Affairs. 2007;26(1):w44-w57
Evolving Healthcare Workforce Roles
Care
coordination
Manage
chronic
conditions
Patient
Wellness
Education
/Self-care
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
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
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
Evolving Healthcare Workforce Roles
• Mental 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
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
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
Evolving Healthcare Workforce Roles
Nutritionists
Health
coaches
Pharmacists
Physician
Mental
health
workers
Social
workers
Nurses
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
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
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
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
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
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
Benchmarks Impacted by Pharmacist:
HEDIS Performance Star Ratings
Measure
Star Weight
Adult Assess to Primary Care
0
Adult BMI Assessment
1
Anti-rheumatic drug for RA
1
Breast Cancer screening
1
Functional Status Assessment
1
Medication Review
1
Pain Screening
1
Colorectal Cancer Screening
1
Controlling High Blood Pressure
1
Diabetes Care – Blood Sugar Controlled
3
Benchmarks Impacted by Pharmacist:
HEDIS Performance Star Ratings
Measure
Star Weight
Diabetes Care – Eye Exam
1
Diabetes Care – HbA1c Testing
1
Diabetes Cre – Monitoring Diabetic Neuropathy
1
Medication Adherence – ACE/ARB
3
Medication Adherence – Diabetes
3
Medication Adherence – Statins
3
Medication Reconciliation Post Discharge
1
Osteoporosis Management
1
Plan All-Cause No Readmissions
1
Statin Therapy for Patients with Cardiovascular Disease
1
Statin Use in Persons with Diabetes
1
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
ACO-45
Courteous & Helpful Office Staff
ACO-46
Care Coordination
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/program-guidance-and-specifications
Benchmarks Impacted by Pharmacist: Care
Coordination/Patient Safety Domain
Measure Number
Description
ACO-8
ACO-11
ACO-12
ACO-13
ACO-35
Risk-Standardized, All Condition Readmission
Use of Certified Electrical Health Record Technology
Medication Reconciliation Post-Discharge
Falls: Screening for Future Fall Risk
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-44
Use of Imaging Studies for Low Back Pain
ACO-37
ACO-38
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/program-guidance-and-specifications
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/program-guidance-and-specifications
Benchmarks Impacted by Pharmacist: AtRisk Population Domain
Measure Number
Description
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
ACO-40
Depression Remission at Twelve Months
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/program-guidance-and-specifications
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 support 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
QUESTIONS?
Other Sites and Models of Care
Genevieve Hale, PharmD, BCPS, BCCP, CPh
Associate Professor of Pharmacy Practice
Nova Southeastern University College of Pharmacy
Essentials of Pharmacy Practice IV
gh341@nova.edu

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