The Imperative Role of Pharmacists in Accountable Care

Accountable care is transforming healthcare in the United States.

Accountable care organizations (ACOs) move away from a volume-driven system—where providers are paid a fee for service—to a value-driven system, where providers are incentivized to keep people well, and achieve high-quality, low-cost outcomes. Although conversion to a value-driven system will take some time, the early majority of ACOs are already refining models and allocating roles for various care providers in the new system.

Organizations, such as the American Society of Health-System Pharmacists,¹ American College of Clinical Pharmacy (ACCP),² and American Pharmacists Association,³ have position papers and/or educational resources about the role of pharmacists in ACOs. Understanding this role requires an appreciation for how ACOs operate. Although a complete review of the various ACO models is beyond the scope of this article, the Centers for Medicare & Medicaid Services (CMS) provides a summary of their models,⁴ and a description of the innovative market disruption ACOs intend to achieve is presented in The Innovator’s Prescription: A Disruptive Solution for Health Care.⁵

In a nutshell, ACOs seek to promote wellness, provide higher-quality care at the lowest possible cost, and are incentivized by shifting a portion of risk for high-cost care to providers from payers and/or purchasers of care. Shifting this risk means shifting the way providers aim to care for the population. Typically, preventing progression of disease and complications, coordinating care, and creating infrastructure to support people across their lifetime are hallmarks of a successful ACO. ACOs aim to prevent the highest-cost episodes of care by being ahead of disease progression. As one hospital/ACO executive said to me, “In our ACO, we’re treating unplanned hospitalizations as failures of our system.” With this background of how the country’s healthcare is becoming more accountable for the care it delivers, the imperative role for pharmacists in ACOs becomes clearer, and can be described in 3 segments: (1) direct patient care, (2) indirect patient care, and (3) being a good partner in the system.

Direct Patient Care

Pharmacists in ACOs continue to routinely deliver direct patient care in a variety of acute, and post- and nonacute settings. The 5 rights of pharmacy care (ie, right patient, right drug, right time, right dose, right route) are still as critical in ACOs as they are in fee-for-service systems. However, in ACOs, pharmacists can play a larger role to ensure cross-continuum medication adherence, and optimal medication action plans.

In the hospital setting, these activities may include optimizing medication regimens, investigating insurance benefits before discharge, and discharge medication counseling. As more hospitals and health systems head up their own ACOs,^6,7 anticipate a more vested interest from these stakeholders in long-term medication adherence and persistence (eg, outside of the hospital walls). The advance of aptly named “meds-to-beds” programs is a sign of this accepted responsibility; in a meds-to-beds program, acute care pharmacists work through nonacute pharmacies—some of which may be owned by the hospitals themselves—to dispense and bill for discharge prescriptions. These prescriptions are brought to the patient’s bedside prior to discharge to reduce abandonment rates, improve overall medication understanding and adherence, and address any transitional medication reconciliation issues.

In the post- and nonacute settings, innovative pharmacy practice in conjunction with other care providers is the new normal. The patient-centered medical home (PCMH) is a central tenet of ACOs. PCMHs are a means of organizing primary care to align otherwise disconnected providers of a single patient, and, ultimately, deliver care in a very patient-centric fashion.² The National Committee for Quality Assurance (NCQA) has established standards for PCMHs,⁸ and certifies practitioners as PCMH experts.⁹ NCQA acknowledges a growing role for pharmacy in the PCMH environment, and encourages open communication with pharmacies about patient care management. Notably, ACCP has a pharmacotherapy self-assessment program focused on PCMHs.¹⁰ PCMHs do not imply the fiscal risk for providers that an ACO carries, but, the core communication and care management principles are directly aligned. Given the need for better communication between practitioners, it’s no surprise that many ACOs are hiring pharmacists who are dedicated to specific patients or chronic disease states. These pharmacists follow the patient in any care setting, and coordinate care with providers at those locations. Because ACOs have accepted more risk for keeping their patients out of high-cost care settings, pharmacists have become more involved in regular home visits to ensure optimal medication action plans are effective.

Specialty pharmacy is another substantial growth sector that merits discussion. With more and more drugs distributed through the specialty channel and numerous biosimilars entering the market, specialty pharmacy is a major focus for care coordination and cost containment. A more detailed account of specialty pharmacy’s role in ACOs has been previously described in an article by Greg Isaak for Specialty Pharmacy Times, “The Role of Specialty Pharmacies in Accountable Care Organizations.”¹¹

Indirect Patient Care

The pharmacist’s role in indirect patient care is as important as their role in direct patient care. Pharmacists are an integral partner in the creation of clinical care protocols and pathways to fostering better care at a lower overall cost. Although all care providers share this responsibility, pharmacists are uniquely trained and positioned to create pharmacotherapy plans and hardwired processes for common, chronic disease states, such as heart failure, asthma, chronic obstructive pulmonary disease, and diabetes. As is described in The Innovator’s Prescription: A Disruptive Solution for Health Care, ACOs need to disrupt how, when, and where care is provided; this is where key roles for pharmacists have been identified.⁵ For example, through protocols with prescribers, many state laws allow pharmacists to administer certain vaccines—eg, influenza, varicella zoster—without a prior prescription. To play an essential role in disease prevention, reduce physician visit costs, and improve patient satisfaction through such a convenient service creates a proverbial “win-win” situation for every ACO. Similar protocols and collaborative practice agreements can be established for management of diseases (eg, hypertension), as well as disease screening services for hypercholesterolemia, diabetes, and more. When engaging in these practices, required to strictly adhere to state laws, but the value generated can be well worth the effort for all stakeholders. Recommending detailed treatment plans for individual patients and sharing them with prescribers is also a clear opportunity for pharmacists in ACOs.

Although there are many benefits, there are potential pitfalls to note here; in attempts to strictly manage costs, some ACOs encourage their patients to shop around for pharmacies carrying their specific medications through discounted or free medication programs. This practice may control short-term costs and increase adherence; however, there is increased risk for grave communication breakdowns resulting in therapy duplications, unnecessary adverse drug events, and other negative outcomes. Some ACOs have leveraged technicians and nurses to perform medication counseling; it’s important to underscore the role pharmacists play in ensuring correct and thorough education and administration training before dispensing any prescription.

Being a Good Partner

Identifying the right way, time, and place to coordinate efforts with ≥1 ACOs can be daunting. It is unlikely that ACOs are going to aggressively track you down to start a relationship. One explanation for this may be that, although CMS ACOs have access to the Medicare Part D prescription claims information for their population, those expenditures are excluded from CMS’s ACO financial risk model. Most ACOs recently reported that they were not prepared to quantify the benefits pharmaceuticals brought to their ACO patients.¹² However, the benefits pharmacists and pharmaceuticals provide are unequivocally aligned with the objectives of ACOs. No ACO can reach its desired goals without the benefits of pharmaceuticals. Pharmacists and pharmacies must appreciate that, in an ACO’s eyes, you are a commodity until proven otherwise—so you must come prepared to prove (or, worst-case scenario be willing to test), the added value you bring to the ACO over every other pharmacy. Be prepared to defend the ACO’s return on investment by leveraging a pharmacist’s skills over those of other providers. Approach the ACO leaders with an open and collaborative mind-set; offer to provide some of the unique services described above; be prepared to have regular and open communication with groups of patients or even individual cases; and understand that technology and interoperability in ACOs is currently a gaping black hole, and that any way you can freely share data will set you apart. Above all else, be prepared to share information that measures your quality-of-care performance; organizations, such as Pharmacy Quality Alliance, can provide a mechanism to share externally validated metrics that showcase your performance. In addition, such metrics may serve as the starting point to inclusion in risk-based financial shared savings.

Conclusion

Today’s ACO models will continue to shift, evolve, and grow. Ready access to care will continue to be a mainstay regardless of these changes, and few are better positioned than pharmacists in this regard. The future belongs to those who are able and willing, at every turn, to go the extra mile to improve the health of their communities. Do not wait to be invited into an ACO—those who wait will be left behind. Take active steps today to present yourself and your organization as the unrivaled assets you can be to ACO success.

Acknowledgments

Dr Pope would like to thank Mimi Huizinga, MD, MPH, and Michael P. Wascovich, PharmD, MBA, for their review of this manuscript.

Disclosure

Dr Pope is an employee and stockholder of Premier, Inc.

References

1. American Society of Health-System Pharmacists. Specific practice areas. www.ashp.org/DocLibrary/BestPractices/SpecificAreasPositions.aspx. Accessed March 15, 2016.
2. American College of Clinical Pharmacy, McBane SE, Dopp AL, et al. Collaborative drug therapy management and comprehensive medication management-2015. Pharmacotherapy. 2015;35:e39-e50.
3. American Pharmacists Association. Accountable care organizations 101. www.pharmacist.com/accountable-care-organizations-101. Published April 1, 2014. Accessed March 15, 2016.
4. Centers for Medicare & Medicaid Services. Innovation models. https://innovation.cms.gov/initiatives/#views=models. Accessed March 15, 2016.
5. Christensen CM, Grossman JH, Hwang J. The Innovator’s Prescription: A Disruptive Solution for Health Care. New York, NY: McGraw-Hill Education; 2009.
6. Centers for Medicare & Medicaid Services. Next Generation Accountable Care Organization Model (NGACO Model). www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-01-11.html. Published January 11, 2016. Accessed March 15, 2016.
7. Centers for Medicare & Medicaid Services. Shared savings program. www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/index.html?redirect=/sharedsavingsprogram. Updated December 2, 2015. Accessed March 15, 2016.
8. National Committee for Quality Assurance. Patient-centered medical home recognition. www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH.aspx. Accessed March 15, 2016.
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