EMAINING RELEVANT IN ACOs AND CINs - Divurgent · 2018-06-12 · are not achieved, provider members may actually be at financial risk depending on the program. Pharmacists, although

white paper

wri t ten by Col in Konschak, RPh, MBA

Robert Farraj , RPh, MBA

How Pharmacists and Pharmaceutical CompaniesPlay a Major Role

REMAINING RELEVANT IN ACOs AND CINs

Abstract

The United States healthcare system is at a crossroads. Costs are quickly becoming unsustainable and the outcomes

achieved relative to these financial investments are not sufficiently adequate. Government and commercial reform

initiatives are being released at an unprecedented pace in order to “bend the cost curve” and provide better value to

payers and consumers alike. At the center of these initiatives are outcomes-based reimbursement and delivery models

such as the Accountable Care Organization (ACO) and Clinically Integrated Network (CIN). Under these arrangements,

providers are reimbursed based on outcomes rather than the traditional transaction-based fee-for-service model.

Providers may also share in the savings of these proposed models. Pharmacists have the potential to be at the center

of these programs. First, they are perfectly positioned to decrease costs associated with adverse drug reactions and

medical errors through medical therapy management. Just as important is their ability to improve the overall quality of

care. Health Information Technology will play a critical role in these models, allowing the pharmacist access to patient

medical records as patients move through the entire continuum of care. The pharmaceutical and medical device

industries have a great deal at stake as delivery models move in the direction of outcomes-based reimbursement.

Comparative Effectiveness Research will play a pivotal role as medications will be selected based on their ability to

improve outcomes and decrease overall healthcare expenditures. Pharmacists have a tremendous opportunity to make

an impact on patient care at reduced cost through the advent of new healthcare models such as ACOs and CINs. If the

profession does not seize this opportunity, the transformation of the healthcare system will move on without it.

Introduction

We have reached a point where there is finally consensus that the current model of healthcare in the United States

is unsustainable. The most expensive system in the world fails to deliver the requisite quality. In spite of previous

attempts at reform, the problems of health care quality, affordability, and accessibility persist. In recent years, healthcare

expenditures in the United States have risen 2.4% faster annually than the rate of growth in gross domestic product

(GDP)1. In fact, CMS stated in 2010 that total national health expenditures for 2009 reached $2.5 trillion—17.6% of GDP.2

National health expenditures as a share of GDP are projected to increase to 19.3% by 20193, given the historical trend

from 1960 to 2008 as a percentage of GDP.4 Many leading economists believe that expenditures above 20% of GDP will

have a significant negative impact on the United States economy.5 This is driving an increase in insurance premiums as

well as mounting consumer out of pocket costs.

Equally concerning is the quality outcomes we get for these investments. The Organization for Economic Co-operation

and Development (OECD) data for the G8 shows that for the last 20 years, the United States has had the lowest life

expectancy of G8 members (comparable countries). Over the same period the United States has had the highest

infant mortality when matched to other G8 countries. More mothers die in childbirth in the United States per 100,000

births than in any other comparable country. The United States has more preventable years of life lost than any other

comparable country. And for lung cancer, we are dead last. We can’t blame high smoking rates, because the US has

some of the lowest rates of tobacco use of any of these countries.6

©2011 DIVURGENT - All Rights Reserved | 1Improving healthcare with client focused solutions.

©2011 DIVURGENT - All Rights Reserved | 2www.DIVURGENT.com • 1.877.254.9794 • [email protected]

These drivers are predominantly responsible for the unprecedented amount of government reform initiatives released

during the last several years. In fact, the United States healthcare system is at the very early stages of what will be its

largest transformation to date. The HITECH Act, Meaningful Use, Value Based Purchasing and the relaxation of the

Stark legislation are all aimed at transforming not only the way we deliver care, but how we pay for it. The most current

attempt at major health reform, the Patient Protection and Affordable Care Act of 2010 (Affordable Care Act), seeks to

elicit new and innovative mechanisms to solve these problems. Along with other reform initiatives, it seeks to shift our

healthcare reimbursement model from a transaction-based system to one that is based on reimbursements that are

tightly aligned with outcomes. Commercial payers are very close behind these government reform initiatives and are

establishing similar payment reforms in the commercial sector.

Through the Affordable Care Act and related commercial payer initiatives, the delivery model is being shifted from

a presently fragmented model to one that is organized across the entire continuum of care. This model is being

referred to as Clinically Integrated Networks and Accountable Care Organizations (ACOs). The ACO model was formally

introduced to the Medicare Payment Advisory Commission (MedPAC) in November 20067 and by Dr. Elliott Fisher8 in an

article published in December 2006. Dr. Fisher described ACOs as partnerships between physicians and hospitals for

coordinating and delivering healthcare services with greater efficiency and higher quality while lowering costs. ACOs

accept ultimate accountability for clinical performance risk but are not responsible for overall insurance risk. Both

public and private sector models strive to improve coordination and delivery of patient care as well as optimize the

reimbursement system.5

Clinically integrated networks (CINs) as allowed by the FTC are legitimate collaborations of otherwise competing

providers (hospitals and/or physicians) organized in a way that improves efficiencies in care delivery (including

quality improvement and cost reduction) in a way that outweighs any potential anticompetitive effects such as fixing

prices among competitors. If providers meet specific criteria for clinical integration, they may not be prevented from

collaborating and even negotiating prices with payers and will not afoul of antitrust laws that prohibit competitors from

price setting.5

Both the ACO and CIN models are attempts to move the delivery model to patient-centric care with reimbursement

based on outcomes. ACOs can refer to structures and reimbursement that may be CMS based or commercial payer

based. The government program developed by CMS was announced in a Final Rule in the Federal Register in October

2011 and is referred to as the Medicare Shared Savings Program. At the highest level, the goals of the MSSP are described

by a Three Part Aim:

1. Better Care for Individuals

2. Better Health for Populations

3. Lower Growth in Expenditures

CMS also stated eight goals9 that should be embraced by all ACOs and clinically integrated networks:


1. Put beneficiaries and families at the center of all activities.

2. Coordinate care for all beneficiaries at any time and any location.

3. Place strong importance on care transitions.

4. Manage resources carefully and respectfully to reduce waste effectively and increase value for beneficiaries.

5. Put in effect communication programs and initiatives that focus on helping patients with health maintenance.

6. Collect, evaluate, and use data on healthcare processes and outcomes to measure what is achieved for

beneficiaries.

7. Be innovative in the service of the Three Part Aim.

8. Ensure continuous development of workforce and affiliated physicians.

The Medicare Shared Savings Program and many commercial payer ACO models are focused on providing quality

outcomes. Reimbursement in these programs is based on delivering quality care centered on pre-defined quality

measures. If outcomes are at the required level, these programs share the savings with provider members. If outcomes

are not achieved, provider members may actually be at financial risk depending on the program. Pharmacists, although

not identified as eligible providers within the Medicare Shared Savings Program, can certainly contract with ACOs CINs

and may be able to participate in commercial ACO CINs.

What does this mean for the healthcare delivery model and the practicing pharmacist? First and foremost, all of these

reform initiatives are aimed at a move towards patient-centric care. In this model, the patient is at the center with

various providers working together having a common goal of improved outcomes. The emphasis on chronic care and

high cost ailments will be a primary focus in the beginning.

Pharmacists are in the unique situation of being a consistent point of contact for the patient. They are in an excellent

position to coordinate both pharmaceutical care as well as directing care amongst the other providers. The pharmacist

should be reimbursed in this model of care and should participate in opportunities to share in the savings generated. It

is critical that the Pharmacist have access to the patient’s electronic medical record and all data generated throughout

the continuum of care, as shown in Figure 1 below.


Opportunities within Medical Treatment Management (MTM)

Decreased Costs Associated with Adverse Drug Reactions (ADRs) and Medication Errors Through MTM

“Every day, pharmacists utilize their skills as medication experts to manage chronic conditions, ensure appropriate

medication use, answer medication-related questions, and counsel patients. These roles directly improve the probability

of ACOs reaching their performance measures.”10

“Pharmacists can benefit ACOs as they have been proven to improve outcomes and lower costs while maintaining

high-quality care. Pharmacists in the inpatient and outpatient settings can contribute to the continuity of care through

communication of patients’ therapeutic plan and medication changes.”10

A recent American Society of Health-System Pharmacists (ASHP) Policy Analysis revealed that the U.S. health care system

incurred more than $177 billion annually in mostly avoidable health care costs to treat adverse events from inappropriate

medication use.10 Since the treatment of chronic diseases costs the health care system $1.3 trillion annually, or about

75 cents of every health care dollar, the proper use of medication becomes even more crucial. Thirty-two percent of

adverse events leading to hospitalizations are due to medications, and only 33 to 50 percent of patients with chronic

conditions adhere to their prescribed medication therapies.11 Pharmacists are uniquely positioned to help patients

optimize appropriate medication use and reduce medication-related problems. They can aid in improving outcomes

through the delivery of patient care services, such as MTM, health promotion and education, and disease prevention

and mitigation.

MTM services are a distinct group of interventions whose overarching goal is to ensure the safe, effective, appropriate,

and economical use of medications by utilizing a patient-centered, interdisciplinary, evidence-based approach.12 These

programs, which primarily focus on improving adherence to therapy and reducing hospital re-admissions, form the

basis for pharmacist activities within the ACO/CIN environment. These activities may include:

• DrugTherapyManagementClinics. Pharmacists ensure that patients are taking their medications correctly

and that drug-related problems are identified and managed, with a focus on chronic disease management.

• ComprehensiveMedicationReviewsandMedicationReconciliation. Patients are given an opportunity to

review their medications with a pharmacist to discuss proper use and avoid inconsistencies in medication

regimens that may occur during transitions in care. The review encompasses over-the-counter, herbals, and

prescription medications.

• DrugUtilizationReviewandIdentificationofGapsinCare. These include programs that assess medication

appropriateness and possible patient safety issues, and making recommendations for therapy changes or

additions to the patient’s physician.

• PrescriptionDrugAdherence Clinics. Pharmacists counsel patients who have been identified as non-

adherent to medications used for chronic diseases to increase adherence rates and improve outcomes.


Role of the PharmacistThe Pharmacist as the Center of Medical Intervention Through MTM

Patients with chronic diseases such as diabetes will often be treated by several different specialists, including a

cardiologist, nephrologist, endocrinologist, and podiatrist. With the possibility of each physician prescribing separate

medications, tests, and procedures, the patient’s clinical pharmacist becomes the only consistent healthcare provider.

MTM by its very nature encourages the pharmacist to serve as the central axis of patient care, ensuring that patients

receive the best choice of therapy, which reduces the risk of adverse events, especially during transitions of care.

The value that pharmacists can provide an ACO has been widely documented but often goes unrecognized. For

example, pharmacist-provided care can reduce drug expenditures, hospital readmissions, length of hospital stay, and

emergency department visits.12 Proven care models utilizing MTM programs such as The Ashville Project and Diabetes

Ten City Challenge have demonstrated the potential to save $1,079 per patient or $23 billion per year for diabetes

alone.13 Improving patient outcomes through coordination of care and lower costs could help ACOs meet benchmark

requirements while also avoiding reduced Medicare reimbursements. Ensuring access to MTM across the continuum of

care is an essential health care service that a high performing ACO will need to provide to be successful. Physicians and

pharmacists collaborating together would be a win for patients, payers, and the overall goals of the ACO.

Pharmacist Role in the Development and Governance of the ACO

Pharmacy leaders interested in being part of an ACO will need to partner with physician groups and work with the

administration to raise the level of understanding of the services their staff can provide. In most cases, physicians

and ACO administrators are unaware of what pharmacists can do and what the scope of pharmacy practice allows.

David Harlow, director of pharmacy operations for Carilion’s New River Valley Medical Center and Tazewell Community

Hospital, notes that “pharmacy leaders should make the case for including pharmacists in an ACO by creating clinical

protocols and business plans for the organization’s chief financial officer and physician groups.”14 Pharmacists can help

physicians improve patient care, especially in the management of complex and chronic diseases. Pharmacists need

to ensure that the value of pharmacy services is properly represented in both the development of ACO legislation and

during the formation of individual ACOs.

Role of Health Information Technology

There is a significant role for health information technology (HIT) in the ACO/CIN models of care delivery. In fact, it may

not be possible to align care along the continuum without significant capabilities to share data, analyze that data and

put relevant information in front of caregivers at the point of care. When reading the Medicare Shared Savings Program

one might conclude that the HIT infrastructure needed to support an ACO/CIN is too daunting to build. CMS alludes

to dozens of technological documents and processes in the rule, including electronic health records (EHRs), personal

health records (PHRs), telehealth, health information exchanges (HIEs), data warehousing, analytics, and member

registries. The resulting ACO CIN HIT platform would involve extremely complex and expensive implementation. In

fact, CMS’s estimate of $1.75 million for ACO infrastructure is a low approximation for most healthcare organizations.

They are likely to spend many times that amount to properly implement all of the HIT elements envisioned for Medicare


ACOs. Furthermore, since implementing this type of ACO platform would require technology not readily available in the

present marketplace, considerable amounts of custom development would also be needed.

The language of the MSSP rule does not dictate the use of specific HIT applications except for EHRs, but heavy reliance

on HIT is clearly the intent. Combining the language of meaningful use and ACOs makes it evident that CMS sees HIT

investment as a necessary starting point on the road to healthcare reform.

CMS is not the only organization experimenting with value-based purchasing (VBP) models such as the ACO CIN. Most

in the industry would agree that some form of the VBP model appears inevitable and experimentation is occurring in

virtually every market in the country. Few of these private models are as complex as the CMS model, and therefore have

a much lower HIT hurdle to clear. As an example, one could envision effective care coordination being put in place in

some markets by simply giving coordinators access to hospital and community physician EHR portals.

Below is an ACO Reference Model (ACORM™) to provide a conceptual framework for planning and implementing the

various components of ACO technology architecture. While the model is intended to prepare health systems for a

Medicare-like ACO, it is believed that many organizations will need only a subset of the technologies described to meet

their near-term needs.

Experts have carefully examined each component in ACORM™ and considered the role of and implementation

implications for each one. Before discussing these components in detail, we note several overarching themes arising

from ACORM™:


• While much of the required HIT investment for ACOs /CINs overlaps with Meaningful Use, most does not,

and will require a new HIT strategic planning approach.

• Much of the technology called for is not readily available in the present marketplace.

• One should expect many HIT products used by payers to be modified for use by providers.

• As incentives build to keep patients healthy outside provider facilities, innovations in home health and

telehealth technology will appear at an accelerated pace.

• Privacy and security infrastructure will take on heightened importance and complexity.

• Such key ACO CIN HIT building blocks as HIEs will quickly expand into new areas of functionality.

• While CMS may be calling for end-to-end HIT capabilities at the startup of an ACO, many private ACO’s can

start with HIT “baby steps.”

The ACORM™ model can be more fully explored in a related white paper, however we want to be clear that health

information technology is a prerequisite for delivering highly coordinated care across the continuum. The Federal

government has many programs aimed at making relevant technologies available at an affordable cost. The formerly

mentioned HITECH Act provides incentives for both hospital and physician providers to purchase and install electronic

medical record systems and the relaxation of the Stark laws allow hospital providers to subsidize a significant portion of

electronic medical record purchases for non-owned community physicians. Both programs have been successful to date

and the implementation of these systems within both hospitals and physician providers is occurring at unprecedented

rates.

ACO CIN HIT investment may rival or even surpass investments made by providers to meet Meaningful Use. Certainly

those providers forming an ACO CIN under the current CMS guidelines have a daunting HIT hurdle to overcome. We

believe that for most healthcare organizations, however, the investments can be modest and incremental. For many

value-based purchasing arrangements, current efforts in the industry to clinically integrate physicians and hospitals

(with HIT playing a key role) are already moving healthcare organizations closer to ACO/CIN readiness. In any case, an

HIT strategic planning process that includes a systematic look at each technology component required for a successful

ACOCIN is a good first step. Most importantly, pharmacists throughout the continuum of care must have access to

patient information as they pass through that continuum.

Role of/Impact on the Pharmaceutical and Device Industry

Pharmaceutical and device manufacturers (pharma) will need to reposition their products and services in light of the

challenges presented by ACOs. The current fee-for-service model rewards physician practices for choosing the most

costly medications and interventions, with an emphasis on the utilization of Medicare A and B via lab testing, elective

procedures, and intravenous medication administration. Under the new incentive plans, which focus on improved

patient outcomes with lowered cost, health care professionals and institutional providers will likely engage in two


actions that will directly impact such companies: (1) defer elective and costly medical procedures, and (2) choose the

least expensive alternative when treatment options are present, including generics.15 Under the American Recovery

and Reinvestment Act of 2009, generic drugs will replace brand name drugs not demonstrating proven clinical benefit.

Pharmaceutical manufacturers will be forced to evolve to meet the demands of this new challenge.

Pharma Must Align Its Goals with ACOs: Improved Patient Outcomes at Lowered Cost

Since ACOs will operate as large integrated networks, the traditional sales model of reach and frequency will not be

an effective method for pharma interaction. ACOs are likely to implement standardized treatment protocols among

physicians within the ACO, with formulary and P&T decisions made at higher levels within the organization. As these

decisions shift from physician to management, pharma must also change its focus towards group management. The

advent of the Physician Payment Sunshine Act of 2009 will continue to place negative pressure on the traditional

pharmaceutical representative and prescriber relationship. The right pharma approach should involve account directors

and executive leadership to demonstrate pharma commitment to the ACO’s mission and values.

Pharma has the potential to affect behavior by demonstrating improved outcomes and decreased overall healthcare

costs resulting from the use of their products. Manufacturers armed with compelling data may be able to influence the

inclusion of their products onto formularies and treatment guidelines, especially for value-priced preventive medicines,

vaccines, and companion diagnostics. If an ACO deems a product will assist in improving its quality of care and attaining

cost-savings goals, manufacturer representatives may be able to directly partner with the organization. ACOs may

encourage manufacturer representatives to help educate affiliated physicians and other healthcare professionals about

the appropriate use of their products within treatment guidelines.

Increased Focus on Medicare D Benefits (IV to Oral)

In order to determine the shared savings under the provisions of the ACO, Medicare will establish baseline benchmarks

that will be updated annually. Medicare will establish, using “the per capita Parts A and B fee-for-service expenditures

for beneficiaries that would have been assigned to the ACO in each of the 3 prior years,” a fixed benchmark, “that is

adjusted for overall growth and beneficiary characteristics.”10 The benchmark will not include charges associated with

the beneficiary through Medicare Part D. This means that drugs paid for as injectables through Part B, or as a part of the

cost basis of a DRG under Part A, will be included in the benchmark for the ACO, but that drugs prescribed and paid for

by the beneficiary through a Part D plan (or as an out of pocket expense) will not be included.

One obvious way for providers to control costs as defined by the benchmark would be to choose a drug treatment

regimen covered by Part D, as opposed to a treatment regimen that would contribute to Part A and Part B charges for

the patient. This idea is in direct contrast to the current fee-for-service model, which incentivizes practices to maximize

the use of Part B services and the most costly drugs since they are paid a fixed percentage over the actual sales price

of the drug. A study published in the Journal of the American Medical Association found that Part D saves Medicare

beneficiaries about $1,200 per year in hospital, nursing home and other costs for each senior who previously lacked

comprehensive prescription drug coverage. According to other experts, this finding equates to about $12 billion per

year in savings across Medicare.


Controlling Part A and B expenses will present challenges to the management of the ACO. There will continue to be a

natural desire for participants to maximize their individual fee-for-service billings, while hoping that the ACO as a whole

will achieve cost savings through mechanisms that do not affect the participant’s own Part A and B billings. To put it

another way, hospitals will want to see the ACO achieve its cost reduction goals in areas other than Medicare A services,

and doctors will not want to see their own fee-for-service billings reduced, resisting reductions in Part B services. Since

there are limited options for cost savings that the ACO has at its disposal, it is highly likely we will see reductions in both

Part A and Part B billings, with a commensurate reduction in medical procedures and intravenous drug administration.

When an injectable drug is one among multiple treatment options available to a physician, there will be increasing

pressure for physician groups to defer the use of injectable treatments in favor of oral alternatives.

Comparative Effectiveness Research

Comparative Effectiveness Research (CER) refers to any work that compares different medical devices, drugs, and treatment

methods to determine which are most effective in treating a disease or condition.16 Comparative effectiveness may

examine clinical benefits or harms (therapeutic effectiveness), and may include discovery of relative cost-effectiveness.

The field has taken on increasing attention in light of the expanding availability of new, and often, expensive medical

interventions. In addition, The American Recovery and Reinvestment Act of 2009 and the Affordable Care Act created

new CER programs with substantial boosts in funding. With cost containment emphasized as a key goal of an ACO,

CER becomes almost a necessity to guarantee that the least costly intervention is used with comparable outcome and

safety profiles. ACOs are likely to utilize the results of CER to develop rationally based treatment protocols. CER is likely

to become even more important as models of performance evaluation continue to shift toward quality of care and cost

effectiveness, in turn affecting reimbursement and compensation. The ultimate goal of CER is to identify which medical

interventions provide the greatest value to the patient, provider, and the payer.

CER presents a challenge and an opportunity to pharmaceutical and device manufacturers. In the end, there will be

winners and there will be losers. One way that pharmaceutical manufacturers can be directly involved is through

commercially sponsored comparative effectiveness research. As reimbursement becomes more restrictive and

markets become more competitive, companies need to determine the relative costs and benefits of their products.

Drug manufacturers are required to provide clinical trial results to support the safety and efficacy of their medications,

and in some cases, such as oncology, are required to show benefit beyond what was considered to be the current

gold standard treatment. The results of these trials contribute to the pharmacoeconomic picture of the drug, and can

also serve as a key differentiator in the marketplace. As current drugs lose patent exclusivity and become generic,

commercial CER becomes critical to protect the position of patented products and show their value to providers and

payers. Newly launched products will now have to meet higher value standards to prove that a more costly drug or

device results in a commensurate increase in clinical benefit for patients. Commercially sourced CER overcomes some

of the issues surrounding federally funded CER such as limited funds and human resources, and often provides results

more quickly, but may also present the element of bias, especially when these studies are performed ultimately for

marketing purposes.


Pharmaceutical manufacturers, once content to exclude themselves from all cost considerations, must involve themselves

deeply in the debate to develop cost-effective strategies that may or may not involve drug therapies. These initiatives

may include partnering with ACOs and providing drug discounts based on medication compliance benchmarks. They

could also encompass disease management (DM) programs. Examples of disease management programs include the

following:17

1. Pfizer: DM programs addressing hyperlipidemia and smoking cessation, and is noted by Medicare executives

for its expertise.

2. Novartis: Majority of DM programs for hypertension and remains a leader in qualitative rankings.

3. Merck: Ranks first in expertise, value, outcomes, and savings, and provides DM support in diabetes and

immunizations.

A disease management arrangement includes interventions to alter prescribing patterns or improve patient compliance

and an assessment of the effects of these interventions against target outcomes specified in the contract. The agreement

specifies guidelines for treatment and requirements for data collection, monitoring, and reporting that are consistent

with target outcomes. In many DM arrangements, the partners share cost savings and risk; other arrangements involve

case management on a capitated basis. A pharmaceutical company involved in risk sharing must change its focus from

market share to optimal use of drugs within the total cost of treatment. The goal of DM programs should not simply be

to decrease the drug budget, but to decease overall costs for treatment.

A Call to ActionAPhA/AMCP/NCPA/ASHP Must Unite for a Common Cause

Lengthy position papers have been filed by the various pharmacy organizations expressing their specific responses to

CMS on the proposed ACO structure. These organizations include the American Pharmaceutical Association (APhA),

the Academy of Managed Care Pharmacy (AMCP), the National Community Pharmacist Association (NCPA), and the

American Society of Health-System Pharmacists (ASHP), and collectively represent the majority of pharmacists in

practice today. Although their specific positions differ slightly, they all agree that pharmacists must take a central

role in both the administration and implementation of an ACO if it is to be successful. Pharmacists have a tremendous

opportunity to make an impact on patient care at reduced cost through the advent of new healthcare models such as

ACOs. In order to achieve this end, pharmacy needs to unite under one common set of principles. While the American

Medical Association has tremendous clout and influence because it represents the majority of physicians in practice,

there is no single association that represents all pharmacists. Without a unified front, pharmacists’ efforts to shape and

mold the ACO model may go unfulfilled.

An Opportunity to Advance the Profession of Pharmacy

Although the benefits of pharmacist involvement in ACOs are numerous and validated as described previously, their

inclusion is far from automatic. Unfortunately, pharmacists are not specifically mentioned as a provider under the


proposed ACO legislation. Since there is currently no provision in the Affordable Care Act to pay pharmacists for their

clinical services, pharmacists are unlikely to receive “direct remuneration from shared savings.” 18 As a result, pharmacists

may decide to contract with the ACO to help it achieve its cost savings goals through optimizing drug therapy for patients,

which will ultimately reduce Medicare A and B expenditures through reduced hospital readmissions and emergency

department visits.19 The National Community Pharmacist Association recommends that the Federal Trade Commission

revise ACO and antitrust policy to include a “safe harbor” provision that would (1) allow pharmacies to collaborate in

order to participate in ACOs and other collaborative care models, and (2) expressly allow independent pharmacies to

collaborate with one another in order to be able to directly participate in ACOs and other collaborative care models.

The models already exist and the benefits have been proven. The policy simply needs to be revised. Pharmacists,

who lack Medicare Part B recognition as providers, should not be precluded from participating contractually, through

shared savings or otherwise, in coordinated care and ACO models. Organizations like the American Society of Health-

System Pharmacists, along with efforts from other pharmacy organizations and individuals, will be key to the successful

involvement of pharmacists in ACOs. The authors of Hospital Pharmacy concluded that:20

“Pharmacists can still advocate their involvement by educating themselves and increasing awareness about the

importance of pharmacy services in the quality of health care. The pharmacy director should educate hospital

administrators who are likely to be unfamiliar with the many roles pharmacists can fill and should “be at the table”

and participate in ACO development. Clinical proposals and business plans that include pharmacy services to

improve the quality of care will create the opportunity for pharmacy involvement in ACO development.”


Robert Farraj, RPh, MBA is Lead Executive Oncology Manager with Merck Oncology, covering private and group

oncology practices, institutions, and Fellowship programs across Delaware and Central Pennsylvania. He has worked

over 17 years in areas including sales and marketing, sales training, contracting, project management, reimbursement,

quality assurance, “buy and bill” injectables, and direct patient care to meet varied Healthcare needs. He is a registered

pharmacist in Delaware and Pennsylvania with an MBA in Management Information Systems from Villanova University.

Colin Konschak, RPh, MBA, FHIMSS, FACHE is a Managing Partner with DIVURGENT and leads its Advisory Services

Practice. He is a highly accomplished executive with over 17 years of experience and recognized achievement in

quality service account management, strategic planning and alliance management. His broad healthcare experience

encompasses pharmaceutical, payer, information technology, and provider industries. He is a registered pharmacist,

possesses an MBA in health services administration, is board certified in healthcare management and is a Six Sigma

Black Belt. He is a co-author of a recently released textbook on the ACO/CIN topic titled, “Clinical Integration: A Roadmap

to Accountable Care”.

DIVURGENT was founded by a team of consulting veterans who are well versed in the healthcare industry. As a premier

healthcare consulting firm, DIVURGENT is focused on the business of hospitals, health systems and affiliated providers.

We provide advisory, activation management, clinical transformation, and revenue cycle management services to

help you improve patients’ lives. Recognizing every organization is unique, we leverage the depth of our experienced

consulting team to create customized solutions, utilizing best practices and methodologies.

ABOUT THE AUTHORS

COMPANY OVERVIEW

References

1. Kaiser Family Foundation. Trends in health care costs and spending. March 2009.

2. Center for Medicare and Medicaid Services. National health expenditures Fact Sheet. Accessed online July 20, 2011, at http://www.cms.gov/NationalHealthExpendData/25_NHE_Fact_Sheet.asp#TopOfPage.

3. Center for Medicare and Medicaid Services. National health expenditure projections 2009-2019. Accessed online May 31, 2011, at: http://www.cms.gov/NationalHealthExpendData/25_NHE_Fact_Sheet.asp#TopOfPage.

4. Kaiser Family Foundation. Industry trend charts. Accessed online July 20, 2011, at http://facts.kff.org/results.aspx?view=slides&topic=3&start=1.

5. Flareau, Yale, Bohn, Konschak. Clinical Integration: A Roadmap to Accountable Care. Convurgent Publishing. November, 2011.

6. Medicare Payment Advisory Commission public meeting November 8-9, 2006. p. 384. Transcript available at http://www.medpac.gov/transcripts/1108_1109_medpac.final.pdf.

7. Fisher ES, Staiger DO, Bynum JP, Gottlieb DJ. Accountable care organizations: the extended medical staff. Health Aff (Millwood). 2007;26 (1):w44–w57.

8. Fed. Reg. Vol. 76, No. 67. April 7, 2011. I.(C) Overview and Intent of Medicare Shared Savings Program. p. 19533.

9. Justin LR, Mark SM, Weber RJ. Director’s Forum: The Pharmacy Director and Accountable Care Organizations. Hosp Pharm. 2011; 46:621-25.

10. Daigle L. Pharmacist’s role in accountable care organizations. ASHP Policy Analysis, January 2011.

11. Sound Medication Therapy Management Programs. Academy of Managed Care Pharmacy. http://www.amcp.org/amcp.ark?p=AA8CD7EC. Published October 2008. Accessed October 18, 2011.

12. Chisholm-Burns MA, Lee JK, Spivey CA, et al. US pharmacists’ effect as team members on patient care. Systemic review and meta-analyses. Med Care. 2010; 48:923-33.

13. The Ashville Project: http://www.pharmacist.com/AM/Template.cfm?Section=Asheville_Project; The Diabetes Ten City Challenge: http://www.pharmacist.com/AM/Template.cfm?Section=Diabetes_Ten_City_Challenge. Accessed on 10/12/2011.

14. Edlin M. Without a team of pharmacists, your ACO will be incomplete. Managed Healthcare Executive. October 1, 2011.

15. Skadden, LLP. The potential impact of the new accountable care organization regulations on the pharmaceutical and medical device industries. Accessed at http://www.skadden.com/newletters/accountable_care-organizations.pdf on 10/14/2011.

16. Concato J, Lawler EV, Lew RA, Gaziano JM, Aslan M, Huang GD. Observational Methods in Comparative Effectiveness Research. Am J Med. Dec 2010;123(12 Suppl 1):e16–23.

17. Armstrong EP, Langley PC. Disease management programs. American Journal of Health-System Pharmacy. January 1, 1996. Vol. 53, No.1, 53-58.

18. Skadden, LLP. The potential impact of the new accountable care organization regulations on the pharmaceutical and medical device industries. Accessed at http://www.skadden.com/newletters/accountable_care-organizations.pdf on 10/14/2011.

19. Yap D. HHS issues proposed rule for ACOs. Accessed at: http://www.pharmacist.com/AM/Template.cfm?Section=Home2&CONTENTID=25790&TEMPLATE=/CM/HTMLDisplay.cfm. on 10/14/2011.

20. Integrating pharmacists into accountable care organizations (ACOs) and coordinated care. Accessed at: http://ncpanet.wordpress.com/2010/12/07/integrating-pharmacists-into-accountable-care-organizations-acos-and-coordinated-care/ on 10-13-2011.


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EMAINING RELEVANT IN ACOs AND CINs - Divurgent · 2018-06-12 · are not achieved, provider members may actually be at financial risk depending on the program. Pharmacists, although