The Emerging Role ofPharmacy in the ACO

Jamie Hale

Chief Pharmacy Officer

Cornerstone Health Care, PA

November 6, 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

Cornerstone Health Care 2013

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

Accountable Care Organizations

4

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."

Health Affairs Blog- D. Muhlestein 021913- accessed April 14 2013http://healthaffairs.org/blog/2013/02/19/continued-growth-of-public-and-private-accountable-care-organizations/

Prevalence of ACO ActivityFeb. 2013

5

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

North Carolina

Archdale Asheboro Advance Claremont Conover Elkin Granite Falls Greensboro Hickory High Point

Jamestown

Jonesville Kernersville Lexington Reidsville Summerfiel

d Taylorsville Thomasville Trinity Winston

Salem 

©Cornerstone Health Care 2013

Current Healthcare System

Primary Care

Radiology

Urology

Pharmacist

Surgery

ENT

Pathology

Social Work

Radiation Oncology

Medical Oncology

Pulmonology

Support Groups

Chaplain

Dietician

Research

Patient

Negative Impact of Fee for Service

• Inability to navigate the system

• Poor health outcomes• Reduced satisfaction and

engagement

Patients

• Increasing costs= higher premiums and payment cuts

• Declining member satisfaction and increased attrition

Payers

• Declining FFS payment rates

• Inability to fund coordinated, evidence-based care models

Physicians

• Increasing costs for poorer benefits

• Disappearing employer coverage

Beneficiaries

• Higher premiums• Decreased

willingness/ability to provide high quality benefits to employees

Employers

• Declining health status• Greater portion of

investment to health careSociety

An Unsustainable Future

2010 2012 2014 2016 2018 2020 2022 2024 2026$1.0

$2.0

$3.0

$4.0

$5.0

$6.0

$7.0

$8.0

Expected future trend (6.5% growth)

Sustainable trend (affordability followed by 4.5% growth)

Ind

ustr

y s

pen

d (

$T)

$2.6T (18% of GDP)

Time

Waste reduction

A period of growth below GDP growth will be necessary to reach

affordability (30% reduction in costs as a percent of GDP)

Trend reduction

After affordability is achieved, long-term growth must be at the

same level of GDP growth to ensure sustainability

$4.3T(21% of GDP)

$2.8T(14% of GDP)

$7.1T(24% of GDP)

$4.0T(14% of GDP)

Sources: National Health Expenditure data, Bureau of Economic Analysis, Oliver Wyman analysis

The funding gap is widening, creating a need for rapid transformation in the market

“Learning and innovation go hand in hand. The arrogance of success is to think that what you did yesterday will be sufficient for tomorrow.”

William Pollard.

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

A BRAVE NEW WORLD

Vanderbilt University Hospital—2013 Presentation-Group Practice Improvement Network, Asheville, NC

Volume

Fee for service model

Patients “discharged”

Disease Management focus

Addressing Sickness

Measuring Mortality/Harm

Value

Value based care model

Patients “transitioned”

Care Coordination and navigation

Addressing Health

Measuring Risk of Harm

14

Payment Models in Value World

MSSP

MA / CommercialGain Share

Full RiskPMPM

Pay for Performance – Quality Driven

What does it mean for the patient?

Clinical Psycholog

y

Radiology

Urology

Pharmacist

Surgery

ENT

Pathology

Social Work

Radiation

Oncology

Medical Oncolog

y

Support

Groups

Chaplain

Dietician

Research

Patient

Navigators

Pulmonology

Moving Towards Value Based Care The aim is improve health outcomes, and to do so with increased efficiency.

Reduced cost of healthcare

Patient experience of care

Improved

population

health

Physician and patient experience

Improved, Triple Aim

More practice resources and

support to improve quality of care

Improvements in patient satisfaction through tailored support services

Remove redundancy and reduce

preventable utilization while achieving better

outcomes

Key Focus Areas to Transform Health Care

18

“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

19

The Facts

4 out of 5 Patients leave with at least one prescription 1

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 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)

• 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)

Medicare Beneficiaries

200+ Biiiiillion Dollars

• $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

2 Institute of Safe Medicine Practice Medication Safety Alert Newsletter: Community/Ambulatory Care Edition Volume 9, Issue 6: June 2010

The Cost of Poor Quality

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 system and referral based

•Rx Intelligence

• Drug Information

• Utilization• Evidence Based

Protocols

• Learning• Provider

Education• CME Support

• Logistics - Resource Management• Spend

Optimization• Vendor

Consolidation• 3rd Party

Contract Review

Pharmacy Care Clinic Services

Practice / Provider Support (PILLS)

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

Infusion Centers

Generic Utilization

• Tied outcome initiatives

• Gain in $PMPM• Generic

Sampling

Specialty Pharmacy

• IV and Oral

POC Dispensing

Community Relationships

• Drive continuity

Employee Pharmacy

Medication Dispensing

Cornerstone Pharmacy and Resource ManagementQuality

Patient Experience

Cost Savings

Strategic

Growth

Comprehensive Medication Management

A Journey to Value

Strategic Vision

• The PCPCC Guide Defines comprehensive medication management in the patient centered medical home and ACO clinical settings

• Included in AHRQ Innovation Center- Quality 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

The PCPCC Defines Comprehensive Medication Management (CMM)

1) Identify patients 2)

Understand patient

perspective

3) Identify use patterns

4) Assess medications

5) Identify drug therapy

problems6) Develop a

care plan

7) Patient Agreement

8) Document steps

9) Evaluations

10) Reiterative

process

10 Steps to Achieve Comprehensive

Medication Management

Clinic outpatient visit avoided Specialty office visit avoided Hospital admissions avoided Laboratory service avoided Urgent care visit avoided Home Health Care Visits

AvoidedLong term care admission

avoidedEmergency department visit

avoided Employee Work days saved

Drug CostPharmacists utilized the Assurance IT electronic therapeutic record system and training through Medication Management System, Inc.- www.medsmanagement.com

Estimated Health Care Cost

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

Business Case: Fee for Value

• 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

Positive “Side Effects”

High Tech and High Touch

Outreach Capabilities

30

Right Patients at the Right Time

Patient-centered population managers unlock significant value in today’s upside down pyramid

Data to Information

Actionable Intelligence

Clinical Outcomes

Pharmacy

Medical

Claims

• 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

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

(<140/90), and Aspirin use

• Ischemic Vascular Disease -- LDL control (<100), use of Aspirin or another anti-thrombotic

• Coronary Artery Disease (CAD)-- Drug therapy for LDL 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-Service-Payment/sharedsavingsprogram/D ownloads/ACO_QualityMeasures.pdf

34

Community Partnerships

Build, buy, or partner

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

35

How do you get your foot in the door?

36

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

37

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

38

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

“…working with

clinical pharmacists

can enhance patient

care by promoting

the appropriate

selection and use of

medications to

optimize

therapeutic

outcomes”

Edgar Maldonado MD Extensivist,

Personalized Life Care Clinic

drug interactions,

adverse effects, med

adherence and prescribing of

drugs inconsiderate

of patient physiology

Patient safety

and experienc

e

Aging population, increasing

patient complexity, reporting

requirements and demand for physician

time

A Thousand Words

Over 30 medications down to 12

43

Listen to the full webinar at

http://bit.ly/pharmacyACO