Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid

Value-Based Care News

How Medication Therapy Management Helps ACOs Manage Costs

By Ryan Mcaskill

NPC has started a case study series that examined how pharmacists can impact ACOs, cost and quality of care.

- There are a number of different ways that organizations can try and reduce costs through the use of the Accountable Care Organization platform. This happens through the use of coordinated care and adding importance to every aspect a patients experience. One area that is pushing for an increased role is pharmacists.

According to the National Pharmaceutical Council (NPC), the use of comprehensive medication therapy management (MTM) can help lower operational costs and improve patient health. In order to prove that, the organization is releasing a series of case studies over the next several months from some of the top ACOs in the country that not only explain how the systems work but also offers tools that other organization can use to implement the strategy within their own systems. The first one, which was released in December, focuses on Fairview Pharmacy Services.

In a recent interview with RevCycleIntelligence.Com,  Robert Dubois, MD, PhD and NPC Executive Vice President and Chief Science Officer, and Amanda Brummel, PharmD, BCACP, Director of Clinical Ambulatory Pharmacy Services at Fairview Pharmacy Services, spoke about the case studies and the role that pharmacies need to play.

According to Dubois, NPC works on behalf of the pharmaceutical industry and one of the areas of focus is the changing reimbursement world. The landscape is changing, moving away from the fee-for-service approach where drugs are on someone elses budget to a more holistic approach with built-in quality benchmarks. Drug costs are no longer separate from other expenditures like hospital and imagining costs. This is because the total episode of care in an ACO world is what’s important and not just managing the cost of care. Hospitals are not going to get any of those savings if they don’t hit those quality benchmarks.

“It’s a much more yin and yang holistic view and we got involved a couple of years ago because we knew that drugs were going to be very important to the success of organizations in this new world, both in terms of the expenditures as well as meeting those quality benchmarks,” Dubois said.

READ MORE: NAACOS: Mandatory Bundled Payments Impede ACO Financial Success

This started lengthy discussions about the role that drugs and pharmacists play in the within an ACO and the thought process around them. NPC spearheaded a working group three years ago made up of major organizations in the space. That included pharmaceuticals (NPC), medical clinics (American Medical Group Association), hospitals and other institutions (Premier and others) and ACOs (Fairview and several others).

This group started to not only discuss the role that medication management plays in the current landscape and determined that it is a focal point that needed to be addressed, but also laid out “a 60,000 foot framework for the interplay between medications and everything else.” This came in the form of an article for the American Journal of Managed Care.

“It was a way of thinking that drugs were not just a cost,” Dubois said. “They are a cost offset opportunity with some conditions and they are also a mediator of quality achievement  for some of the areas where those quality benchmarks are there. So that was part one, framing the dialog.”

Part two consisted of seeing is ACOs were actually taking this advice and managing medication optimally. However, there are a number of concerns within an ACO, which include having the right EHR system, contracting structure, proper payments for doctors, best way to identify patients and using proper risk adjustment techniques, that medication management can get lost in the shuffle.

The work group created 15 characteristics of what “a high flying organization” should be able to do to manage medication properly. These included using a comprehensive medication therapy management strategy, merging all relative data sources and having pharmacists engage more deeply into the quality of care. The group examined 46 different ACOs on the criteria and found that a large majority of them fell short of the basics for optimal medication management.

“Then were were all sort of depressed and looking around saying ‘gosh, no one is able to handle this right, that isn’t a great article to write. Are their any beacons on the hill of groups that are actually doing this and solving some of these issues?’” Dubois said. “So we went back to our internal group and said ‘you guys are six of the leading ACOs, how are you handling some of these issues?’ Lo and behold it turned out that among the different six, they each had a different story to tell.”

Many of these ACOs were doing things differently. This included the use of data, managing specialty drugs or centralizing medication refill services so doctors did not have to spend a half hour every day to handle this process remotely or at the point of care.

When deciding which of these stories would be the first in the series of case studies, Fairview was chosen because “Amanda put her hand up first,” Dubois joked. In reality, Fairview had also implemented these systems for some time and had more hard data to back it up than others.

“We had years of experience and because we ourselves had been looking from a primary care standpoint and changing our care model a lot of the innovation work we had actually started before we became a pioneer ACO, so that was a big part of it,” Brummel said.

According to Dubois, the other benefit to the Fairview story and having the data available, is that it makes for a more compelling read for an organization that are looking to follow the same path.

“The other piece of the puzzle was that the problem with case studies are people read them and they say ‘oh that’s great but that’s Wisconsin, I’m in New Jersey, and there are a whole lot of things that are different here or that’s a tightly integrated, long standing group practice, I could never replicate that,’” Dubois said. “So we said, to be helpful we need to give people a glimpse of how they might take a program done in Wisconsin with some peculiarities of that and take it to other locations which are designed and configured differently. So we wanted to have a broader set of lessons that just what was working at one organization.”

Each of these case studies comes with actual tools, templates and training programs that a reader can take and use in their own organization.

This is part one of this interview. Click here for part two.


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