ACCOUNTABLE CARE ORGANIZATIONS: AN OPPORTUNITY FOR COMMUNITY PHARMACISTS?

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1 ACCOUNTABLE CARE ORGANIZATIONS: AN OPPORTUNITY FOR COMMUNITY PHARMACISTS? PENNSYLVANIA PHARMACIST ASSOCIATION MID-YEAR CONFERENCE FEBRUARY 20, 2015 Christine M. O Leary, PharmD, BCPS DISCLOSURES Christine M. O Leary: No financial disclosures This presentation is intended for educational use only. Nothing in this presentation should be construed as an endorsement of any particular product or service. Review of specific laws or regulations should not be construed as legal advice. The information interpretation/opinions expressed are solely that of the presenter and no other organization/employer. 1

2 Accountable Care Organization Policies Accountable Care Organization Policies 2

3 PROGRAM OBJECTIVES At the completion of this activity, the participant will be able to: Identify the regulations and structure of an Accountable Care Organization (ACO). State the names of current ACOs in Pennsylvania. Recognize the role of community pharmacies in an ACO. Classify opportunities for a community pharmacy to participate in an ACO. Given a case scenario, determine if the community pharmacy qualifies to participate in an ACO. WHAT IS AN ACCOUNTABLE CARE ORGANIZATION? 3

4 DEFINITION OF AN ACO A collection of providers jointly held accountable for achieving measured quality improvements and reductions in spending for a given population of patients across the care spectrum McClellan et al Health Affairs. 2010;29: WHY THE MOVE TO ACCOUNTABLE CARE? Control health care costs Improve health care quality Improve patient satisfaction Achieving the Triple Aim 4

5 WAIT.THIS SOUNDS FAMILIAR DIFFERENCE BETWEEN AN ACO AND AN HMO Accountable Care Organization Responsible for the clinical outcomes across care continuum Health Maintenance Organization Responsible for payment of clinical services Provider lead Not responsible for payment of claims Focused on primary care/prevention Driven by the health plan Responsible for claim payments Focused on controlling costs Patients can go outside the network without penalty Patients are required to use network providers Accountable Care Organizations 101. APhA ACO ISSUE BRIEF SERIES Beis S. Ohio Society of Health-System Pharmacists

6 ATTRIBUTES OF AN ACO Patient-centered Team-based Primary care core Coordinated care Focused on quality THAT S A PATIENT-CENTERED MEDICAL HOME..RIGHT? PCP Practice PCP: Primary Care Provider Image: 6

7 THE MEDICAL NEIGHBORHOOD ACO PCMH Pharmacy Specialist Hospital/Health System PCMH PCMH: Patient-centered medical home Image: Beis S. Ohio Society of Health-System Pharmacists TRUE OR FALSE? Only organizations certified by the Center for Medicare and Medicaid (CMS) can be ACOs? A. True B. False 7

8 TRUE OR FALSE? Only organizations certified by the Center for Medicare and Medicaid (CMS) can be ACOs? A. True B. False TYPES OF ACOS Pioneer ACO Medicare Share Savings Programs (MSSP) Commercial ACO Medicaid ACO SK&A Market Insight Report Cegedim. 8

9 Pioneer ACO* MSSP Commercial ACO Medicaid ACO Public contract with CMS (length varies) Upside & downside payment model Pre-determined universal quality metrics Patient population: Medicare Beneficiaries (minimum 5,000) *Original # of Pioneer ACOs: 32; currently 19 (Jan2014) Public contract with CMS (3 years) Upside-only or Upside & downside payment model Pre-determined universal quality metrics Patient population: Medicare beneficiaries (minimum 5,000) Private contract with a health plan (1 year; ex: IBX, Aetna, Cigna) Payment model: created by health plan, agreed upon with provider Quality metrics vary from plan-toplan Patient population: plan or provider discretion (5,000-10,000) Public contract with state Medicaid (length varies) Payment model: determined by state Quality metrics vary but attempts being made to align with CMS Patient population: Medicaid beneficiaries (varies) SK&A Market Insight Report Cegedim ACO Financing Models. APhA ACO ISSUE BRIEF SERIES Requirement Public ACO (MSSP) Commercial ACO (Private) Time Commitment 3 years 1 year Board Requirements Yes; physician majority No PCMH/ACO Accreditation No Yes; either CMS, URAC*, or NCQA ± Quality Metrics Yes; 33 determined by HHS Yes; determined through payer and provider negotiations *URAC: Utilization Review Accreditation Commission; ± NCQA: National Committee for Quality Assurance Accountable Care Organizations 101. APhA ACO ISSUE BRIEF SERIES 9

10 WHICH OF THE FOLLOWING STATEMENTS IS TRUE? A. A practice must be a certified Patient-Centered Medical Home to be part of an Accountable Care Organization? B. A community pharmacy must be accredited by a national organization to participate in medication aspects of an accountable care organization? C. An accountable care organization can be created by a health plan contracting with a group of providers. D. An accountable care organization payment contract must either public or private; it cannot be both. CAN THEY DO BOTH? 2013 estimates by Leavitt Partners Accountable Care Organizations 101. APhA ACO ISSUE BRIEF SERIES 10

11 ACO PAYMENT MODELS Full Capitation Partial Capitation Bundled Payment Shared Savings ACO Financing Models. APhA ACO ISSUE BRIEF SERIES SHARED SAVINGS Upside only: model no penalty for losses Upside & downside model : penalty for losses ACO Financing Models. APhA ACO ISSUE BRIEF SERIES 11

12 IT S ABOUT SAVINGS AND QUALITY GOAL OF AN ACO Effective population health management Effective management of cost associated with care Population health management: ACOs are response for the quality outcomes of all patients within their patient population (aka panel of patient, attributable lives ) ACO Financing Models. APhA ACO ISSUE BRIEF SERIES 12

13 QUALITY MEASURES 33 CMS quality measures 4 domains: Patient/Caregiver Experience Care Coordination/Patient Safety Preventative Health At-Risk Populations CMS: Center for Medicare and Medicaid Services Experience; Coordination/Safety 1. Getting timely care, appointments & 2. information 3. Physician communication 4. Physician rating 5. Access to specialists 6. Health promotion & education 7. Shared decision making 8. Health status/functional status 9. Risk Standardized, All Condition Readmissions 10. Admissions: COPD/Asthma in older adults 11. Admissions: CHF 12. Percent of PCPs who qualify for electronic health record program incentive payment 13. Medication reconciliation following discharge 14. Screening for fall risk Preventative Health 14. Influenza immunization 15. Pneumococcal immunization 16. Adult weight screening & follow-up 17. Tobacco use assessment & cessation intervention 18. Depression screening 19. Colorectal cancer screening 20. Mammography screening 21. Hypertension screening At-Risk Populations Diabetes composite (22-26, all or nothing) 22. Hgb A1C 23. LDL 24. BP 25. Tobacco use 26. ASA 27. Diabetes: Hgb A1C control 28. Hypertension: BP control 29. IVD*: Complete lipid panel & LDL in control (LDL < 100) 30. IVD*: ASA or antithrombotic use 31. HF: β-blocker therapy for left LVSD ± CAD composite (32-33, all or nothing) : 32. Drug therapy for lowering LDL 33. ACE/ARB therapy for diabetes or LVSD *Ischemic vascular disease; ±Left ventricular systolic dysfunction Source: 13

14 Experience; Coordination/Safety 1. Getting timely care, appointments & 2. information 3. Physician communication 4. Physician rating 5. Access to specialists 6. Health promotion & education 7. Shared decision making 8. Health status/functional status 9. Risk Standardized, All Condition Readmissions 10. Admissions: COPD/Asthma in older adults 11. Admissions: CHF 12. Percent of PCPs who qualify for electronic health record program incentive payment 13. Medication reconciliation following discharge 14. Screening for fall risk Preventative Health 14. Influenza immunization 15. Pneumococcal immunization 16. Adult weight screening & follow-up 17. Tobacco use assessment & cessation intervention 18. Depression screening 19. Colorectal cancer screening 20. Mammography screening 21. Hypertension screening *Ischemic vascular disease; ±Left ventricular systolic dysfunction At-Risk Populations Diabetes composite (22-26, all or nothing) 22. Hgb A1C 23. LDL 24. BP 25. Tobacco use 26. ASA 27. Diabetes: Hgb A1C control 28. Hypertension: BP control 29. IVD*: Complete lipid panel & LDL in control (LDL < 100) 30. IVD*: ASA or antithrombotic use 31. HF: β-blocker therapy for left LVSD ± CAD composite (32-33, all or nothing) : 32. Drug therapy for lowering LDL 33. ACE/ARB therapy for diabetes or LVSD Experience; Coordination/Safety 1. Getting timely care, appointments & 2. information 3. Physician communication 4. Physician rating 5. Access to specialists 6. Health promotion & education 7. Shared decision making 8. Health status/functional status 9. Risk Standardized, All Condition Readmissions 10. Admissions: COPD/Asthma in older adults 11. Admissions: CHF 12. Percent of PCPs who qualify for electronic health record program incentive payment 13. Medication reconciliation following discharge 14. Screening for fall risk Preventative Health 14. Influenza immunization 15. Pneumococcal immunization 16. Adult weight screening & follow-up 17. Tobacco use assessment & cessation intervention 18. Depression screening 19. Colorectal cancer screening 20. Mammography screening 21. Hypertension screening *Ischemic vascular disease; ±Left ventricular systolic dysfunction At-Risk Populations Diabetes composite (22-26, all or nothing) 22. Hgb A1C 23. LDL 24. BP 25. Tobacco use 26. ASA 27. Diabetes: Hgb A1C control 28. Hypertension: BP control 29. IVD*: Complete lipid panel & LDL in control (LDL < 100) 30. IVD*: ASA or antithrombotic use 31. HF: β-blocker therapy for left LVSD ± CAD composite (32-33, all or nothing) : 32. Drug therapy for lowering LDL 33. ACE/ARB therapy for diabetes or LVSD 14

15 WHAT IS THE ACO ACTIVITY IN PENNSYLVANIA? WHICH OF THE FOLLOWING ORGANIZATIONS IS A COMMERCIAL ACO IN PENNSYLVANIA? A. River Health ACO, LLC B. Wellspan Health C. Keystone ACO D. Delaware Valley ACO 15

16 MSSP ACOs in Pennsylvania ACO Name Areas Covered Website Accountable Care Clinical Services, PC CA, CT, IA, MA, PA Allegiance ACO NJ, PA Atlantic ACO NJ, PA Chautauqua Region Associated Medical Partners, LLC NY, PA Crystal Run Healthcare ACO, LLC NY, PA bout-us/aco.aspx Delaware Valley ACO NJ, PA Greater Baltimore Health Alliance MD, PA Keystone ACO NY, PA Lancaster General Health Community Care Collaborative, LLC PA LHS Health Network, LLC NJ, PA Maryland Accountable Care Organization of Western MD LLC MD, PA, WV River Health ACO,LLC PA Saint Vincent Healthcare Partners THP-Meritus ACO, LLC NY, PA MD, PA, WV Source: Commercial ACOs in Pennsylvania* ACO Name Partner Location in PA Humana s Accountable Care Hospital/Physician s of Continuum St. Lukes University Health Network Allentown, Bethlehem Penn Medicine Independence Blue Cross Philadelphia Renaissance Health Network Keystone Health Plan East Independence Blue Cross Wayne Wellspan Health Aetna York *List not all inclusive 16

17 CAN COMMUNITY PHARMACIES GET A STAKE IN ACOS? ABSOLUTELY! But we need to know the Value Proposition AND how to communicate it 17

18 KEY CONSIDERATIONS Drivers of an ACO s medication management approach Objective data to support inclusion of community pharmacies in ACOs Strategic communication ALL OF THE FOLLOWING ARE GENERALLY RECOGNIZED AS DRIVERS OF AN ACOS MEDICATION MANAGEMENT APPROACH, EXCEPT: A. Type of ACO B. Maturity of the ACOs development C. Primary focus of the ACO D. Pharmacist : Physician staff ratio 18

19 KEY CONSIDERATIONS Drivers of an ACO s medication management approach Type of ACO Maturity Primary focus Objective data to support inclusion of community pharmacies in ACOs Strategic communication Who to talk to What to say How to say it KEY CONSIDERATIONS Drivers of an ACO s medication management approach Type of ACO Maturity Primary focus Objective data to support inclusion of community pharmacies in ACOs Strategic communication Who to talk to What to say How to say it 19

20 DRIVERS OF AN ACO S MEDICATION MANAGEMENT APPROACH Type of ACO Medication costs in the risk-bearing contracts? Medication-related quality measures? Maturity Newly formed? Established? Hiring pharmacists vs contracting Primary focus Readmissions Care Transitions Chronic Disease Management ACO Financing Models. APhA ACO ISSUE BRIEF SERIES OBJECTIVE DATA TO SUPPORT INCLUSION OF COMMUNITY PHARMACIES IN ACOS Barnett et al, 2009: Analysis of MTM in Community Pharmacies Multistate MTM services in community pharmacies January 1, 2000, through December 31, 2006 Estimated cost savings = $7.1 million Barnett et al. J Manag Care Pharm Jan-Feb;15(1): Amara et al. Hosp Pharm.2014; 49 (3):

21 OBJECTIVE DATA TO SUPPORT INCLUSION OF COMMUNITY PHARMACIES IN ACOS Trinity Pioneer ACO Launched August 2013 Collaboration: Iowa Pharmacy Association, Iowa Health System, Community Pharmacy Foundation, McKesson, NACDS Foundation Partnerships: Outcomes MTM, Collaborative Education Institute OBJECTIVE DATA TO SUPPORT INCLUSION OF COMMUNITY PHARMACIES IN ACOS Trinity Pioneer ACO Pharmacy Structure Trinity Pharmacists Identify High Risk Patients Iowa Health Pharmacists Triage High Risk Patients MTM Community Pharmacist Providers MTM, Med rec, monitor start of high-risk med, document in Outcomes MTM platform 21

22 OBJECTIVE DATA TO SUPPORT INCLUSION OF COMMUNITY PHARMACIES IN ACOS Trinity Pioneer ACO Preliminary Results October 2013 thru June 2014 Total patients served: 349 Total MTM claims: 850 Average 2.4 claims per patient OBJECTIVE DATA TO SUPPORT INCLUSION OF COMMUNITY PHARMACIES IN ACOS Wisconsin Pharmacy Quality Collaborative Principle: Pharmacy Society of Wisconsin Funding: $4.1 million CMS Health Care Innovation Award 3 year grant (July 1, 2012 to June 30, 2015) Goal: reduce health care costs ~ $20 million Aspects: Pharmacies must be accredited Registration, implement standard practices, sign Good Faith Agreement, have at least one WPQCcertified pharmacist onsite, assessments Q6mos 22

23 OBJECTIVE DATA TO SUPPORT INCLUSION OF COMMUNITY PHARMACIES IN ACOS WPQC Pharmacy Involvement Pharmacies: 338 registered and 317 accredited Pharmacists: 1420 registered and 1215 certified Students: 257 registered and 204 certified WPQC Financial Impact: Pilot program results $5-10 : $1 ROI (Level I services) $2.5-5 : $1 ROI (Level I & Level II services) Current results $5-6 : $1 ROI (Level I & Level II services) OBJECTIVE DATA TO SUPPORT INCLUSION OF COMMUNITY PHARMACIES IN ACOS Independent Pharmacy & Population Health Management (PHM) Pharmacists Caring for Diabetics: a pilot program in Missouri Announced 2013 Collaboration: National Community Pharmacy Association, American Health Care Background: PMH model based on Ashville Project Financial forecasts based on Hickory Project; ROI $8.43 : $1 23

24 STRATEGIC COMMUNICATION Who to Talk to Depends on ACO structure ACOs: Highlights and Considerations for Pharmacists. APHA ISSUE BRIEF SERIES. STRATEGIC COMMUNICATION Sample ACO Structure: MSSP (multi-health system) 24

25 STRATEGIC COMMUNICATION Who to Talk to Leadership Physician-led ACOs Hospital-led Point of Contact Chief medical officer or chief operating office Chief medical officer or chief operating office Insurer-led Chief contracting office or provider relations director ACOs: Highlights and Considerations for Pharmacists. APHA ISSUE BRIEF SERIES. STRATEGIC COMMUNICATION What to say and How to say it Strategic communication mad lib Health Policy 101. AcademyHealth

26 STRATEGIC COMMUNICATION What to say and How to say it Strategic communication mad lib I want to talk to you about It s important because Let me give you an example That s why I am asking Health Policy 101. AcademyHealth PRACTICE CASE STUDY Mr. John Q. Pharmacist is the manager of Neighborhood Pharmacy USA; an independent pharmacy in a rural area of Pennsylvania. Mr. Pharmacist recently learned that the local health system has become a public/private ACO (contracted with the Medicare Shared Savings Program and Independence Blue Cross). Neighborhood Pharmacy USA has offered Medication Therapy Management successfully for several years. Mr. Pharmacist would like to approach the newly formed ACO to market his MTM services. 26

27 FINAL THOUGHTS ACOs policies and structure evolving Early pharmacy advocacy is critical APhA comments to CMS: March 2014 better integration of the Part D prescription benefit, especially MTM, into ACOs is necessary to achieve the goal of improved outcomes and efficiency Collaboration/Partnerships will be key: PPA, NACDS, NCPA, ASHP, Schools of Pharmacy, Legal, IT APhA Response to CMS Request for Information HELPFUL RESOURCES American Pharmacist Association ACO Issue Briefs Series MTM Central Center for Medicare & Medicaid Services Payment/sharedsavingsprogram/index.html?redirect=/share dsavingsprogram/ Institute for Healthcare Improvement Health Affairs 27

28 QUESTIONS? PLEASE PENNSYLVANIA PHARMACIST ASSOCIATION MID-YEAR CONFERENCE FEBRUARY 20, 2015 Christine M. O Leary, PharmD, BCPS REFERENCES 1. McClellan M, McKethan AN, Lewis JL, Roski J, Fisher ES. A national strategy to put accountable care into practice. Health Affairs May;29(5): IHI Triple Aim Initiative. The Institute for Healthcare Improvement. Available at: Accessed on January 17, Beis S. Accountable Care Organizations: Opportunities for Pharmacist. Proceedings of Ohio Society of Health-System Pharmacists Annual Meeting. April 10, Top 30 Accountable Care Organizations. SK&A Market Insight Report Cegedim Relationship Management. 5. Accountable Care Organizations 101. APhA ACO ISSUE BRIEF SERIES. American Pharmacist Association. Available at: Accessed on January 17, ACO Finance Models. APhA ACO ISSUE BRIEF SERIES. American Pharmacist Association. Available at: Accessed on January 17, Medicare Shared Savings Program. Center for Medicare & Medicaid Services. Available at: Payment/sharedsavingsprogram/index.html. Accessed on January 17, Accountable Care Organizations in Pennsylvania. Independent Pharmacy Alliance. Available at: Accessed on January 24,

29 REFERENCES 9. Barnett MJ, Frank J, Wehring H, et al. Analysis of pharmacist-provided medication therapy management (MTM) services in community pharmacies over 7 years. J Manag Care Pharm Jan-Feb;15(1): Amara S, Adamson R, Lew I, Slonim A. Accountable Care Organizations: Impact on Pharmacy. Hosp Pharm 2014; 49 (3): Trinity Pioneer ACO MTM Program. Iowa Pharmacy Association. Available at: Accessed on January 31, Wisconsin Pharmacy Quality Collaborative. Pharmacy Society of Wisconsin. Available at: Accessed on January 31, Pharmacist Caring for Diabetics: a pilot program in Missouri. National Community Pharmacy Association. Available at: Accessed January 31, ACOs: Highlights and Considerations for Pharmacists. APHA ISSUE BRIEF SERIES. American Pharmacist Association. Available at: Access on January 24, Strategic Communications Workshop. AcademyHealth. Health Policy 101 Annual Meeting. October Washington, DC. 16. Response to CMMI Request for Information. American Pharmacist Association. Submitted: March 1, Available at: Accessed on: January 24,