Technician Learning Objectives 3/25/2014. Pharmacy Practice Changes in ACA Accountable Care Organizations

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1 Pharmacy Practice Changes in ACA Accountable Care Organizations Avani S. Desai, PharmD & Emory S. Martin PharmD Sunday, April 12, :05 10:05 am Pharmacist Learning Objectives At the conclusion of this roundtable discussion: 1. The pharmacist attendee will be able to describe the funding changes in an ACA ACO that impact the pharmacist s potential role. 2. The pharmacist attendee will be able to describe the typical ACA ACO patient and how their care may change based on the 33 ACO quality goals. 3. The pharmacist attendee will be able to list pharmacist functions that may develop with an ACO as modeled by the VA System 2 Technician Learning Objectives At the conclusion of this roundtable discussion: 1. The pharmacy technician attendee will be able to describe the funding changes in an ACO that impact the potential role of pharmacy in patient care. 2. The pharmacy technician attendee will be able to describe the typical ACO patient. 3. The pharmacy technician attendee will describe programs aimed at quality found in the VA System 3 1

2 ACO 101 Currently over 500 recognized ACOs in the US Dozensof ACOs in Texas Memorial Hermann ACO (Houston, TX) Methodist Patient Centered ACO (Dallas, TX) Seton Health Alliance (Austin, TX) Rio Grande Valley Health Alliance (McAllen, TX) Patient Definition Medicare beneficiaries May include homeless or uninsured 4 ACO 101 ACO: Group of providers and suppliers of services (e.g., hospitals, physicians, and others involved in patient care) that will work together to coordinate care for the Medicare Fee- For-Service patients they serve. Patient-centered Evidence-based medicine Patient & provider partnership Reports on quality and cost Goal: To deliver seamless, high-quality care for Medicare beneficiaries Accountable Care Organization 2013 Program Analysis. Quality Performance Standards Narrative Measure Specifications 5 ACO Shared Savings Requirements Must meet 33 clinical quality indicators -AND- Must meet a Minimum Savings Rate (MSR) 6 2

3 Two Models For Savings One-sided Model : shared savings, but not losses, for entire term of 1 st agreement Share up to 50% savings Two-sided Model : shared savings and losses for entire term of the agreement Share up to 60% savings ACOs meeting or exceeding Minimum Loss Rate will share in all losses, up to a loss sharing limit Accountable Care Organization 2013 Program Analysis. Quality Performance Standards Narrative Measure Specifications 7 ACO Savings Detail Financing in the ACO Only health care providers who bill Medicare directly for Part A hospital and Part B physician-office services can participate directly in ACOs and share savings Part D outpatient drug costs are not computed when the CMS totals ACO savings to Medicare. BarlasS. Pharmacists Want a More Explicit Role in ACOs P T. Oct 2011; 36(10): Accountable Care Organization 2013 Program Analysis. Quality Performance Standards Narrative Measure Specifications 8 Scoring 33 Quality Measures For pay for performance measures, the minimum attainment level will be set at the national 30th percentile of the performance benchmark. Performance at or above the 90thpercentile of the performance benchmark will earn the maximum points available for the measure. BarlasS. Pharmacists Want a More Explicit Role in ACOs P T. Oct 2011; 36(10): Accountable Care Organization 2013 Program Analysis. Quality Performance Standards Narrative Measure Specifications 9 3

4 Focus within the Quality Measures Emphasis on effective outpatient management of chronic diseases to reduce admissions Emphasis on effective transitional care management to reduce readmissions 10 improvement in communication with patients; patient education; coordination of care after discharge. high quality outpatient care and adherence to care high quality outpatient care and variation in management Accountable Care Organization 2013 Program Analysis. Quality Performance Standards Narrative Measure Specifications 11 seen within 30 days following discharge in the office by the physician providing on-going care. The clinician is aware of the inpatient facility discharge medications and will either keep..or change the inpatient facility discharge medications. Includes brief counseling (3 mins or less), and/or pharmacotherapy Diabetes patients with most recent hemoglobin A1c < 8.0 percent and LDL-C <100 mg/dl 12 4

5 Percentage of patients ages 18 to 75 years of age with a diagnosis of diabetes who indicated they were tobacco non-users Patients whose most recent blood pressure < 140/90 mmhg Patients with most recent LDL-C < 100 mg/dl Patients who have a LDL-C 100 mg/dl OR patients who have a LDL-C result 100 mg/dl and have a documented plan of care to achieve LDL-C 100 mg/dl, including, at a minimum the prescription of a statin 13 ACO Cost Reductions Existing effective care model + 33 clinical quality indicator savings + Other voluntary initiatives = Minimum Savings Rate (MSR) 14 Barriers to Pharmacists in ACA ACO s Inadequate reimbursement for clinic-basedpharmacist services aimed at reducing admissions. Pharmacist is not a PROVIDER No. of pharmacists trained or with experience in medication and outpatient management Physician acceptance of pharmacist's role Inadequate reimbursement for new inpatient-based pharmacist services aimed at reducing readmissions. DRG payment only Difficult to preferentially target ACO patients Pharmacists not included as independent providers for post-discharge transitional care management services (TCM services) under two new CPT codes, and

6 16 Many ACO s have overlooked the role of pharmacists, but they could benefit from chronic disease medication management and better coordination of prescriptions as patients move from home to hospital to nursing home November 2013 The current exclusion of pharmacists from teams may be a result of payment policies that fail to directly pay pharmacists to manage medication. It may also be complacence. 17 From the Literature: Pharmacists in ACA ACO Functions The literature in 2011 reveals lots of excitement about the potential of expanded practice in an ACP Since then, formally published experience is small 18 6

7 From the NEWS: Pharmacists in ACA ACO s? CAUTION: Many articles discussing pharmacist roles in an ACO are notfrom an ACA ACO but rather potential roles drawn from public and private managed care groups or- academic medical centers. The following examples showcase pharmacist-based programs that have been implemented within the respective health care settings, any of which may become ACO s in the future. Copyright 2011, Academy of Managed Care Pharmacy. 19 From the NEWS: Pharmacists in ACA ACO s? CAUTION Much of the ACO news is breaking news. NOT accessed 3/19/ ASHP UNC Internal Medicine TCM Clinic On arrival, a nurse checks in the patient and assesses vital signs. The pharmacist spends ~30 min for in-depth medication reconciliation and other procedures incident to a physician s care. The physician provides the physical exam. The physician and pharmacist develop a plan. The pharmacist does the wrap-up. Transitional Care Management CPT codes 99495/6 billed by the practice. $163/$

8 Each practice will need to determine the best way for them to organize staff and clinician roles within the practice to accomplish the recommended changes... For example, medication reconciliation might be performed by the physician or by a pharmacist depending on the staff composition of the practice. Patient teaching and enhancing patient self-management skills may be done by a nurse, health educator, medical assistant, and/or a lay volunteer. IHI HowtoGuideImprovingTransitionsHospitaltoOfficePracticeReduceRehospitalizations.aspx Accessed March 18, Healthcare Partners, CA HealthCare Partners is currently conducting two pilots with 13 clinic-based pharmacists One is a telephonic reconciliation program for high-risk patients after discharge to minimize readmissions attributed to inappropriate use of medications. 30% of medications reviewed had issues The other identifies patients who are not achieving therapy goals, such as appropriate HbA1c levels, and then initiates and titrates medical therapy based on physicianapproved protocols. 23 Desert Oasis Healthcare Implemented a collaborative practice protocol using pharmacists to bridge the quality Over 24 months ( ) 387 patients with initial HbA1c > 9% were seen in the program Mean initial HbA1c 11.05%; HgA1c at 180 days 8.08% Poorly controlled seniors reduced from 21% to <12% Reduction in bed day utilization realized Patient Satisfaction: 100% Hodgkins B and PerlickT. Carpooling with Pharmacy October 10, Accessed 3/12/

9 Comprehensive Medication Desert Oasis Healthcare Hodgkins B and PerlickT. Carpooling with Pharmacy October 10, /wwwroot/userfiles/documents/25 6/brian-hodgkins-and-tim-perlickit-takes-a-village.pdf Accessed 3/12/ Baby Steps Initiate a pharmacist-coordinated HF discharge program. Institute a bedside discharge medication delivery service. Set-aside time within existing Pharmacist Clinic for ACO patient referrals Pharmacist Diabetes Clinic & Pharmacist Lipid Clinic Pilot a new Pharmacist Adherence Clinic for ACO patient referrals Facilitate referrals from target physician group 26 The VA as a Model for ACO Similarities/Differences Similarities: operates as an integrated national health network, coordinates care, tracks outcomes, bundled payment based upon performance Differences: does not bill to CMS or any other Federal program Pharmacist roles within the VA Prescriptive authority in PACT medical home Management of outpatient chronic diseases: DM, HTN, HLD, COPD, HIV, HF Medication reconciliation at admission, transfer, and discharge Discharge counseling for high-risk medications 27 9

10 VA Programs for ACA ACO s to Consider There are VA programs with goals similar to the 33 clinical quality indicators for ACA ACO s There are other VA initiatives aimed at improving quality and reduced overall cost of care 28 Clinical Pharmacy Program Office (CPPO) The CPPO develops advanced roles of the clinical pharmacist to better manage disease states VA Pharmacist Scope of Practice Over 2600 pharmacists with a scope of practice (39%) 73% of these pharmacists have post-graduate residencies, board certifications, or other certifications 69% spend over 50% of their week in activities related to their scope of practice 29 VA Transition of Care Program Medication Reconciliation Across Sites Standardized process for pharmacists to hold, edit or discontinue prescriptions at other VA sites New process to ensure medication reconciliation of patient s medications to include clinical pharmacists at both ends 30 10

11 Reducing Readmissions at Houston VA Medical Center Clinical pharmacists on floor coordinate with outpatient staff pharmacists Bedside medication education for high risk therapy (anticoagulation, insulin, etc) and CHF patients by pharmacist Bedside medication delivery by technician 31 VA Pharmacists in the Clinic 32 VA Pharmacists White C. Pharm Prac News FEBRUARY 2014 VOLUME:

12 Pharmacists with a Scope of Practice 34 Documenting Success Enhanced Metrics to measure Clinical Pharmacy Activities Over 3.5M clinical pharmacy encounters in FY12 Pharmacists practicing at the top of their license performing comprehensive medication management services Pharmacists Achieve Results with Medications Demonstration (PhARMD) Project Development of a clinical reminder tool to standardize documentation of clinical pharmacy interventions across the system Use by over 30 VA sites during pilots 35 Patient-Centered Medication Information Management: 2013 Programs Virtual Medication Use Crisis Conference* (Qtrly 4 Hr Series) Tracks include Partnering with Patient/Caregiver, Medication Information Management, Optimizing Resources, and Leveraging Teams and Transitions External Peer Review Process (EPRP) Pilot Collecting National Medication Reconciliation metrics that align with VA Medication Reconciliation Directive Monthly Meetings and Projects Shared Strong practice sharing documentation, education, monitoring, policy, and change management to help meet NPSG Active SharePoint site, educational posters, pamphlets, videos, presentations 36 12

13 More Programs for 2013 Cross-Program Office Projects: VA National Alliance for Patient Medication Information Standardization* Emergency Department/Urgent Care Center Medication Information Taskforce InterprofessionalMedication Information Management Education Module* May is Medication Reconciliation Awareness Month! Joint efforts with Department of Defense (DoD), TriCare, and Indian Health Service

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