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Prescription: Washington

Pharmacists Want to Become Part of Accountable Care Groups

Medicare to Define Which Professionals Can Join in 2012
Stephen Barlas

Regardless of what happens if and when the health care reform’s individual mandate to buy health insurance finally ends up in the Supreme Court, and regardless of any changes Congress makes in the Patient Protection and Affordable Care Act (PPACA), some of its non-controversial provisions will be implemented.

This is particularly true of the few provisions in the bill that are ostensibly devoted to cost containment. The Centers for Medicare and Medicaid Services (CMS) is fleshing out one of those elements. That PPACA provision requires Medicare to undertake a pilot program to determine the best form for Accountable Care Organizations (ACOs), giant community health care organizations centered on primary care physicians—who, instead of being employed by hospitals, will actually either run or own the hospitals. Their money will be at risk, but they will share in any cost savings. ACOs are seen as cost-saving ventures that integrate care for chronic disease and meet quality guidelines. ACOs have become a hot topic in the wake of passage of the PPACA, and they could well become the health care organization of the future.

Which health care professionals will be invited into the party is what the CMS is now trying to establish—hence the fervent pleas from all sorts of pharmacy groups begging for an invitation to this first round of pilot programs, which are scheduled to begin in 2012.

The main issue for pharmacy groups is the extent to which ACOs will be required to provide medication therapy management (MTM) services. These services were a concern for pharmacy groups during the congressional debate on the PPACA. An effort was made to get the final law to allow Medicare to expand payment for MTM services within the fee-for-service system. Reimbursement for MTM services is currently restricted, and the PPACA did contain some provisions that might or might not ameliorate that situation.

But ACOs are a whole new animal that could grow to monster proportions, outside the fee-for-service concept or even outside Medicare’s managed care concept. Therefore, what the CMS says about MTM services within ACOs is of the utmost importance. The fact that ACOs are one of the only provisions in the PPACA that address cost savings gives pharmacy groups a leg to stand on, in terms of being included in MTM services, which do save money.

Brian A. Gallagher, RPh, JD, Senior Vice President of Government Affairs for the American Pharmacists Association (APhA), says that MTM programs that are part of The Asheville Project and Diabetes Ten City Challenge have demonstrated the potential to save $1,079 per patient ($23 billion per year) for diabetes alone. The Asheville Project showed that MTM interventions, if applied nationwide to the appropriate management of cardiovascular disease, could save $5 billion per year, whereas MTM services could save $1.6 billion for patients with asthma.

Mr. Gallagher says, “Given the successes of these care models, we encourage CMS to consider the opportunities for these programs to serve as templates for programs that could be replicated and scaled in ACOs.”

Pharmacists might not be mentioned in the ACO provision of the PPACA, but they are definitely playing a role in the few ACOs in the U.S. that are already up and running. The most prominent examples appear to be the three sites participating in the Dartmouth/Brookings Institute ACO Collaborative: the Carillion Clinic in Virginia, the Norton Health-care System in Kentucky, and the Tucson Medical Center in Arizona.

Steven Heilman, MD, Chief Medical Information Officer at Norton in Louisville, says that his ACO has run one pilot program aimed at cutting readmission rates for congestive heart failure (CHF). By the way, the PPACA also allows Medicare to pay bonuses to hospitals that reduce readmission rates. This is a separate provision, apart from the ACO pilots. In any case, the Norton ACO, which comprises Norton and Humana employees who are treated by Norton physicians, sends hospital pharmacists to the bedsides of patients admitted for CHF.

Paul Allen, PharmD, Associate Vice President of Pharmacy Services at Norton, explains that the pharmacist arrives at the patient’s bedside after the nurse finishes the workup. The pharmacist then looks for omissions or mistakes that the patient might have made (e.g., forgetting the name of a medication or stating a wrong dose) when talking to the nurse. The pharmacist also looks at the dosage of any angiotensin-converting enzyme (ACE) inhibitor the patient is taking. If the maximum dose has not been prescribed, the pharmacist can suggest an increase to the physician. The pharmacist is involved with each patient from admission to discharge. At that point, the pharmacist can offer counseling to the patient.

Dr. Heilman says that pharmacist involvement in the CHF pilot program resulted in Norton’s finding of 1.5 medication discrepancies per patient. He calls that a “soft return” in a financial sense, because it is difficult to link a reduction in medication discrepancies to a decrease in readmissions. That being said, Norton’s ACO pilot program for CHF demonstrates that pharmacists can play a positive role in reducing health care costs and improving quality of care. That is a hard fact.