The shift from a fee-for-service to a fee-for-value model in pharmacy means an increased emphasis on clinical outcomes.
Do you have a dream that one day the US health care system will work as a patient-centered, highly sophisticated, coordinated system, based on optimal resource utilization? A system capable of achieving the best possible clinical outcomes and the highest level of patient and provider experience at the lowest possible cost?
This dream is quickly becoming a reality as progressive organizations rally behind health care reform to create a transformational shift of economic value in the health care industry. Organizations making this shift to a value-driven foundation will lead the way in establishing the new rules of patient engagement as the traditional fee-for-service, volume-based delivery model falls by the wayside.
True Patient Accountability
The accountable care organization (ACO) has quickly become a leading model of health care transformation that is capable of delivering care commensurate with the goals of value-driven care. Being an ACO means taking responsibility and accountability for the health of a defined population, while being held to benchmark levels for quality and cost. ACOs may come in a variety of shapes and sizes and include integrated health systems, multispecialty provider groups, physician-hospital partner organizations, and independent provider associations.
For all of these respective provider groups, making the decision to transform into an ACO is not an easy one. There are no road maps, instruction manuals, or “easy buttons.” The transition requires a clear understanding that today’s system is broken and the belief that only a relentless pursuit of a patient care model that is value-driven, integrated, and highly coordinated is acceptable.
The Unsustainable Model
So how does a multispecialty group practice, highly successful in the existing fee-for-service marketplace, make the decision to go down the difficult, costly, and time-consuming path to become an ACO? It’s simple: very carefully. For Cornerstone Health Care, the decision was based on the recognition that the existing model of care could not be sustained and that someone had to do something about it. So why not Cornerstone?
Influencing the current system of health care to align incentives for the patient, provider, and payer will ultimately generate cost savings. It has been estimated that a shift to value will eliminate $500 billion in waste due to low-value-add processes and procedures. In conjunction, the patient-centered population health models will cause a shift of more than $1 trillion in value from the fee-for-service model to the value model and will create more than a dozen new $10-billion high-growth markets.
Simultaneously Working in 2 Worlds
Thus far, one of the most difficult challenges of the transition has been the necessary evil of working simultaneously in a fee-for-service and fee-for-value system. The current situation is much like having a foot in each of 2 speedboats going in opposite directions. Cornerstone’s journey to transform to a value-based care system has been a continuous work in progress. In exemplifying the true spirit of process improvement, many theories have been tested, several have fallen short of target, and new ones have been formulated.
Factors identified as critical to success center on patient selection, resource optimization, cost and quality analytics, care coordination, and population health. The ultimate progression of the value-driven health care system will go from an initial focus on the highly complex, poly-chronic population with the highest expenditures to populations at low risk for disease.
There Is Value in TEAM
Program development that encompasses a team-based approach to care with all disciplines working at the top of their licensure is essential. The care redesign process utilizes an intricate system of health navigators, patient education coordinators, encounter specialists, social workers, dietitians, advanced practice professionals, pharmacists, and other health care professionals working in conjunction with the physician in the development and application of a patient care plan carried throughout the continuum.
Personalized Life Care and Cardiac Function
Thus far in the Cornerstone journey to value-driven care, the 2 most noteworthy examples of a shift from traditional medicine have been the creation of the Personalized Life Care Clinic (PLC) and the Heart Function Clinic.
The PLC is an extension of the primary care environment designed exclusively to provide high-touch care to the sickest, most vulnerable patients. The multidisciplinary team, headed by an extensivist physician, focuses on patients who have recently been discharged from the hospital, along with those in later stages of poly-chronic disease states. The primary goal is to create a care plan that will help prevent further hospitalizations or emergency department (ED) visits and ultimately stabilize the patient to transition back to a normal primary care setting. In this practice, patients receive extended visit times, multiple touch points and follow-up with PLC staff for assessments and reminders, and even home-based visits when needed. Since inception in May 2013, the PLC has enrolled over 88 high-risk patients, resulting in an overall decrease in hospitalization events of 39%.
The Heart Function Clinic, not labeled heart “failure” (as function is the goal), was established to provide a high-touch high-care environment for one of the most at-risk patient populations with regard to ED visits and hospitalizations. Also utilizing the team-based approach, patients of the clinic receive care from a multidisciplinary embedded team consisting of a nurse practitioner, health navigator, psychologist, nutritionist, and pharmacist working in conjunction with the cardiologists. This approach allows for a specific focus on the acute problems associated with congestive heart failure (CHF), while also allowing for evaluation of underlying disease states that may also be causing problems.
The very first patient of the clinic, a 51-year-old female with CHF, chronic obstructive pulmonary disease, diabetes, and morbid obesity, proved to be a tremendous success story. Prior to enrolling in the program, this patient experienced 35 days in either the hospital or the ED over a 6-month period. For the period after enrollment, the patient experienced only 8 days over the next 7 months in either the hospital or the ED.
So what does this change to value-driven care ultimately mean to the practice, pharmacy, and the patient?
First Things First
For the practice, it means putting first things first—the patient. It is providing the right care by the right people, in the right place, at the right time. It encapsulates a spirit of collaboration across the care continuum and somewhat forces channels of communication and coordination that have previously not occurred. Joint accountability in a group practice suddenly shifts the dynamics of the relationships between primary care providers (PCPs) and specialists, as the PCPs ultimately hold the largest accountability in overall quality measures and patient attribution. It breaks down barriers to optimal patient care by allowing new mechanisms for patient engagement, potentially including no-copay environments, rides to essential appointments, meal vouchers, gym memberships, and prescription drugs. It’s the ultimate game changer.
What About Provider Status for Pharmacy?
For the pharmacy, the shift to value-driven health care and particularly the model of accountable care provides a golden opportunity to establish a practice of pharmaceutical care without the barrier of designated provider status. The ACO quality metrics alone make the argument for the importance of pharmacists on the patient care team, with 18 of 33 metrics involving optimization of medication management. Parallel that with the staggering amount of waste and adverse events associated with poor quality around medication use—often labeled as the $290-billion problem—and you have a justification.
Within this model, pharmacists can be utilized at the top of their licensure, serving as the drug experts in a large variety of roles and settings. For Cornerstone, the implementation of value-based pharmacy services is based on a 1- to 3-year strategic vision that facilitates patient interaction across the continuum. These services focus on optimization (quality and cost) of patient care based on a model of pharmaceutical care that utilizes comprehensive medication management as the foundation.
Predicated on patient population and practice needs, pharmacists can be embedded directly in the clinic setting, provide centralized services from pharmacy care clinics, or provide outreach services directly to patients via secure video technology or telephony. Each of these settings provides an opportunity for pharmacists to conduct visits directly with patients to ultimately create a care plan to manage medication therapy to further specific clinical goals and avoid drug therapy problems that lead to non–value-added expenses, such as hospital admissions and ED visits. Additional opportunities for pharmacy services include practice and provider support for drug education, development of evidence-based care guidelines, formulary management, supply chain optimization, and medication stewardship.
Shifting from Sick Care to Well Care
The silver lining to all of this reform and care model transformation is that it truly moves the patient front and center. Only paying for services based on a performance-based methodology that balances cost, quality, and overall satisfaction helps ensure that patients only receive services that are necessary and timely. The shift in population health management creates a new level of practice investment in the healthy patient, with the intent of keeping them healthy. The value-driven model will ultimately put decision making in the hands of consumers as cost and quality indicators become more transparent.
At the end of the day, the shift to value-driven health care is a simple concept: doing the right things for the right reasons. The organizations that are ahead of this curve, and making the commitment to be transformative and transparent in the shift to value, will find that a pursuit of quality and satisfaction in a cost-conscious mentality will prevail as the “new normal” in health care—with rewards far exceeding those in the fee-for-service world.
Jamie Hale, RPh, serves as the chief pharmacy officer and director of business operations for Cornerstone Health Care, a multi-specialty group practice accountable care organization, headquartered in High Point, North Carolina. As a member of the leadership team, he is responsible for the optimization of both clinical and business transformation initiatives designed to meet the triple aim. His primary area of clinical focus is developing and implementing an integrated pharmaceutical care practice model based on the principles of comprehensive medication management. He transitioned to Cornerstone in December 2012 after a 15-year career at Wake Forest Baptist Health, where he last served as the administrative director of pharmacy. His experience in health system leadership has spanned across the continuum of care, including inpatient operations, specialty pharmacy, retail pharmacy, home care, long-term care, clinical services, critical access hospitals, and pharmacy benefits management. Jamie earned his degree in pharmacy from the University of North Carolina at Chapel Hill and received Six Sigma certification through BMG University.