Jon Easter, BSPharm, RPh

When the Institute of Medicine (IOM) released its landmark 2001 “Crossing the Quality Chasm” report, it called for providers to support continuous healing relationships” with their patients. Although we have seen some progress through the proliferation of patient-centered medical homes (PCMHs), most clinicians have not fundamentally altered their basic approach to engaging with their patients. In most cases and in most places, PCMHs have tinkered around the edges to meet specific new requirements, but most primary care physicians generally remain on the proverbial treadmill, trying to treat a high volume of patients in the typical fee-for-service payment model.

The PCMH is a good start as an organizing framework for a care delivery model, but achieving true care transformation remains elusive in the context of traditional approaches to payment that simply add on small bonus payments around the margins. Conversely, primary care practices that have entered into alternative payment models (APMs) that hold the practices accountable for a global budget have been more transformative. In some cases, these APMs have generated a fundamental reorientation from episodic, sick-care encounters with the delivery system to a continuous cycle of care.

Fundamentally changing the payment model is a necessary but insufficient step. Alignment of incentives is a prerequisite, but providers still need a lot of additional support to reorient, reorganize, and reshape the care paradigm. Primary care providers, especially those operating in small practices, need substantial technology and infrastructure support. However, before an organization invests in that core support, it’s imperative that they know what patients want. To paraphrase Yogi Berra, “If you don’t know where you’re going, you might not get there.”

Ultimately, ensuring that the payment model squares with patient needs and preferences also affects the long-term legitimacy and viability of the APM. For anyone who lived through the rise and fall of managed care in the 1990s, the need to engage consumers in the evolution of new payment models is abundantly clear—both in terms of perceptions and reality. Even at that time, plans denied only about 1% of recommended hospitalizations, slightly more than 1% of recommended surgeries, and just over 2.5% of specialist referrals.

 Furthermore, consumer concerns with managed care products were mostly not based on personal experience, but instead on external influence, as 54% of Americans who said managed care did a bad job were largely influenced by family, friends, and the media.

What then, was the root cause of the managed care backlash of the 1990s? Was it a lack of access to essential health care or the opaqueness of the health care decision-making process and the patient’s role in it? If health care stakeholders can learn one lesson from the 1990s managed care backlash, it is the central importance of engaging and communicating with patients. Ultimately, patients are skeptical of any model that does not directly solicit and value their input in critical health care decisions.

The Increasing Financial Burden for Patients

Escalating health care costs have caused purchasers to gradually shift more costs onto patients. Whether one refers to this as “more skin in the game” or a “heavier patient financial burden,” the trend has placed greater responsibility on consumers to understand and manage the costs of their care and to understand the risks and benefits of the care they are receiving.

The popularity of high-deductible health plans (HDHPs)—for which individuals generally pay lower premiums for higher deductibles&mdash;and their accompanying health savings accounts (HSAs) to pay for the costs that HDHPs do not cover, has grown at an accelerated pace. HDHPs barely existed at the turn of the millennium; however, between January 2011 and January 2014, the number of enrollees covered by HDHPs/HSAs rose at an average annual rate of 15%, from 11.4 million to 17.4 million,

 with approximately 75% of these patients covered in the large-group market.

HDHPs affect consumer behavior, but research suggests they can be a blunt instrument. When seeking health care, HDHP/HSA enrollees spend more in out-of-pocket (OOP) costs before their insurance kicks in, causing individuals with high deductibles to be more concerned about higher-cost care and services.

 Overall, patients in HDHPs decrease their use of health care services. A large study found that patients in HDHPs significantly decrease the amount of preventive care they seek, such as colorectal and cervical cancer screenings and child immunizations, although the Affordable Care Act (ACA) prevents these plans from charging co-pays for preventive services.

 Another study showed that low-income HDHP enrollees are less likely to use high-severity emergency care due to unaffordable OOP costs.

With these trends, it is especially important that providers understand their patient’s context and needs—such as whether they are aware of their plan’s policies, the OOP costs they can incur, and the potential consequences of avoiding care&mdash;so they can address them up-front and ensure better adherence to appropriate tests and treatment. This context is important as purchasers, both public and private, try to guide consumers to effective decision making regarding health plan selection and the use of services within the constraints of those plans.

Financial context is important for the average consumer, but it does not change the priorities of what patients are looking for from the care delivery system. One way of understanding and addressing patient needs is to put them at the center of the care redesign process. Patient needs can best be understood by asking patients questions and then observing them.

The National Partnership for Women and Families has conducted some of the most important research to date that employs both quantitative and qualitative techniques. Specifically, Bechtel and Ness described in 

in 2010 the 4 key attributes that patients seek in primary care: whole-person care, comprehensive communication with and between providers, support in improving self-management, and 24/7 access to providers and care.

 Clinicians need to focus on each patient as a “whole person rather than a collection of body parts” or a list of conditions or diseases. Disease-oriented care management often fails to address the underlying, connecting, and defining needs that people face—some of which may not even be clinical in nature.

The US health care system suffers from silos of clinical interventions, where the only constant is the individual in need of care and support. That places an enormous burden on the patient and his or her family to coordinate, manage, and communicate about care needs. Effective primary care needs to relieve that burden and develop effective ways to communicate with patients on a continuous basis and among the appropriate providers.

Patients also seek support and empowerment in building their capacity to manage their own health in collaboration with their personal caregivers and providers. That support should include partnership, guidance, and tools for self-management, and an environment of trust and respect.

Successful primary care requires ready access, especially for those with chronic conditions or complex health care needs. Most health care happens outside the 4 walls of a clinic or hospital, yet most providers have no mechanism for integrating observations of daily living into the care management process. This has been well described by Project Health Design, a Robert Wood Johnson Foundation-funded multiyear effort.

What does the future look like in terms of how primary care is organized, what services they provide, and the experiences of patients and families? The idea that new technology could help transform the patient experience has often hit a wall because the historic payment model separates the financial beneficiaries of these advances from those who have to make the up-front investments in them.

The move away from a turnstile, volume-based health care economy to one that focuses on value has created a strong business case for the provision of patient- and population-centered care. A variety of health information technology (HIT) tools can help providers better manage care and population health,

 starting with a foundation of patient registries and electronic health records (EHRs).

Patient registries are fundamental to population health management as a means of conducting patient monitoring and outreach, and identifying high-risk patients. EHRs can be used to capture the data necessary for advanced analytics, such as vital signs, diagnoses, and medications. More sophisticated HIT tools include automated outreach technologies, which use data analytics to identify and notify patients in need of preventive or chronic disease care, and platforms that can remotely monitor high-risk patients in need of continual care management and allow providers to intervene before their health deteriorates. More complex applications include advanced analytics and data warehouses to identify high-risk segments of the population, aid clinical decision making, and measure performance and clinical outcomes in real time. New payment models change the incentive structure for deploying these tools, although several barriers still exist, including lack of data standards, insufficient skills in data and analytics, and noncompatible HIT systems.

These new technologies will have even more impact when they are combined with patient-facing HIT to deliver the right information to the right person at the right time. Sometimes described as information prescribing, information therapy (Ix) uses algorithms to identify patients’ information gaps, target information to particular moments in care, tailor the content to patients’ particular circumstances and needs, and deliver it in a way that the information is understandable, actionable, and meaningful. Much of health care relates to the transmission and use of information, but the average patient forgets 40% to 80% of everything he or she hears in the doctor’s office by the time he or she gets home.

Ix leverages new technology to support people throughout their ongoing care needs. For example, aspects of Ix are prevalent in the objectives of meaningful use of EHRs, such as patient reminders for preventive or follow-up care, after-visit summaries, and the provision of patient-specific education resources. When you provide timely information in advance and follow up on in-person encounters with the delivery system, you begin to create a more continuous cycle of care (see Figure).

Figure: Information Therapy Helps to Promote a Continuous Cycle of Care

There are many other ways to deploy patient-facing HIT to better support patient-centered primary care. One of the most basic ways of engaging patients is allowing them to easily schedule appointments, request prescription refills, access their medical records, pay their bills, and exchange information with their providers. Online patient portals, provided by many medical practices/providers, are recognized as a promising way to address these needs and they have become the focus for providers trying to achieve stage 2 meaningful use.

A recent Athena Health analysis found some surprising results about factors that hinder—or rather, do not hinder&mdash;patient portal adoption

		Patient age does not affect portal adoption. Patients in their 60s have similar rates of portal adoption as patients in their 40s, and although the probability of having a portal account begins to drop among patients in their 70s, they are only about one-third less likely to have one than their younger counterparts.

		Higher portal adoption is not contingent on practice size. Single-provider practices and large medical groups show very similar portal adoption rates.

The analysis found that patients are much more likely to create portal accounts if they begin registration in their provider’s office. Patients are much more likely to engage with technology if they know it helps them connect with their personal clinicians and those providers support it. Providers have also noted that practical functionalities, such as self-service appointment scheduling and bill payments, are key in attracting patients to portal use.

The uptake of telemedicine to engage patients beyond the 4 walls of a practice or hospital is growing. Recent analyses have shown that 27 states and Washington, DC, currently have telemedicine parity laws in place. In addition, in 2014, the Centers for Medicare & Medicaid Services reimbursed nearly $14 million in telehealth claims.

 According to a recent survey conducted by the National Business Group on Health, 74% of employers plan to offer telehealth benefit options to their employees in 2016—a notable increase from 48% in 2014.

Studies show that telemedicine can help patients better engage in their care. For example, a remote monitoring program for patients suffering from heart failure, the Connected Cardiac Care Program, was developed by Partners HealthCare to improve self-management among patients at high risk for hospitalization. Participants in the program used a remote monitor to track their health information, such as blood pressure, weight, and heart failure symptoms, at home and send it to a nurse electronically in real time. Participating patients were also provided with telephone-based education sessions for 8 weeks. Overall, findings showed that the program significantly decreased hospitalizations for up to 90 days post discharge and mortality rates for up to 120 days.

Having access to various types of patient information can help providers better engage their patients in their treatments and overall health. However, patient data collected at different points of the care continuum largely remain locked in different silos of the system, making it difficult for a provider to gain full view of a patient’s experience and information. Moreover, other useful behavioral, socioeconomic, and daily-life data often lie outside of a health care provider’s purview.

The American Heart Association recently claimed that the use of wearable devices (wearables)—such as fitness bands and smart watches that track fitness and wellness data&mdash;can improve health behaviors.

 Consumer demand for these devices reached a record high in January 2015; however, their overall lack of integration with the health care sector could be a missed opportunity.

 In recent months, the demand for wearables has experienced a sharp decline. One speculation is that patients are expecting these devices to be more actionable in improving their health rather than just tracking their data. Better connecting the wealth of data collected by wearables to a patient’s interaction with their provider might be one way of meeting this demand and improving patient engagement.

What is the role of pharmacy in proactively connecting and engaging patients in a world of new care delivery models and HIT advancements? There are many examples of pharmacists taking an expanded role to facilitate appropriate medication use, especially with patients who have chronic conditions.

As we move into value-based payment models, it becomes important to proactively partner with patients in a longitudinal way to assist them with comprehensive medication management (CMM). CMM is defined as taking a holistic, patient-centered approach to optimizing medication use. The goal is to achieve positive clinical outcomes and lower overall health care costs. Existing medication management approaches typically focus on drug cost minimization, not achieving value. CMM aligns the goal of value-based payment models, which are focused on better outcomes, with the goal of the patient, which is to better understand their complex medication regimen. This proactive, holistic engagement with the patient produces an informed patient who comes to rely on coaching, technology, and coordinated care to actively participate in managing their own health.

To bring this concept to life, GlaxoSmithKline collaborated with Community Care of North Carolina (CCNC) to build and test a medication management predictive analytics model that helps a provider identify patients who are at risk for negative outcomes. Not only does the model, called Care Triage, predict patients at risk for hospitalization due to drug therapy problems, it also recommends care guidance to the appropriate caregiver in the optimal setting at the right time to facilitate the proactive care mentioned above.

The collaboration’s pilot finding to date has been fascinating. Usage data showed that patients with chronic diseases were seeing their primary care physicians about twice a year, but were visiting their community pharmacy an average of 30 times each year! Because a population health strategy should engage patients where they are, these insights helped CCNC build a community pharmacy—enhanced services network, which is moving the role of the pharmacist beyond dispensing medications. As a result, CCNC received a $15-million federal grant to study community pharmacy within a medical neighborhood. The University of North Carolina Eshelman School of Pharmacy is managing the evaluation of this grant and helping to identify the best practices of these services. We believe this new population health venue can be a powerful resource for meeting patients at a time and place that is convenient for them, which will facilitate true patient engagement.

 into the patient-centered medical home will transform PCMH from an overused—and sometimes misused&mdash;acronym into a care delivery model far more capable of delivering on IOM’s 15-year-old call for continuous healing relationships. Whereas reimbursement hardly rewarded&mdash;and, in fact, may have discouraged&mdash;this care delivery approach at the turn of the millennium, the conditions are gradually changing. As the payment innovations of the ACA and the Medicare Access and CHIP Reauthorization Act of 2015 transition from demonstrations and pilots to fixed elements in Medicare reimbursement policy, and similar private-sector models also become the norm, value-based payment will become increasingly entrenched into the US health care system. In the context of that evolution, the demands of new payment models will finally reward providers that can deliver on the IOM’s promise.

Josh Seidman, senior vice president at Avalere Health, advises clients on health delivery and payment innovation, with a focus on using information technology (IT) to guide value-based care models. He applies his background in quality, health IT, and patient engagement to accountable care, delivery system transformation, and new payment models. Josh holds a PhD and an MHS in health policy and management from Johns Hopkins Bloomberg School of Public Health and a BA from Brown University. Josh is immediate past president of the Society for Participatory Medicine and was a William B. Ziff fellow for patient engagement with the Center for Advancing Health.

As senior director, payment and delivery reform at GlaxoSmithKline (GSK), Jon Easter leads a team that is focused on shaping the external health policy environment. Specifically, his team works to facilitate the adoption of evidence-based quality measures and to improve the delivery of care through better coordination and medication management. Jon has spent 20 years in the pharmaceutical industry. In addition to his public policy experience, he worked in GSK’s Care Management Division and covered the Pacific Northwest for the state government affairs organization. John’s experience also includes a stint in the health information technology industry, fueled by a passion for health care transformation, where he worked to advance the adoption of electronic health record and e-prescribing systems. Jon has a BS in pharmacy and is a licensed registered pharmacist.

Tanisha Carino is vice president of US Public Policy for 

 (GSK). She leads public policy strategy development and execution, ensuring GSK plays a positive role in shaping US legislation, regulation, and the public payer environment. A Fulbright scholar with more than 15 years of experience in health policy and strategy development across government, industry, and academia, Tanisha is recognized as a thought leader in market access, commercial trends, health technology, evidence-based medicine, and the evolving US regulatory environment. Tanisha earned her PhD in health policy from Johns Hopkins University and serves as an associate faculty member in Johns Hopkins Bloomberg School of Public Health. She is on the board of directors for Bread for Washington, DC.

		Appendix B. A brief history of managed care. National Council on Disability website. www.ncd.gov/publications/2013/20130315/20130513_AppendixB#_ednref11.

		Blendon RJ, Brodie M, Benson JM, et al. Understanding the managed care backlash. 

. 1998;17(4):80-94. doi: 10.1377/hlthaff.17.4.80.

		New census survey shows continued growth in HSA enrollment [news release]. Washington, DC: America’s Health Insurance Plans; July 9, 2014. www.ahip.org/Press-Room/2014/HSA-Census-Survey/.

		Altman D. The ‘value’ trade-off in high-deductible health plans. 

 http://blogs.wsj.com/washwire/2015/05/21/the-value-trade-off-in-high-deductible-health-plans/. Published May 21, 2015.

		Beeuwkes Buntin M, Haviland AM, McDevitt R, Sood N. Healthcare spending and preventive care in high-deductible and consumer-directed health plans. 

		Wharam JF, Zhang F, Landon BE, Soumerai SB, Ross-Degnan D. Low-socioeconomic-status enrollees in high-deductible plans reduced high-severity emergency care. 

. 2013;32(8):1398-1406. doi: 10.1377/hlthaff.2012.1426.

		Bechtel C, Ness DL. If you build it, will they come? Designing truly patient-centered health care. 

. 2010;29(5):914-920. doi: 10.1377/hlthaff.2010.0305.

		Brennan PF, Downs S, Casper G. Project HealthDesign: rethinking the power and potential of personal health records. 

. 2010;43(suppl 5):S3-S5. doi: 10.1016/j.jbi.2010.09.001.

		Shaljian M, Nielsen M. Managing populations, maximizing technology: population health management in the medical neighborhood. Patient-Centered Primary Care Collective website. www.pcpcc.org/resource/managing-populations-maximizing-technology. Published October 2013.

		Hall SD. Few healthcare organizations using advanced analytics tools. FierceHealthIT website. www.fiercehealthit.com/story/few-healthcare-organizations-using-advanced-analytics-tools/2015-04-30. Published April 30, 2015.

		Seidman J, Wallace P. Improving population care and disease management using Ix principles. Healthwise/Center for Information Therapy website. http://cdn-www.healthwise.org/docs/document/8131.pdf. Published December 14, 2004.

		Clain D. The current state of patient portal adoption. The Health Care Blog. http://thehealthcareblog.com/blog/2015/08/10/the-current-state-of-patient-portal-adoption/. Published August 10, 2015.

		Leventhal R. KLAS report names top vendors at driving patient portal adoption. Healthcare Informatics website. www.healthcare-informatics.com/news-item/klas-report-names-top-vendors-driving-patient-portal-adoption. Published April 27, 2015.

		Davis S. More Blues plans are connecting members, docs through telehealth. AIS Health website. http://aishealth.com/archive/nblu0915-06. Published September 9, 2015.

		Grensing-Pophal L. Tracking healthcare trends. Human Resource Executive Online website. www.hreonline.com/HRE/view/story.jhtml?id=534359199. Published September 2, 2015.

		Mobile technology may help people improve health behaviors: American Heart Association scientific statement [press release]. Dallas, TX: American Heart Association; August 13, 2015. http://newsroom.heart.org/news/mobile-technology-may-help-people-improve-health-behaviors.

Articles

Although we have seen some progress through the proliferation of patient-centered medical homes, most clinicians have not fundamentally altered their basic approach to engaging with their patients. 

Patient Engagement and Wellness: A Critical Piece of the Puzzle as Health Care Moves to Value-Based Models

Appropriate interventions can help the “near sick” stay healthy.

Pharmacists—stand up and be recognized! In recent years, the role of the pharmacist has been increasingly acknowledged as an integral part of a coordina-ted and patient-focused health care delivery model.In fact, many provider organizations are seeing the important role of medication management to enhance health care quality, produce better clinical outcomes, and lower the total cost of care, with an overall goal to deliver patient-centered care.

 to the naval base in Pensacola, Florida,

 ambulatory, patient-centered medical homes (PCMHs) can now be found across the country. These organizations and many more like them, highlight the important role the pharmacist plays on the health care team to proactively manage medications for patients with chronic conditions. Today, the interation between the physician and pharmacist is called a “warm hand-off”—the transition that helps ensure coordination and produce individualized patient-centered care.

In order to uncover the true value of care coordination and medication management, we need to first look at the needs of the patient, and how our current health care system leaves a large unmet need when it comes to proactive treatment, better health outcomes, and quality. It begins with the epidemic of chronic disease in the United States, where it is estimated that 157 million Americans will have at least 1 chronic disease by 2020, with 81 million individuals facing multiple chronic conditions.

 Chronic conditions drive the majority of health care costs, and effective and appropriate medication adherence can minimize costs and improve quality of care in this population.

In 2012, the Congressional Budget Office published guidance stating that every 1% increase in the number of prescriptions filled by Medicare beneficiaries leads to a net decrease in medical spending of 0.2%.

 However, ensuring that patients take their medicine as prescribed is no easy task. In fact, 50% of patients do not adhere to their medication regimens, costing the US health care system an estimated $290 billion in preventable spending each year.

 Even patients who had health insurance and no cost sharing for medications still had close to a 40% nonadherence rate, according to a recent study.

Management guru Steven Covey has a relevant quote that helps frame what we need to do in order to truly improve patient care. We must “Start with the end in mind.” For far too long, we have looked first at adherence, instead of seeing adherence as the result of a systems-based approach to medication management. It’s time to pull care coordination, medication management and medication adherence all together, integrating pharmacists on care teams and ultimately placing the needed emphasis on the role of outcomes based on comprehensive medication management as a core component of care coordination. However, we need to have the right tools and incentives in place to be successful.

Connecting the Dots: Providing Medication Management Across the Medical Neighborhood 

In 2013, GSK and Community Care of North Carolina (CCNC) began collaborating to build HIT tools that could facilitate proactive medication management. The goal is to start with the end in mind. Better outcomes and patient engagement are achieved by connecting the right providers, in the right settings of care, with the right medication management guidance.

GSK statisticians combined with CCNC population health and decision support experts to design prospective models that could identify patients who were at risk for drug therapy problems. They added a logistics component that turned the predictive models into prescriptive modeling, which allows a provider to understand his or her patient’s medication challenges in real time to determine effective ways to overcome barriers to delivering quality care. The combined tool was first tested in a data laboratory, and then in late 2013 CCNC began testing in 2 real-world settings: Southern Indiana and North Carolina. This summer, testing expanded into additional pilot settings of care, including accountable care organizations (ACOs) and community pharmacies.

Early Learnings: Reframing How We Think About Population Health

One of the expanded test sites for the predictive models and logistics engine is GSK itself, as part of a separate patient-centered medical home pilot with CCNC that began in 2012. After interim results from the PCMH pilot suggested more should be done to close chronic condition care gaps, which are directly tied to appropriate medication use, CCNC implemented a comprehensive medication management program for the GSK population in early 2014. CCNC, using the new health information technology, applied predictive models to gauge drug therapy problem risk scores for the population using aggregate data. The results of the risk scores were fascinating.

The composite risk score takes into account 6 predictive models, which include risk of hospitalization and various drug therapy problems (eg, therapeutic considerations). Patient scores range from 1 to 100. A score of 65 to 74 suggest a high risk of getting sick, or a “near sick” population. A score of 75 to 100 is classified as an “already sick” population. Predictably, the GSK population has a very low incidence of “already sick” compared with the NC Medicaid population. However, GSK had a significant proportion of the “near sick” population, which is categorized as folks who have 1 to 2 chronic conditions but are currently highly functional. The problem is that this population could have significant underlying drug therapy problems, typically underutilization of appropriate medications, which might lead to complications down the road. This suggests that proactive medication management could lead to better management of their condition and avoidance of more costly complications in the future.

Upon further review of aggregated “near sick” populations, CCNC discovered something else very interesting. Members of this group, because they are not acutely sick, only go to the physician once a year on average and go to the hospital less than once a year. But they visit their pharmacy close to 30 times a year! We need to rethink our approach. In order to proactively and effectively engage with this population, one needs to think about the right setting, the right provider, and the right guidance. Appropriate interventions to help the “near sick” stay healthy could be comprehensive medication reviews provided by the community pharmacist—right in the pharmacy.

These early learnings around the “near sick” suggest a powerful opportunity for community pharmacy. There is a population of patients who need medication management services in order to avoid more costly exacerbations in the future, and who, by and large, aren’t being seen on a regular basis by their physician because they aren’t acutely sick. More rigorous scientific study is needed. GSK and CCNC, along with a pharmacy school, are currently in the planning stages of a formal evaluation. However, it is clear that taking care of patient populations isn’t just about caring for patients once they get to the doctor. It’s about identifying and engaging with patients who aren’t walking into a physician’s clinic every day, but who are at risk for negative outcomes. And that is where community pharmacy can help—one patient at a time.

Obstacles Become Opportunities: A Call to Action 

As a fellow pharmacist, I’ve seen good outcomes-based medication management at work through up close and personal involvement in the Asheville Project and the American Pharmacist Association Foundation’s expansion of the model in the Diabetes Ten City Challenge. The obstacles to expand pharmacist services for patient care are also well documented, and we’ve heard about them for years.

Whether it is the lack of payment for services (no provider status), the scarcity of data, the difficulty of resourcing and work flow in a community setting, or the lack of training, pharmacists have battled the “chicken and egg” dilemma for a long time. But something is different now. It’s called value. And if we in health care can’t figure out how to begin moving from the current volume-based system to providing value in the new system, we are at risk of missing the boat. I heard one speaker recently say it is like having one foot in a volume canoe and one foot in a value canoe—very unstable.

The good news is that everyone in health care is trying to figure how to make that shift to stable ground—and a steady approach to health care&mdash;focused on value. That’s why GSK and CCNC are collaborating. We were sure we didn’t have all the answers, but through experimentation and pilot programs, we were confident that we’d collect learnings and insights that would help inform what medication management in the new world of value should look like, and how it can benefit patients to achieve better outcomes while lowering total cost of care. Through experiential learning, we can apply the insights from our pilots to inform our thinking, and share it with other health care stakeholders and policy makers. Together, we can develop best practices and evidence about how best to deliver value through optimizing medication management.

Through our collaboration and others like it, we’re starting to see the pharmacists as an integral part of a value-based system. Things are coming together. Technology is emerging that identifies patients in need and keeps them engaged. Providers are recognizing the need for clinical integration and are starting to share data. Payers are piloting new approaches to paying for services that produce better outcomes and lower readmissions. Pretty soon, pilots will be evolving into mainstream practice. That is transformation. And the best part: it’s the patient, your family and mine, who will benefit the most. If you haven’t already, it’s time to jump in—the water is warm. 

Jon Easter, BSPharm, RPh, is senior director, delivery and payment reform, at GlaxoSmithKline (GSK). His primary focus is health care transformation and the health information technology (HIT) policy environment, where he works to maximize its value to enable better health care quality, enhance the US health care delivery system, and ultimately improve patient outcomes. At GSK, Jon has championed the company’s involvement in North Carolina First in Health, one of the nation’s leading patient-centered medical home projects. He was also directly involved with replication of the Asheville Project, a recognized model for care coordination to improve patient outcomes for chronic disease. Jon has spent 20 years in the pharmaceutical industry. In addition to his public policy experience, Jon has implemented patient registry systems within GSK’s care management division, covered the Pacific Northwest for the state government affairs organization, and spent several years as a sales representative and district sales manager.

		Patient-centered medical home. Cleveland Clinic website. http://my.clevelandclinic.org/medicine-institute/patient-centered-medical-home.aspx.

		Fournier leads pharmacists on primary care teams in Navy medical homes. Amercian Pharmacists Association website. www.pharmacist.com/fournier-leads-pharmacists-primary-care-teams-navy-medical-homes. Published February 1, 2014.

		Wu S, Green A. Projection of chronic illness prevalence and cost inflation. RAND Corporation. October 2000.

		Congressional Budget Office. Offsetting effects of prescription drug use on Medicare’s spending for medical services. November 2012. www.cbo.gov/sites/default/files/cbofiles/attachments/43741-MedicalOffsets-11-29-12.pdf. Accessed July 2014.

		New England Health Institute. Improving patient medication adherence: a $290 billion opportunity. www.nehi.net/bendthecurve/sup/documents/Medication_Adherence_Brief.pdf. Accessed July 9, 2014.

		Cutler DM, Everett W. Thinking outside the pillbox—medication adherence as a priority for health care reform. 

Appropriate interventions can help the "near sick" stay healthy.


Avoiding First Event: The Importance of Adherence in the "Near Sick"

Pharmacists should solidify their place within the patient-centered medical home. Here is an early model that achieves better health outcomes through comprehensive medical management and a team-based approach.

I have worked in the pharmaceutical industry for more than 20 years. At my core, I am a pharmacist by training, and have long had a passion for exploring ways to integrate pharmacy practice into care teams with a goal of improving outcomes and lowering the total cost of care.

For me, this quest began in the mid-1990s working in state government affairs for GlaxoSmithKline (GSK) in the Pacific Northwest on pharmaceutical care initiatives with local pharmacy associations and schools of pharmacy. As I moved into the US Public Policy group at GSK, my role transitioned to educating policy makers on the results and benefits of the Asheville Project (

www.nbch.org/The-Asheville-Project-Case-Study

) and eventually, to support a collaboration with the American Pharmacists Association Foundation to replicate the Asheville model through the Diabetes Ten City Challenge.

We haven’t been alone at GSK. Many leaders in the profession have worked tirelessly to elevate pharmacy practice as part of care coordination models. But challenges to date around payment for services, scope of practice, and a lack of technology needed to implement effective comprehensive medication management solutions have slowed the progress. However, to use an old cliché, there is light at the end of the tunnel. Today, the movement toward a value-based health care system in the United States represents an incredible opportunity for pharmacists, and most of all, for patients.

The United States health care delivery system is currently designed to focus on episodic care and acute illness. Most health care reform experts have articulated the need to improve the health care delivery infrastructure to enable better proactive management of chronic diseases and prevention services. However, implementing a better health care delivery system is interdependent on achieving payment reforms that align incentives to clinical outcome improvements, as well as connecting the care delivery infrastructure with health information technology, which facilitates the sharing of information and provides the needed quality data mining necessary for payment.

Improving the health care delivery system is a key, interdependent component of overall health care reform. One way to do this—coordinating the delivery of health care through a Patient Centered Medical Home (PCMH)&mdash;is gaining popularity among public and private payers as well as policy makers. The medical home model is gaining momentum because of its value proposition for the patient, physician, and payer by improving outcomes while lowering costs.

The medical home model is gaining strong political support as well. The 2010 Patient Protection and Affordable Care Act (ACA) contains several provisions relating to the PCMH. Most notable is the creation of the Center for Medicare and Medicaid Innovation (CMMI), which is piloting broad payment and delivery system reforms across the country. CMMI has launched 2 large demonstration programs, the Multi-Payer Advanced Primary Care Practice (

http://innovation.cms.gov/initiatives/Multi-Payer-Advanced-Primary-Care-Practice/

) and the State Innovation Models Initiative (

http://innovation.cms.gov/initiatives/state-innovations/

), both of which have a significant PCMH component.

In addition to the federal activity, most states understand the value of the medical home and several are currently implementing pilot programs. According to a recent Health Affairs (http://archive .pcpcc.net/2012/11/6/health-affairs-article-half-states-are-implementing-patient-centered-medical-homes), 25 states have enhanced provider payment systems to encourage implementation of the PCMH within their Medicaid program.

Unfortunately, of all the great care coordination work being done across the country, very few of these initiatives have included clinical pharmacists on the care team. Appropriate use of medications is a key element of a coordinated care delivery system, and in my opinion, pharmacists are the best suited to lead the effort to optimize therapy and help patients achieve their clinical goals.

Nowhere is the value proposition of the patient-centered medical home model more clear than at Community Care of North Carolina (CCNC), an organization with which GSK is proud to have a long history of collaboration.

) began in 1998 in order to improve health care quality and save costs. The program now provides care to more than 1 million Medicaid recipients in North Carolina and has grown to encompass 14 networks, 4500 primary care physicians, and 1000 medical homes. According to a 2011 Milliman analysis, CCNC saved the state of North Carolina almost $1 billion between 2007 and 2010, primarily through lower emergency department and hospitalization utilization. The Healthcare Leaders Council awarded CCNC its Wellness Frontiers Award in April 2013 for implementing evidence-based care management programs that prevent disease and encourage wellness.

CCNC relies on patient-centered medical homes, population health management, case management services, and community-based networks to deliver care. The program provides each Medicaid recipient a case manager to serve as their coach to make sure they understand doctors’ orders and get to their appointments on time. CCNC has further developed their care coordination networks by adding several disease management initiatives, including asthma, diabetes, and congestive heart failure, as well as a chronic obstructive pulmonary disease pilot program.

Pharmacists began to work with CCNC on its medical home program in 2007 after it was noticed that there were patients with diverse medications who were prone to polypharmacy-related problems. It was evident that pharmacists could enhance clinical outcomes by providing medication management (pharmaceutical care) services while also managing drug costs. While medication cost savings are a convenient ancillary benefit to the program, the primary objective of CCNC pharmacy projects has not been to minimize medication costs, but rather to achieve therapeutic optimization to maximize health.

This is a subtle but important distinction since the former contributes toward the volume-based system we are moving away from while the latter allows for prescriber and patient-centered interventions such as coaching for adherence that in some instances actually increase medication costs, but ultimately improve care, when appropriate.

A team-based approach—pairing a pharmacist with the case manager&mdash;has been used so that an assessment of each patient can be made and points can be prioritized to inform the primary care physician before they see the patient face-to-face.

Throughout the CCNC networks, there are now more than 50 pharmacists who are the lead project managers and facilitators of pharmacy-related activities within a certain geographic boundary. They participate in activities such as developing proposals for new initiatives, reporting to the network leadership on existing initiatives, or presenting at local medical management meetings. The scope of activities in the CCNC networks offers a unique opportunity and challenge for pharmacists, and there is a growing need for more.

So where else are the pharmacists working within a PCMH environment? It seems obvious that one of the key areas of care coordination between a health care provider and the community is that of comprehensive medication management. To date, predictably, most pharmacists playing an integral “care coordination” role are located within the public integrated delivery systems, such as the Veterans Administration and Health Resources and Services Administration, as well as the private integrated delivery systems, such as Kaiser Permanente. Unfortunately, the “siloed” nature of ambulatory medicine has prevented significant uptake in pharmacist participation to date.

Fortunately, the Patient Centered Primary Care Collaborative (PCPCC) recognized this opportunity and organized a multi-stakeholder workgroup to formalize the role of the clinical pharmacist within the PCMH. That group published the second edition of “Integrating Comprehensive Medication Management to Optimize Patient Outcomes” in June 2012 for physicians, insurers, payers, and pharmacists to follow as they formalize the medication management relationship between a pharmacist and provider care coordinator.

Additionally, previously in 2009, Dr. Edwin Webb from the American College of Clinical Pharmacy authored a white paper entitled “Integration of Pharmacists’ Clinical Services in the Patient-Centered Primary Care Medical Home.” Dr. Webb references several recommendations of the Institute of Medicine’s “Quality Chasm” report, and based on those recommendations, he suggests pharmacist integration into the PCMH should be based on 7 essential principles. These principles emphasize the need for pharmacists’ clinical services in a patient-focused environment, as well as highlight the need for a flexible care delivery design that is focused on outcomes with access to HIT systems. The final principle calls for aligned payment policies to substantiate the medication management process.

Given the momentum to evolve our health care delivery and payment system to one that is proactive, coordinated, and connected, I cannot think of a better time for pharmacists to solidify their place within medical homes across the country. As pharmacists, we must step up if we are ever to demonstrate the critical role of comprehensive medication management in achieving better health outcomes and lowering overall health care costs. What an opportunity for us, and there is no time to waste—the patient is waiting.

Jon Easter, BSPharm, RPh, is senior director, delivery and payment reform, at GlaxoSmithKline (GSK). His primary focus is health care transformation and the health information technology (HIT) policy environment, where he works to maximize its value to enable better health care quality, enhance the US health care delivery system, and ultimately improve patient outcomes. At GSK, Jon has championed the company’s involvement in North Carolina First in Health, one of the nation’s leading patient-centered medical home projects. He was also directly involved with replication of the Asheville Project, a recognized model for care coordination to improve patient outcomes for chronic disease. Jon has spent 20 years in the pharmaceutical industry. In addition to his public policy experience, Jon has implemented patient registry systems within GSK’s care management division, covered the Pacific Northwest for the state government affairs organization, and spent several years as a sales representative and district sales manager. 

Pharmacists should solidify their place within the patient-centered medical home. Here is an early model that achieves better health outcomes through comprehensive medical management and a team-based approach. 
