Randy P. McDonough, PharmD, MS, CGP, BCPS, FAPhA

Install the engine. Install the hood. Install the wheels. In December 1913, Henry Ford revolutionized the automobile industry by introducing the assembly line to American factories, In many ways, this concept has been applied to 

 over the years. We have trained staff to excel in their sole duties in the prescription process: inputting, counting, and verifying. And down the line the prescription moves.

This method might work well in a quantity-driven environment, but in an industry rampant with direct and indirect remuneration fees and reduced product reimbursement rates, quantity-driven pharmacy production just means commoditized products dispensed faster and more efficiently. 

However, a paradigm shift is occurring within the health care system, moving from quantity-driven to quality-driven. Community-based pharmacy 

 have been forming throughout the country over the past few years with a strong focus on patient outcomes and coordination of care. Thus, these networks can leverage their ability to reduce overall health care costs by contracting with accountable-care organizations, health systems, and payers. However, these payers will measure success and reimburse providers, pharmacists included, based on key performance metrics. In other words, payment is tied to the ability of pharmacists to provide quality and reduce overall health care costs, otherwise known as value-based reimbursement.

Many pharmacists may be uncertain of their ability to adjust their practices to prepare for these new opportunities, affect performance metrics, or engage patients and providers in a way that challenges norms. They may be concerned about being “held accountable” to performance metrics and patient outcomes because these weren’t required of them in the past. To succeed in this evolving health care system, pharmacists must transform their practices beyond efficient product distribution. It is important now to devote more time and training to re-engineering processes within the community-based practice that supports and promotes patient-centered care and quality-driven practices. Implementing new workflow processes takes time, but there are 4 key tips to start transforming a pharmacy to a value-based care model.

 Historically, the industry has focused on filling as many prescriptions as possible and dispensing quickly, accurately, and cheaply. However, everyone working in a pharmacy must embrace the culture shift from merely focusing on prescriptions to focusing on patients. A community-based pharmacy practice that has embraced these new concepts of value-based care and high performance on quality metrics must embrace a new practice paradigm. In this new paradigm, pharmacists are freed up to perform enhanced clinical services with patients. This requires optimizing efficiencies within the pharmacy by using technicians to drive the dispensing processes, implementing 

 processes, and using automation and technology. It takes a team effort to be successful.

Operating as a team within the pharmacy seems simple, but it is often the most difficult yet critical aspect to ensuring success in a value-based care model. Even for those who see the vision, challenges may arise when educating staff members on the mission of quality-driven care. All staff members must understand their role in the pharmacy. It comes down to maximizing every patient encounter and recognizing gaps in care. Help the staff understand that when Mr. Jones calls every other day for refills, he would benefit from medication synchronization. Help them understand that when Ms. Parker says that she forgets to take her blood pressure medications, she would benefit from adherence packaging. When Ms. Brown comes into the pharmacy after her prescriptions have been sitting in will call all week because she couldn’t find a way to get there, she would benefit from delivery service. More complex barriers may also require coordination with care managers and other members of the health care team.   

 Pharmacies will not be able to meet key performance indicators unless they integrate themselves within the health care team. Traditional pharmacy-based metrics have focused primarily on medication use and adherence rates. However, successful performance in a value-based care model includes much more than these specific medication-related metrics. Pharmacists need to ask 3 questions during encounters with patients: Have they achieved their therapeutic outcomes? Are their medications safe? Are their medications effective? If the pharmacists answer “no” or “I don’t know,” then there is a potential medication-related issue.

Pharmacists must become interventionists when they identify medication-related problems, providing clinical recommendations to prescribers and other providers to ensure that patients are achieving their therapeutic outcomes. This may include recommending additional medications, discontinuing medications, or changing doses.

Developing relationships with local prescribers allows for the bidirectional exchange of information. Demonstrating the value of pharmacy services fosters these partnerships. The bottom line is to identify partners in the community that want to work with the pharmacist in this capacity. Make them understand that pharmacy services include much more than dispensing alone.

Beyond clinical metrics, pharmacists are also responsible, like other providers, for controlling health care use and costs for patients. This means making sure that patients are optimally treated with safe and effective medications to reduce emergency department visits, hospitalizations, and excessive use of overall health care resources. Also, pharmacists must ensure smooth transitions of care for patients by providing medication reconciliation services and communicating closely with other providers to resolve medication irregularities. Finally, community-based pharmacists must also identify gaps or disparities in care during patient encounters. Once the disparities are recognized, it becomes important to understand the reasons why these gaps exist—such as lack of provider access to patient information, lack of patient access to appropriate health care providers, lack of patient engagement, and lack of care coordination. Developing strategies to reduce the gaps can improve care efficiencies and costs.

 From a payer perspective, high-risk patients are the costliest. Therefore, this may be a population that community-based pharmacists can have the most impact on both clinically and financially. This strategy, commonly called population health management, should be a focus for pharmacists.

In North Carolina, the highest-risk patients are age 62 on average, typically fill 10 prescriptions per month, and have at least 3 chronic conditions. These complex, chronically ill patients need assistance navigating the health care system. Pharmacists can potentially have the most impact on these patients by ensuring appropriate therapy and attainment of therapeutic goals, adherence to therapy, optimizing patient outcomes, and reducing overall health care use.  

Consider data mining to identify these patients. Adherence is one of the easier metrics to tackle. Work with dispensing software or other vendors to develop reports that highlight patients with less than 80% adherence. Engage these patients to determine barriers to adherence, and use motivational interviewing to develop patient-centered goals. Enroll these patients in a medication synchronization program to improve adherence and, more important, decrease consequences associated with non-adherence such as hospital admissions.

Once a pharmacist has a handle on approaching non-adherence, he or she should begin to focus on more difficult outcome-based metrics that are more related to appropriateness of therapy (eg, statin therapy in patients with diabetes), the need for additional therapy (eg, the use of controller therapy in patients with asthma), or appropriate dose (eg, statin intensity level based on patients’ 10-year risk of cardiovascular risk). Pharmacists can consider offering disease state management classes, administering long-acting anti-psychotic injections, educating patients when to use the primary care office versus the emergency department, and providing comprehensive medication reviews with chronic-care management. Customize the pharmacy’s service sets to the population served to achieve better outcomes, thereby helping the pharmacy meet corresponding quality-based metrics.  

 This is key. Historically, pharmacies are engineered for episodic care: A patient presents a prescription, and there is an efficient system in place for getting the individual with the filled prescription out the door as quickly as possible. But then what? Does it matter if that medication worked? Has the patient’s health improved? Community-based pharmacists need to re-engineer their workflow to accommodate chronic care, not just episodic care. High-performing pharmacies have clinical medication synchronization in place so that the dispensing of medications is aligned with medication and disease state management. In this way, pharmacies can continuously evaluate the safety and efficacy of therapy as well as barriers to care. Remember, chronic-care management means constant-care management. To successfully implement this component, a pharmacist may want to delegate follow-up duties to a member of the pharmacy staff. Monthly follow-up calls for complex patients and calls to a patient after the initial fill of a new chronic medication are a couple of examples. Some pharmacies have implemented a community-based antibiotic stewardship program in which patients are called a few days after an antibiotic is started to ensure the proper course of therapy, safety, and efficacy. Ongoing monitoring and follow-up with patients is essential to successfully caring for patients.

Start somewhere. By stepping out of our roles of pushing the prescription down the assembly line month after month, we are empowered to make a much larger impact on patients’ health. Value-based care models improve patient outcomes and create a marketplace presence for pharmacies that go above and beyond for patients. Implementing innovative strategies to achieve quality-based metrics will allow pharmacies to continue to drive forward and compete in a value-based marketplace.

Randy P. McDonough, PharmD, MS, CGP, BCPS, FAPhA, is the co-owner and director of clinical services at Towncrest and Solon Towncrest Pharmacies, Towncrest Compounding Pharmacy, and Innovative Pharmacy Solutions.

Shannon Rudolph, PharmD, is a graduate of University at Buffalo and completed her PGY-1 Community Pharmacy Residency at UNC Eshelman School of Pharmacy with Moose Pharmacy in Concord, North Carolina. She currently serves as the Executive Fellow at the Iowa Pharmacy Association.

Articles

A paradigm shift is occurring within the health care system, moving from quantity-driven to quality-driven.

A Payer Has Expressed Interest in Our Enhanced Services Network: Now What?

After reading this article, the reader should be able to:

						Realize the limitations of current pharmacy performance measures.

						Explain the practice changes needed to affect pharmacy performance measures

						Clarify the lack of financial incentives available to pharmacists who have integrated patient care services into their practices

						Propose a new reimbursement model that provides fair and reasonable compensation for pharmacists’ performance

The Affordable Care Act (ACA) was signed into law on March 23, 2010.

 The purpose of the ACA is to lower health care costs, improve quality and system performance, and enhance patient access to health care services.

 As a result, newer integrated health care delivery models, including patient-centered medical homes and accountable care organizations, have been created to help promote enhanced care at lower costs.

 The ACA also prompted changes in how health care providers are reimbursed for their patient care services, moving from a fee-for-service model to a value-based purchasing system that shifts risk from payers to providers.

 New pay-for-performance (P4P) strategies are being used by payers to improve quality by providing bonus incentives to providers based on their performance, forcing health care providers to focus on quality of care to ensure that patients are achieving positive health outcomes.

Although P4P programs are being utilized by hospitals and physicians,

 pharmacies are also affected by the P4P initiatives. In 2007, Medicare instituted star ratings for health plans that provide Part C and Part D benefits.

 Pharmacy performance measures that can affect a plan’s star ratings are included in plans that provide Part D benefits. Currently, there are 5 pharmacy performance measures for which pharmacies are evaluated. Three are related to patient adherence, one to medication safety, and another to the completion rate for medication therapy management (MTM) comprehensive medication reviews.

 Another Part D measure that is currently a display measure is statin use in diabetes; this is expected to become a full measure in 2018.

 Initially star ratings and quality performance measures applied to Medicare Part C and D Plans, but these measures have expanded to and used by accreditation organizations, state insurance exchanges, and commercial insurance plans.

Limitations of Current Pharmacy Performance Measures

The ACA affects community pharmacy practice in many ways. Community pharmacists are experiencing:

		An inordinate amount of products being reimbursed below pharmacy cost (underwater Maximum Allowable Costs),

		Loss of patients because of narrow networks and mail order, and

In addition, product distribution/dispensing continues to be commoditized, leading to reduced profit margins to the point where pharmacy owners may opt to close or sell.

 The overall effect of all of these factors is an economic crisis for community pharmacies, leading to a disruption to how community pharmacy is being practiced.

Keeping a practice static and not changing with the times is a formula for failure. Given the economic constraints affecting community pharmacies, it is absolutely essential that practices maintain access to patients and their daily lives. As pharmacy performance measures have been implemented in practice, community pharmacists have been guided by the supposition that quality performance in a community pharmacy improves the chances of being part of a narrow network which means access to patient lives.

Thus, access to lives is just one component needed to survive.

In addition, pharmacists need to be paid fairly and reasonably for their performance and patient care services. Some health plans have initiated a P4P model for pharmacists, but these plans have been the exception and not the rule in practice.  In other words, most community pharmacists have experienced a reduction in their reimbursement for dispensing, without a corresponding subsequent increase in reimbursement related to their clinical performance.

The current performance measures for pharmacy are a start, but to truly have an impact, pharmacists’ services should be tied to patient outcomes and health care spending. Medications are an important tool in medical care, but if they are not used appropriately, they can lead to adverse events, increased health care costs, and even death.

 The current pharmacy performance measures may be surrogate measures for clinical endpoints, but they do not tell the whole patient care story since the current measures are mostly limited to certain medication classes, not the whole patient. Medication management is complex and requires working effectively with patients as well as prescribers. Community pharmacists who have transitioned their practices to focus on patient care are spending their time:

		Helping patients manage their medications,

		Identifying and resolving drug therapy problems,

		Collaborating and communicating with other health care providers, and

		Documenting their clinical activities so that they have complete patient histories.

These patient care services receive little recognition and/or payment (if any), although the community pharmacist is often the last line of defense before a patient receives a potentially life-altering (or life-threatening) drug.

As mentioned previously, product distribution has been commoditized, but pharmacists’ clinical oversight and management of drug therapy needs to be valued by payers and reimbursed sufficiently to ensure that clinical services are available, sustainable, and continuous. Therein lies the major limitation of the current health care system and pharmacy performance measures—a lack of recognition of the real value of community pharmacists. Reimbursement for pharmacists’ services needs to be drastically improved and should be the standard, not the exception.

Reengineering Community Pharmacy Practice

Community pharmacists are realizing that to keep their practice relevant and sustainable, they need to become more clinically focused. Many community pharmacists may need to reengineer their practices to incorporate clinical services, enhance drug therapy management, and improve patient monitoring. Reengineering a community pharmacy practice requires an investment of time, money, and resources. A community pharmacy practice that is focused on patient medication management requires staffing changes, such as hiring technicians responsible for dispensing functions including computer entry, prescription filling and labeling, and patient triage. An alternative is investing in technology such as automated dispensing. For state boards that allow it, community pharmacies may utilize a tech-check-tech medication verification process. Ultimately, the goal of a reengineered community pharmacy practice is to relieve pharmacists from dispensing functions so that they can provide medication management and monitoring services to their patients, to ensure that patients are achieving their clinical outcomes which should lead to improved quality metrics being evaluated by payers.

In community pharmacies that have transitioned their focus from dispensing to patient care, pharmacists concentrate on overseeing patient medication management to identify and resolve potential or actual drug therapy problems. Pharmacists must focus on ensuring that their patients achieve their therapeutic outcomes with safe and effective drug therapy. If any of these conditions are not met, pharmacists need to intervene and provide clinical recommendations to patients, caregivers, and/or prescribers.

Documentation of drug therapy problems, clinical interventions, and outcomes of clinical activities is an essential and necessary component of the patient care process. Because most dispensing systems were not created to support clinical services, investments in newer pharmacy systems may be needed to achieve these goals. Working with patients and prescribers requires a clinical documentation system that integrates with the dispensing system, reformats patient data into usable and efficient clinical records, and allows pharmacists to document their clinical activities.

To support their clinical activities, community pharmacists may need to remodel their pharmacies so that prescription and clinical workflows are integrated and efficient and so that pharmacists have the necessary space to review patient records and provide semiprivate or private patient consultation/care. If technologies such as automation or robotics are integrated into the practice, structural remodeling of the pharmacy may need to be considered as well. The remodeling changes implemented should have the net effect of increasing practice efficiency in order to maximize the pharmacists’ time with patients. Ultimately, these changes should help pharmacists optimize the care of their patients ensuring positive therapeutic outcomes with safe and effective therapy which in turn improve outcomes of the payers in terms of healthier patients and reductions in total health care spend.

All of these changes come at a cost to community pharmacies. As mentioned previously, a major issue affecting community pharmacy practice is the loss of revenue due to insufficient reimbursement on the product side without an adequate generation of revenue on the service side. The rapid decline in product reimbursement has not coincided with an increase in reimbursement for services. The little that has been paid to community pharmacies for P4P outcomes has been a trickle compared with the loss of revenue. Obviously this model cannot continue indefinitely; it has resulted in community pharmacy closings, often in rural areas where access to pharmacists’ services will be missed.

The current system also does not reimburse pharmacists for ongoing clinical services or patient outcomes. Pharmacists are paid to provide MTM services to select Medicare Part D beneficiaries, but the numbers of patients who have participated in MTM services been low due to a variety of reasons including eligibility of patients (drug spend) and patient participation.

 However, the Center for Medicare and Medicaid Services (CMS) recently announced a Part D Enhanced MTM model to encourage Part D plans to invest in MTM strategies to optimize medication use and improve care coordination,

 and this may encourage prescription drug plans to expand their MTM offerings in the 5 regions announced by CMS.

In addition to this CMS announcement, federal legislation recognizing pharmacists as providers under the Social Security Act has been introduced.

 This legislation highlights that a common reason for lack of pharmacist reimbursement is that pharmacists are not recognized as providers by CMS. Pharmacists have been able to bill for clinical services as “incident to” the physician. This practice has its challenges and limitations, one of which is lower reimbursement due to a lower coding of care.

 The Pharmacy and Medically Underserved Areas Enactment Act, if passed, will allow patient access and coverage to pharmacists’ services in medically underserved communities. This legislation may improve patient access to important services.

Ultimately, payers will decide what they believe is of value to them and their beneficiaries. Depending on the patient population, diseases that are costly to manage or the cost of medications may determine the mix of services that payers deem necessary and pay pharmacists. It is important for community pharmacists to be reimbursed fairly for products and patient care services. Prospective payment for providing a standard base of patient care services is important because, as mentioned previously, there are costs associated with patient medication management and monitoring services. In addition, a share-savings model can be simultaneously implemented so that pharmacists who help payers reduce total health care costs through their patient care services will share in the savings with the payer.

From a pharmacy perspective, this may require a tiered approach to managing patients in order to increase practice efficiency and effectiveness. For example, the lower tier of patients represents all the patients who are beneficiaries on the health plan. For these patients, pharmacists provide an enhanced model of care whereby all patients receive standardized care including prospective drug utilization services, patient education and counseling, identification and resolution of drug therapy problems, ongoing patient drug therapy monitoring, and documentation of all clinical services performed by the pharmacists.

The next tier represents patients with medical conditions that are costly to the payer. Pharmacists may need to use additional services to appropriately manage these patients. Disease-state management services enter into this tier along with health coaching and motivational interviewing. The goals for these patients are to ensure that they are appropriately treated with medications and lifestyle management, that medications are appropriately monitored and managed, that regular collaboration and communication with other health care providers occurs, and that patients achieve their therapy goals, which in turn should result in positive therapeutic outcomes with reduced health care costs.

The upper tier represents the higher-risk patients who have comorbidities and multiple prescriptions. These patients can be the most costly plan beneficiaries, and pharmacists need to spend more time with them to appropriately manage their therapies and ensure that all medications are safe and effective. These are the patients who should receive MTM services at regularly scheduled visits (eg, monthly to quarterly). Community pharmacists will need to provide these MTM services in semiprivate or private rooms separate from the dispensing area. After each visit, community pharmacists will document their clinical activities, communicate with the patients’ prescriber(s), and ensure that patients are effectively managed and are achieving their therapeutic goals.

In this model, prospective payments ensure a certain standard of care and shared savings encourage community pharmacists to ensure that their patients are achieving their therapeutic goals with safe and effective medications. Prospective payments can come from the drug side of the benefit; shared savings, from the medical side. In this model, drug costs may increase because patients are closely managed and optimally treated to reach therapeutic outcomes, but total health care spending should decrease because of reductions in hospital admissions, emergency room visits, and unnecessary use of health care resources. Payers, health care systems, and pharmacists all benefit from this model, but ultimately the patients benefit the most.

The Affordable Care Act has moved providers from a fee-for-service system to a value-based purchasing system.  This includes community pharmacists who are being paid less to dispense medications. Community pharmacists are being driven to provide patient care services that will impact patient outcomes.  Unfortunately the reimbursement for patient care services has not kept pace with the declining product reimbursement.  Although P4P programs have been implemented, it is not consistently being done by all payers or in all markets.  A new reimbursement strategy is needed that pays pharmacists reasonably and fairly for their clinical services.  One suggested reimbursement model provides pharmacists with prospective payment for a standard base of services along with a shared savings program determined by the plan.  In this model, pharmacists provide a tiered approach to patient care—standard baseline services, disease-state management, and case management.  Pharmacists who provide these services help the patients achieve positive therapeutic outcomes with safe and effective therapy which leads to improved health outcomes and reduced total health care spend.

Randy P. McDonough, PharmD, MS, CGP, BCPS, FAPhA is the Co-Owner/Director of Clinical Services at Towncrest and Solon Towncrest Pharmacies, Towncrest Compounding Pharmacy, and Innovative Pharmacy Solutions.

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New pay-for-performance strategies are being used by payers to improve quality by providing bonus incentives to providers based on their performance, forcing health care providers to focus on quality of care to ensure that patients are achieving positive health outcomes.