In 2017, the United States was reported to have the highest per-capita health care spend, all while having some of the poorest health outcomes compared with other high-income countries.1

Increasing cost is the result of larger challenges facing our health care system, which include barriers to accessing care, difficulty managing at-risk populations, high hospital readmissions, lack of proper care coordination and data integration, and low medication adherence. Not only are these challenges costly and inefficient, they often result in poor patient outcomes. To address them, health systems in the United States are attempting to turn this trend around by innovating toward the Quadruple Aim of improving the patient care and physician experiences and population health while decreasing the per capita cost of care.2

A new strategy to achieve these lofty goals is enterprise collaborations. These differ from traditional acquisitions or mergers because they leverage the expertise and strength of 2 or more health care organizations to improve population health while maintaining the cultural and financial independence of each provider.3 Such collaborations are not new approaches to health care challenges in the United States. Between 2005 and 2016, a study of 16 multistakeholder health care alliances identified the keys to successful enterprise collaborations4: align overall collaboration goals with individual partner goals, evolve with changing stakeholder needs, and identify a clear value proposition (ie, provide programs or services that are valued enough to be financially viable in the local or regional market).4

Relationships among collaborators run the continuum, from less integrated and mature to highly integrated, with the most ideal and robust collaborations having common goals, multiple clinical touchpoints, and 2-way data sharing. For an enterprise collaboration to succeed, it must be flexible to meet the individual challenges and pressures of each partner, their particular communities, and the distinctive patient populations they serve. These collaborations have demonstrated some success. For example, they have decreased health care costs, increased access to care, and improved care coordination and transitions, data integration, management of at-risk populations, medication adherence, patient experiences, and support for patients.5

Below is a description of the value of enterprise collaborations, which describes the challenges that these collaborations can address and presents a case study of a successful enterprise collaboration between an integrated health care system, Community Health Network (CHN) in Indianapolis, Indiana, and a national pharmacy, Walgreens Co in Deerfield, Illinois.

Case Study
In 2016, CHN and Walgreens collaborated to synergize their organizational strengths to improve care for the communities that they serve. The collaboration included agreements related to the operation of retail clinics at Walgreens store locations, as well as pharmacy and employee access initiatives. The goals were clear and mirrored those of the Quadruple Aim: improve health outcomes, increase patient satisfaction with health care, increase provider satisfaction, and reduce overall costs of care. Four key components were central to its success:
  • CHN agreed to lease space and operate health care clinics located within local Walgreens stores.
  • CHN’s employee benefit was modified to improve access to Walgreens services.
  • The 2 parties agreed to set up a leadership structure to oversee the collaboration.
  • Walgreens purchased pharmacies located within CHN’s facilities.

These components allowed CHN and Walgreens to establish a robust enterprise collaboration structure that has benefited both organizations and the populations that they serve.

Clinic Partnership 
The clinic partnership was undertaken to expand CHN access points, improve health care coordination, and share outcomes reporting, without increasing costs. Patients’ ability to access care provided by CHN improved by expanding the network’s footprint in the local community through the lease and operation of 12 health care clinics formerly managed by Walgreens. These convenient community locations offered patients an affordable alternative to costly emergency or urgent care by expanding their ability to access CHN through online appointment reservations and walk-in appointments, as well as evening and weekend evening hours. Improved clinic access has also attracted individuals to the CHN system. The expanded CHN clinics averaged between 8000 and 11,000 patient visits per quarter, and about 30% of patients were new to CHN.

The clinics, staffed by CHN nurse practitioners, facilitated better care coordination between pharmacy services and primary care. For example, electronic scripts sent by the clinics’ nurse practitioners to the on-site pharmacy were prioritized for fast fulfillment.

Because CHN clinics used its electronic health record (EHR) system, clinicians seeing patients at the retail clinics had access to relevant clinical history and were able to make electronic referrals within the CHN EHR system.

Pharmacy Service Collaboration 
Pharmacy service collaboration similarly improved care coordination by assisting the pharmacy and hospital systems’ support of patient adherence, managing at-risk populations, and decreasing hospital readmissions. Walgreens purchased and operates 3 CHN pharmacies located within the hospital system and provides 2 key programs to assist CHN with care transitions and adherence management: bedside delivery and the new-to-therapy (NTT) programs. By partnering with Walgreens pharmacies, CHN was able to provide better pharmacy access to its employees. For example, the average travel time for any employee to a Walgreens pharmacy was 8 minutes, and 93% of employees were within 15 minutes, making access to medications convenient.

Adherence Programs
In Walgreens’ NTT program, a local pharmacist calls patients who have new medications 2 to 3 days after prescription pickup for 13 eligible disease states. The NTT consultation uses motivational interviewing techniques to address concerns or questions, assess their readiness to continue treatment, and maintain daily adherence. Patients using specialty medications are enrolled in a disease state-specific Walgreens Connected Care program. All CHN employees and patients have access to this program, with the goal of increasing adherence and providing additional savings through reduced avoidable hospitalizations and emergency department and urgent care visits.

CHN employees also have the ability to access specialty medications at both central fill and retail locations. The clinical programs that accompany the top specialty disease states, such as chronic inflammatory disease, oral oncology, multiple sclerosis, and cystic fibrosis, focus on keeping patients adherent to their medications.

Copay Assistance
Copay assistance is an additional benefit of the Walgreens collaboration. The Walgreens pharmacy team has the ability to assist patients with identifying and securing additional funding to reduce out of pocket costs. For example, the average total copay assistance amount per month for CHN patients declined from $6000 to $50 per patient, on average. This program increased the ability of approximately 300 patients per month to afford medications.

Data Analysis
Each organization contributes to ongoing data analysis that helps uncover underlying trends in clinical outcomes and utilization. The 2 organizations analyze the following metrics: bedside delivery percentage, clinic wait times, medication adherence, NTT outreach success, number of daily clinic visits, referrals into the CHN system, rehospitalization rates, and specialty pharmacy spend. Analysis of pharmacy and specialty data help inform cost containment strategies and patient-specific insights for targeted pharmacy programs, such as bedside delivery and NTT.

Meds to Beds
Patients who are hospitalized can opt to have prescriptions delivered to their hospital rooms prior to discharge via the bedside delivery program, commonly referred to as meds to beds. At time of delivery, the pharmacist or pharmacy technician conducts a medication consultation to advise the patient about the proper way to take medications and the importance of adherence. After discharge, the pharmacy calls patients to ask if they have questions about their medications or adverse effects. Key metrics measuring the success of this program are the STAR ratings related to “patient’s knowledge of medication upon discharge” and the percentage of discharged patients going home with medications from the facility. The bedside delivery program served 9168 patients in 2017 and continues to provide medication access to more than 2500 patients per quarter, on average.

Population Management
This collaboration has the ability to improve population management via improved access to patient-level pharmacy data and by increased oversight of specific patient populations. CHN changed the pharmacy benefit design to lower medication copays for employees and their dependents who use Walgreens central mail order, local specialty, and retail pharmacies. Thus, CHN can better manage and monitor specific populations and improve access to pharmacy data and management of drug discount programs.

340B
This collaboration has helped improve management of the 340B program, which is a federal government program that allows eligible health care organizations to purchase outpatient drugs from manufacturers at reduced prices for specific patient populations. This program is meant to help eligible organizations fund the costs of health care services for underinsured or uninsured populations. The program rules are complex and include management of patient and physician eligibility, drug inventory and dispensing, and monitoring and reimbursement. As part of the collaboration between organizations, Walgreens supports the 340B program on behalf of CHN.

Enterprise Collaboration Oversight 
Oversight is a crucial component of this collaboration’s success. Initially, a joint governance committee was established to oversee and manage various aspects of the collaboration, such as clinical programs, clinic and pharmacy transitions, contracts, information technology compatibility, patient benefits, and specialty pharmacy access. Oversight focuses on achievement of overall goals, day-to-day operations, and reporting of shared program metrics. Quarterly, the governance committee identifies opportunities and reviews metrics to enhance reporting to ensure that the collaboration achieves the goals of the Quadruple Aim.

Conclusion 
Enterprise collaborations can help meet challenges of the health care marketplace. As demonstrated by the CHN and Walgreens case study, collaborations can support better management of populations, programs, and health care services. Leveraging each partner’s strengths to design and implement programs, partnered with data exchange and measurement, can result in optimizing health care outcomes and containing costs and possible opportunities for expansion of the collaboration. 
 
Ronald J. Hazen, MPH, is a senior analyst; Heather Kirkham, PhD, MPH, is director of health analytics, research, and reporting; Ryan Atkinson, PharmD, MBA, is senior director of health outcomes and specialty business innovation; and Kathryn Bronstein, PhD, RN, is vice president of health outcomes, all at Walgreen Co. in Deerfield, Illinois.

Anu B. Dhamecha, PharmD, is director of pharmacy benefits at Community Health Network in Indianapolis, Indiana.


References
  1. Schneider EC, Sarnak DO, Squires D, Shah A, Doty MM. Mirror mirror 2017: international comparison reflects flaws and opportunities for better U.S. health care. The Commonwealth Fund website. commonwealthfund.org/press-release/2017/mirror-mirror-2017-international-comparison-reflects-flaws-and-opportunities. Published July 12, 2017. Accessed February 21, 2019.
  2. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Annals Fam Med. 2014;12(6):573-576. doi:10.1370/afm.1713.
  3. Schneider M. Affiliation and its benefits to the hospital and community. Nurs Adm Q. 2016;40(4):342-345. doi: 10.1097/NAQ.0000000000000187.
  4. Alexander JA, Hearld LR, Wolf LJ, Vanderbrink JM. Aligning forces for quality multi-stakeholder healthcare alliances: do they have a sustainable future? Am J Manag Care. 2016;22(suppl 12):s423-s436.
  5. US Department of Health & Human Services. AHRQ Health Care Innovations Exchange. Agency for Healthcare Research and Quality website. innovations.ahrq.gov/. Accessed February 21, 2019.