Finally: Outcomes Marketplace Reaches Industry’s Shores
Humana and Pharmacy Quality Solutions’ incentive program could be a turning point for community pharmacy.
Sometimes, as a writer, you are so struck by what you read when researching and attempting to summarize a topic that you are better off simply letting the original work speak for itself.
“Mean A1c decreased at all follow-ups, with more than 50% of patients demonstrating improvements at each time. The number of patients with optimal A1c values (< 7 %) also increased at each follow-up. More than 50% showed improvements in lipid levels at every measurement. Multivariate logistic regressions suggested that patients with higher baseline A1c values or higher baseline costs were most likely to improve or have lower costs, respectively. Costs shifted from inpatient and outpatient physician services to prescriptions, which increased significantly at every follow-up. Total mean direct medical costs decreased by $1200 to $1872 per patient per year compared with baseline. Days of sick time decreased every year (1997-2001) for one employer group, with estimated increases in productivity…at $18,000 annually,” according to study results from the Asheville Project.1
The Asheville Project demonstrated that a pharmacist in a community pharmacy who is focusing efforts on outcomes related to therapeutic goals can enjoy a greater use of pharmaceuticals, an overall reduction in health care costs, and successful improvements. The bottom line is better care and outcomes and lower costs. The project’s findings epitomized the widely cited “triple aim” strategy of Donald M. Berwick, MD, MPP, FRCP, 8 years before he took the reins as administrator of the Centers for Medicare & Medicaid Services.2 So, why did it take 20 years to have the first, scaled community-based pharmacy payment and incentive program to get patients to therapeutic goals?
EVIDENCE WITHOUT A MANDATE OR MARKETPLACE IS USELESS
I cannot count the number of times I have heard academics espouse the need for peer-reviewed evidence of pharmacist and pharmacy effectiveness for “provider status.” Yet evidence of improved outcomes and reduced total cost of care only matter if there is a marketplace demand for them. That demand did not exist 20 years ago when the Asheville Project produced its findings. At the turn of the century, the health care system remained an almost entirely fee-for-service one, and when the outcomes marketplace did emerge, pharmacy was largely left out. The pay-for-outcomes policy movement began with shared savings pilots in the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, was subsequently amplified in the Patient Protection and Affordable Care Act of 2010, and solidified in the bipartisan Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, which effectively sought to end fee for service and put every Medicare provider, except pharmacies, into a pay-for-outcomes model.
PUNISHING POOR PERFORMANCE AND REWARDING GOOD PERFORMANCE FOR PHYSICIANS
With every day that passes, opportunities for performance- based contracting among physicians and their accountable care organizations grow. Seminal efforts over the past 2 decades included transforming primary-care payment through per-member, per-month population health payments and shared savings models; hospital performance through readmissions and patient satisfaction; and outpatient surgeries with bundled payments, which were capitated regardless of how many health care resources the patient used after surgery. These risk-andreward programs use tangible outcomes to affect provider behavior and payment.
OUTCOMES MEASURES LOOSELY RELATED TO CARE DELIVERY DO LITTLE TO ADVANCE PHARMACY CARE AND SUSTAINABILITY
Heretofore, process measures such as comprehensive medication review completion and prescription fill rates have left pharmacies nibbling at the margins of health care services delivery. In addition, they are subject to throughput competition by blast faxes requesting therapeutic interchange, call centers, postal service delivery, machines set to autofill, and waived copays and 90-day fills. But what about therapeutic goals? Isn’t that the whole point of prescribing the drug in the first place? To date, there has not been an at-scale, seminal effort tying patient outcomes to payment in pharmacies. Until now.
LONG TIME COMING
The nation’s second-largest Medicare Advantage insurer, Humana, recently announced a pay-for-outcomes program for more than 800 pharmacies in 6 states. It represents the first, large-scale incentive program based on therapeutic goals and end points. Importantly, the program’s focus targets 2 measures usually reserved for medical providers and directly tied to optimizing drug therapy: A1c testing for diabetes and A1c under control through the 2020 program year.
Pharmacies receive a payment for documenting that an A1c test has been performed and for reducing A1c levels in patients who are out of range using Pharmacy Quality Solution’s (PQS’) EQuIPP platform. This is not a grant or a papered-over pilot but a strategy that Humana employs in coordination with PQS to improve star ratings and advance quality and population management reach to community pharmacies. These star ratings measures affect the ability of insurers to market their plans and receive bonuses for performance. Humana should be applauded for its foresight and innovation to include pharmacies in the outcomes marketplace. The idea of insurers and pharmacies partnering on outcomes measures must not stop here. Pharmacies should expect and prepare for additional A1c- and therapeutic outcomes—based opportunities. PQS is already planning for multiplan entity deployments in late 2020 and into 2021. This is not and cannot be a flash in the pan. All pharmacies should welcome these opportunities and rally together to perform well with and compare with other care team members. Our collective future is on the line.
COULD THIS BE THE SEMINAL PROGRAM WE LOOK BACK ON IN 2 MORE DECADES?
Community pharmacy sustainability lies with value expressions uniquely positioned in the community that are based on local access to a health care provider, strong interpersonal and interprofessional relationships, and using the dispensing process as a differentiating means of patient engagement. Holding pharmacies and pharmacists responsible for therapeutic outcomes is an important sea change in both the business and practice of pharmacy. Imagine an annual review and performance dashboard related to improvement in patients’ health and not to inventory management. Pay for outcomes creates fundamental shifts in patient interaction, staff motivation, and workflow. It may also improve workplace morale and professional well-being.
ROOTING FOR OUR COLLEAGUES
If community pharmacies can participate in the same risk-and-reward propositions related to clinical and global outcomes as other care team members and do so successfully, we will earn a sustainable future. True marketplaces have no artificial limitations on who can participate and no bias, and they reward the capable. We should all be rooting hard for these 854 pharmacies and their ability to use their position and skills in the community to improve measurable diabetes outcomes. It could be the start of something big.
Troy Trygstad, PharmD, PhD, MBA, is the vice president of pharmacy provider partnerships for Community Care of North Carolina, which works collaboratively with more than 1800 medical practices to serve more than 1.6 million Medicaid, Medicare, commercially insured, and uninsured patients. He received his PharmD and MBA degrees from Drake University and his PhD in pharmaceutical outcomes and policy from the University of North Carolina at Chapel Hill. He also serves on the board of directors for the American Pharmacists Association Foundation and the Pharmacy Quality Alliance.
- Cranor CW, Bunting BA, Christensen DB. The Asheville Project: long-term clinical and economic outcomes of a community pharmacy diabetes care program. J Am Pharm Assoc (Wash). 2003;43(2):173-184. doi:10.1331/108658003321480713
- Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood). 2008;27(3):759-769. doi:10.1377/ hlthaff.27.3.759