Pharmacist Integration is Essential to Implementing Value-Based Care Models


High engagement and collaboration between health systems and health plans is essential to implementing value-based models, according to a session at the Pharmacy Quality Alliance 2021 Annual Conference.

With the rise of value-based care models over the past decade, pharmacists can have a major impact on the total cost of care and success of models in health care systems, according to a session at the Pharmacy Quality Alliance 2021 Annual Conference

Paying for value means paying for results rather than a simple transaction, explained presenter Brendan O’Hara, RPh, BCACP, a clinical pharmacist with Blue Cross North Carolina. Projected national health expenditures anticipate that health care will have a 19.4% share of the national gross domestic product by 2027, with a majority of those expenditures going toward the sickest patients.

O’Hara reviewed several payment models, spread across 4 categories. The first category, he said, consists of the classic fee-for-service model, which he said is not sustainable. The second category involves a fee-for-service model that is linked to quality and value, whereas the third category is an advance payment model (APM) built on the fee-for-service model. Finally, the fourth category involves population-based payment.

Transitioning to these systems requires time, O’Hara said, as well as systematic changes throughout the entire health care system. Pharmacists in all environments—including community pharmacies, hospital pharmacies, and health plan pharmacists—can play an important role in these changes.

Pharmacists have a large impact on the total cost of care, O’Hara said, especially because they have a high-level view of the patient’s care and the total costs. Through working with high utilizers on collaborative drug therapy management and being involved with other providers, pharmacists can minimize costs while optimizing health outcomes, according to O’Hara.

Furthermore, some quality measures used by the Centers for Medicare and Medicaid Services can be directly impacted by pharmacists, including completion of a Comprehensive Medication Review, the statin use in persons with diabetes measurement, and medication adherence measures in many disease states. Measures in the Healthcare Effectiveness Data and Information Set are also impacted by pharmacists, such as the Asthma Medication Ration, diabetes and hemoglobin A1c control measures, and behavioral health measures.

Finally, O’Hara said high involvement from both health systems and health plans is essential in successfully implementing value-based plans. Signs of low health system engagement can include having pharmacists not directly involved in quality improvement; having pharmacists secondary to other teams and serving in solely a referral capacity; and not following through with opportunities to collaborate with the health plan.

Similarly, signs of an unengaged health plan include scheduling only ad-hoc meetings with the health system; providing clarification of quality measures only as needed; and discussions of quality without implementing an action plan.

High engagement in both health systems and health plans can be seen in many ways, especially through increased collaboration between the two. A highly engaged health system has pharmacists directly involved in quality improvement efforts; discusses processes with the entire team and tracks best practices; documents changes directly in electronic health records; and has made steps toward Cost of Care initiatives.

A highly engaged health plan conducts monthly meetings with the health system; has specific pharmacists identified to lead quality processes; has identified the work and support ideas of health system pharmacists; and shares data with the health system, according to O’Hara.

The impact of high engagement can be seen in health outcomes data, O’Hara said. Research by Blue Cross NC has shown improved HBA1c control as well as improvements in blood pressure control and statin use when health systems and health plans are both involved in quality improvement. He added that a close collaborative relationship was essential to noticing how a coding issue caused a sharp decrease in blood pressure control measures in the spring of 2020, allowing it to be corrected quickly.


O’Hara, B. Integrating Pharmacists in Value-Based Care. Presented at: Pharmacy Quality Alliance; May 13, 2021. Accessed May 13, 2021.

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