Population Health Management

Pharmacy Practice in Focus: Health SystemsMarch 2015
Volume 4
Issue 2

Pharmacists play a vital role in chronic disease management.

Pharmacists play a vital role in chronic disease management.


As health care systems continue to experience pressure to improve their quality and outcomes while traditional reimbursement for services declines, it has become increasingly clear that new models for patient care delivery are needed. One such model is population health management (PHM). In this model, a clinical team oversees the medical management of a population to optimize preventive services, identify high-risk patients, and improve disease management. The overall goal is to contain costs for the population by keeping the patients as healthy as possible while avoiding increased expenditures like emergency department (ED) visits, hospitalizations, and procedures.

Pharmacists are well positioned to play an integral role in this model. However, this will likely involve making changes to your current position. For the past 2 years, I have had the opportunity to practice in an innovative teambased clinic, with a focus on PHM. This experience has provided me the opportunity to learn strategies that work, challenges to consider, and areas for further exploration.

Working as a Team

Physicians are learning that PHM cannot be accomplished by a single individual. About 10 years ago, researchers estimated that it would take a physician approximately 18 hours per day to provide all the necessary chronic and preventative care for their patients.1,2 Practices will be unable to meet the demands of PHM unless they have additional team members who can manage chronic diseases and coordinate care between office visits. Pharmacists are uniquely skilled to provide these services through their own prescriptive authority or collaborative practice agreements. For example, a physician group may be struggling to achieve goal blood pressure (BP) control for its diabetic patients, and reimbursement could be decreased if this goal is not met. The practice could hire a pharmacist to focus on titrating blood pressure medications at clinic visits or remotely in order to meet this goal.

While many of the current teambased approaches involve a pharmacist being housed in a primary care or specialty clinic, there are not enough pharmacists to staff every office, and an individual office may not be able to financially support a pharmacist’s compensation. However, a large health network or group of practices may be open to adding several pharmacists to work with the neediest patients and direct improvements in chronic disease management at a network level where they can manage patients on a larger scale, thus improving access and utilization.

Although pharmacists have established clinical services in many academic institutions, as well as the Veterans Affairs health system, PHM may be relatively foreign to more traditional private and public practices. Transitioning to PHM activities can be challenging for practices as they bring in new team members and learn to share the responsibility for patient care. Many physicians are excited to have pharmacists join the team, but may not fully understand your level of training and expertise in chronic disease management. I recommend educating providers on your skills and preparing for the clinic several months before starting to see patients. Once you are at your clinic or facility, face-to-face time with providers is critical, both initially and as you advance your practice.

Patient Registries

PHM relies heavily on electronic health information. Registries, the computerized systems that house data for patients with a specific disease state, are an essential tool. For example, a registry can be built for all the diabetic patients, and include pertinent information such as glycated hemoglobin (A1C), blood pressure values, and statin use. Using the data compiled, registries can stratify patients into risk categories to allow targeted interventions for the neediest patients. At my clinic, our highest risk diabetic patients are categorized as “red” due to a score that is weighted for A1C value, BP control, low-density lipoprotein control/statin use, current tobacco use, and incidence of recent inpatient admission. We focus on the red patients at weekly “huddles” with the entire care team, which includes the primary care provider, nurse care manager, nutritionist, clinical pharmacist, medical assistant, and social worker. Patients with a high A1C level may be referred to the pharmacist to work on insulin titration, or we may identify a patient who is lost to follow-up.

Without tools such as a registry, it is nearly impossible for a practice or health care system to identify the highest risk patients. While current models tend to group patients by disease state, an ideal model would calculate a global risk score for a patient based on factors like total chronic disease burden, utilization of ED and inpatient services, and lifestyle factors (eg, access to medications). This type of scoring allows a pharmacist and other team members to truly focus on the patients with the greatest need.

New Forms of Patient Encounters

In order to manage an entire population, it may no longer be feasible or reasonable to conduct the majority of medical management through individual face-toface patient visits. Consider conducting some of your interventions by phone, electronic messaging, or through video conferencing. Instead of scheduling two 30-minute visits in an hour, you may be able to interact with 4 to 6 patients during that hour. This works especially well for focused insulin titration or hypertensive patients with home BP monitors.

Phone visits can be helpful for gathering information, but there are times when actually seeing the patient is necessary. For example, if a patient was recently discharged from the hospital, it would be ideal for you to see the medication bottles rather than try to review medication changes through a phone conversation. Our clinic has recently started using a program called TouchCare, which allows anyone with an Apple device to conduct a secure visit, similar to FaceTime, with their provider. The program is easy for patients to use and enhances the electronic visit (e-visit) experience. Such technology could be especially helpful for patients who need a follow-up visit but are geographically far from the clinic.

Although e-visits offer unique benefits, there are challenges to and considerations for their implementation. In the current fee-forservice model, providers are not compensated as well (or at all) for conducting remote encounters; practices may not embrace new technologies unless it is shown to be financially beneficial. Each clinic must also decide how to incorporate these visits into the work flow. In my clinic, e-visits are scheduled in 15-minute slots within each provider’s schedule. I believe it important for e-visits to be scheduled at a specific time so the patient can be ready for the encounter, however, there can be a tendency for them to start late due to circumstances within the clinic schedule that cause the provider to be delayed. It may be ideal to schedule a dedicated block of time in each provider’s schedule to conduct e-visits in order to be efficient and respectful of patients’ time. Finally, it is important to find a platform that is accessible and reliable for patients.

Reimbursement: What Will It Look Like?

One of the biggest questions about PHM is how to reimburse practices for delivering excellent care. In the fee-for-service model, there is no standardized way to compensate a provider for services beyond office visits and procedures. A pharmacist may spend several hours a day doing e-visits with diabetic patients to adjust insulin, but receive no reimbursement for his or her work. In order for PHM to be sustainable and for pharmacists to have a viable role, there must be a way for practices and health care systems to be financially compensated.

Different models exist for valuebased reimbursement. In pay-forperformance, a provider’s reimbursement is based on attaining specific quality standards, such as percentage of diabetic patients on a statin or achievement of BP goals.3

Another way to control costs and reward efficient medical care is with bundled payments. In this model, the provider group accepts a prospectively determined payment for management of an acute episode, management of chronic disease for a defined period of time (usually 1 year), or primary and preventive care for a particular population. The best designed bundles would include adjusted reimbursement based on risk of patients, providers being held accountable for avoidable complications, inclusion of a stop-loss provision, and outcomes reporting.4 Reimbursement could also be structured like an accountable care organization or shared savings model in which provider organizations accept responsibility for managing a population in terms of quality and finances. Groups are rewarded through shared savings programs if they lower health care costs while meeting quality measures.3

It is still unclear how reimbursement will be structured in the future as we move away from the fee-for-service model. We may see a blended model with a smaller payment for an office visit and a larger payment to a health care system for meeting quality standards. While each system has its own merits and downfalls, they all require health care systems to take on more responsibility for managing their population to achieve quality at a lower cost.

Final Thoughts

Medicare recently announced that by the end of 2016, 30% of payments should be based on value, with an increase to 50% by 2018.5 As large entities like Medicare make these changes, more insurers will follow to make PHM possible. PHM opens the door for patients to receive more care from pharmacists than in previous models. Let’s not miss this exciting opportunity!

Caroline Howard, PharmD, BCACP, CPP, is a graduate of the UNC Eshelman School of Pharmacy in Chapel Hill, North Carolina, and is board certified in ambulatory care. She is a clinical pharmacist practitioner at Carolina Advanced Health, a team-based primary care clinic.


  • Østbye T, Yarnall KS, Krause KM, Pollak KI, Gradison M, Michener JL. Is there time for management of patients with chronic diseases in primary care? Ann Fam Med. 2005;3(3):209-214.
  • Yarnall KS, Pollak KI, Østbye T, Krause KM, Michener JL. Primary care: is there enough time for prevention? Am J Public Health. 2003;93(4):635-641.
  • Ritchie A, Marbury D, Verdon DR, Mazolini C, Boyles S. Shifting reimbursement models: the risks and rewards for primary care. Medical Economics. Published April 8, 2014. http://medicaleconomics.modernmedicine.com/medical-economics/content/tags/aca/shifting-reimbursement-models-risks-and-rewards-primary-care?page=full. Accessed January 22, 2015.
  • Porter ME, Lee TH. The strategy that will fix health care. Harvard Business Review. Published October 2013. https://hbr.org/2013/10/the-strategy-that-will-fix-health-care/. Accessed January 22, 2015.
  • Better, smarter, healthier: in historic announcement, HHS sets clear goals and timeline for shifting Medicare reimbursements from volume to value [press release]. US Department of Health and Human Services website; January 26, 2015. www.hhs.gov/news/press/2015pres/01/20150126a.html. Accessed January 30, 2015.

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