Healthcare Reform Challenges Creating New Opportunities

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Healthcare is ever changing and with those changes must come adaptation. There is a focus on quality of care versus quantity of care. Team-based care and pay-for-performance models are on the rise and pharmacists are a part of the equation.

Primary Care Healthcare Reform Overview

The U.S. healthcare system is experiencing rapid transformation. The Patient Protection and Affordable Care Act (ACA) is impacting the delivery of healthcare and the manner in which payment is provided for this care. ACA changes have an overall focus that aligns with the Institute for Health Improvement’s “Triple Aim” concept for U.S. healthcare improvement that includes: improving the individual experience of care; improving the health of populations; and reducing the per capita costs of care for populations.1

Primary care providers are being impacted by these reform changes. Providers now manage a large amount of quality metrics that must be tracked and reported. There are currently thousands of unique quality metrics that are being collected and evaluated.2 The metrics focus on:

  • Patient health outcomes (i.e.; diabetes control, blood pressure control and other forms of health improvement markers);
  • Health risk reduction and preventative measures (i.e.; immunizations, smoking cessation, elderly fall risk assessment, etc.);
  • Early disease detection (i.e.; various cancer screenings, patient satisfaction evaluations);
  • Care processes (i.e.; checking blood pressure, measuring Hb A1c levels on appropriate frequency);
  • Patient access to care in a timely manner; and
  • Patient satisfaction with the care provided. 3,4

In addition to all the data capture and reporting requirements for primary care providers, payment reform is now being tied to quality and satisfaction metrics. Current fee-for-service payment models incentivize higher quantity of patient care services and procedures but are not impacted by patients’ overall health quality or outcomes. As a result, the average U.S. primary care visit lasts 11 minutes.5 The more patients seen, the higher the revenue generated in this payment model.

With the introduction of ACA healthcare reform initiatives, primary care payment models are changing. The new payment models provide payment that is closely aligned with providers who produce results that are indicative of higher quality and value. They are termed pay-for-performance (P4P) or fee-for-value (FFV) payment models. Primary care provider reimbursement may still have a portion of the payment that is linked to fee-for-service reimbursement, but there is a substantial portion of payment (or penalty in some cases) that is linked to targeted quality, care access and patient satisfaction metrics. In addition, some of these payment models may also require providers to go at-risk for the cost of care for a patient population. The at-risk portion of the payment model means a provider may be responsible for a portion or all of the cost associated with care that exceeds a predetermined goal dollar amount allocated for a patient population. As an incentive to participate in an at-risk model, providers are also typically able to receive a bonus payment from a portion of savings (aka shared savings) produced when the total cost of care is less than the predetermined goal dollar amount for the patient population.

Many of the new payment models impact primary care providers through contracts with private insurance companies. In 2015, the Medicare Access and CHIP Reauthorization Act (MACRA) created primary care payment reform within the Medicare system.6 MACRA introduces a pay-for-performance component to Medicare Part B that will tie payment for primary care providers to quality metrics.7

Changing the Role of Primary Care Providers

New payment and patient care models for primary care are focused on patient-centric care and are expected to require a team-based care model for primary care practices to maintain financial sustainability. This may cause dramatic changes in primary care settings. In the new practice models, physicians are expected to continue providing access to care to a large population of patients but are now being held accountable for patient outcomes. With many of the outcome measures focused on chronic disease management, care process improvements and some preventative health improvements, physicians would struggle to accomplish success alone. Primary care physicians have to re-engineer their practices and processes. They also have to identify and utilize healthcare-team members who bring value through interventions and services that lead to the desired patient health outcomes.

Team-based care models are needed for physicians to successfully provide patient care in a timely fashion while also producing higher quality patient outcomes. Thus, physicians have to become team coaches and not necessarily independent star players.Dr. Christina Taylor, from The Iowa Clinic, analogized the new role of physicians to be similar to that of a pit crew chief for a race car. The pit crew chief’s responsibility is to ensure the race car runs at peak performance, but the chief utilizes pit crew members for designated services, such as changing the tires, refilling the gas, washing the windshield and so on. Physicians need a pit crew that consists of different healthcare providers: nurses, nurse practitioners, physician assistants, dietitians, social workers and/or pharmacists.

What Does Community Pharmacy Have in Common with Primary Care?

Successful adherence programs have the potential for major impacts on both pharmacies and primary care providers’ performance outcomes. If patients are adherent to the appropriate drug therapy, then their health outcomes typically improve and total healthcare costs decline. Providers who are being evaluated on total cost of care are impacted by the drug cost component. While improved adherence raises the total drug cost, this cost is generally outweighed by reducing other healthcare costs due to disease management and control.

Community pharmacies are entering the pay-for-performance payment world as well. In 2012, the Centers for Medicare & Medicaid Services (CMS) introduced the Five-Star Quality Rating System in an effort to define, measure and reward quality healthcare provided through Medicare Part C and D plans.8 The ratings directly evaluate private insurers and prescription benefit managers (PBM) contracted to administer Part C and D plans. Quality metrics and performance can be traced to the community pharmacy level. Thus far, pharmacies have been evaluated predominantly on the following Prescription Drug Plan (PDP) Star Ratings metrics:

  • Adherence rates for oral diabetes medications
  • Adherence rates for cholesterol (statin) medications
  • Adherence rates for renin angiotensin system antagonist medications (ACEIs, ARBs, aliskerin)
  • MTM Comprehensive Medication Review (CMR) completion rate
  • Appropriate use of high-risk medications9

The focus of the PDP Star Ratings is to improve care for costly chronic diseases while also attempting to reduce the risk of avoidable healthcare costs and adverse drug events. In the past, the Star Ratings were not directly connected to payment for community pharmacies. This is changing as Medicare PDPs are introducing pay-for-performance contracts related to Star Ratings. Many of these contracts provide incentives and penalties integrated within the reimbursement for dispensing the drug. Therefore, it is vital for community pharmacies to adjust their practice models in response to these new quality metrics. Medication synchronization, packaging and other programs to improve adherence to drug therapy need to become standard services offered to patients. Community pharmacists who integrate recommendations for cost effective drug therapy options within the adherence service may produce a more profound impact on the total cost of care. This represents a tremendous value proposition that aligns with performance-based payment incentives.

Turning Primary Care Challenges into Opportunities

Primary care providers are faced with the challenge of building cost-effective care teams as they attempt to grasp a new model for economic sustainability with payment reform. Team members who produce improved quality outcomes are of higher value to primary care providers. Many of the Medicare Star Ratings that impact community pharmacies align with the same patient populations and chronic conditions that are driving quality metrics for primary care providers. Because of the importance of appropriate medication therapy utilization by these patient populations, there is an incentive for collaboration when primary care providers understand the value community pharmacists bring to the table to help produce positive patient outcomes and reduce healthcare costs. These positive outcomes, in turn, generate financial rewards for providers. This incentive can be even stronger, if the physician is participating in an at-risk/shared savings payment model.

Laying the Foundation

Promotion of community pharmacy services is key to educating primary care providers on the value of community pharmacists.Promotions should focus on community pharmacists’ services that can directly impact primary care providers’ quality metrics. Two basic areas include immunization and drug therapy adherence services. Consider that influenza immunization rates are a quality metric required by multiple payers. Current documentation of patient immunization statuses in electronic medical records is required for primary care providers to receive positive quality metric scores. When providing immunizations to patients, notify their primary care provider. Not only does this provide valuable information to the primary care provider; it creates a positive perception of community pharmacists as team-based care members. Adherence to appropriate drug therapy can have a major impact on primary care provider quality metrics tied to patient outcomes and total healthcare cost containment. Share with the provider the pharmacy’s ability to improve patient adherence rates to drug therapy with this service.

What’s Next?

Healthcare and payment reform will continue to evolve. The current changes are only the beginning of the journey. This article is the first in a series on new opportunities for community pharmacists to collaborate with primary care providers. The next topic will explore chances to expand adherence programs for an enhanced impact on patient outcomes while also fostering a strong relationship with physicians with the potential for new revenue sources related to pharmacists’ services.

1 Berwick, Donald, et al. “The Triple Aim: Care, Health and Cost.” Health Affairs. May 2008. 27(3): 759-769.
2 Avalere Quality Measures Navigator. Avalere Health. Web. 1 Sept. 2016. http://avalere.com/business-intelligence/quality-measures-navigator
3 “Part C and D Performance Data.” Centers for Medicare & Medicaid Services. Sept. 1, 2016. Web. 1 Sept. 2016. https://www.cms.gov/medicare/prescription-drug-coverage/prescriptiondrugcovgenin/performancedata.html
4 “Patient-Centered Medical Home (PCMH) Recognition.” NCQA. Web. 1 Sept. 2016. http://www.ncqa.org/programs/recognition/practices/patient-centered-medical-home-pcmh
5 Rabin, Roni. “You’re on the clock: Doctors rush patients out the door.” USA Today. April 20, 2014. Web. 1 Sept. 2016. http://www.usatoday.com/story/news/nation/2014/04/20/doctor-visits-time-crunch-health-care/7822161/
6 “MACRA – Delivery System Reform, Medicare Payment Reform.” Centers for Medicare & Medicaid Services. Web. 1 Sept. 2016. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html
7“CMS Quality Measure Development Plan: Supporting the Transition to the Merit-based Incentive Payment (MIPS) and Alternative Payment Models (APMs).” Centers for Medicare & Medicaid Services. May 2, 2016. 1 Sept. 2016. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Final-MDP.pdf
8 “Medicare Star Ratings: Stakeholder proceedings on community pharmacy and managed care partnerships in quality.” American Pharmacists Association and Academy of Managed Care Pharmacy. J Am Pharm Assoc. 2014;54:228-240. http://www.amcp.org/starsproceedings/
9 “2017 Medicare Part C & D Star Ratings Measures.” Centers for Medicare & Medicaid Services. Web. 1 Sept. 2016. https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/Downloads/2017-Measure-List.pdf

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