BETHESDA, MD 27 August 2012—Participation in an accountable care organization (ACO) requires the support of all members of the health care team, says the pharmacist responsible for outpatient pharmacy services at Minneapolis-based Fairview Pharmacy Services.
"As pharmacists, we really need to make sure that we integrate ourselves into the team, and we do that by taking responsibility for our patients' drug therapy," said Amanda Brummel, during a July 26 webinar sponsored by the Patient-Centered Primary Care Collaborative.
She said pharmacists in the ACO setting are accountable for ensuring that a patient's drug therapy is appropriate, effective, and safe and the patient is compliant with the treatment plan.
Fairview Health Services was one of 32 organizations selected to participate in the Centers for Medicare and Medicaid Services (CMS) Pioneer ACO model. As of late July, more than 350 health care providers at the health system's clinic sites were part of the ACO.
Brummel estimated that about 8,000 of the nearly 20,000 Medicare beneficiaries who receive care from the ACO could benefit from the medication therapy management (MTM) services provided by pharmacists.
Fairview pharmacists have been offering comprehensive MTM services to patients since 1997. The MTM program was established through a partnership with the University of Minnesota College of Pharmacy.
Brummel said MTM pharmacists at the integrated health system work onsite at primary care practices, where they meet with patients to optimize their medication regimens. The pharmacists are salaried employees of the health system, and they usually provide MTM services two days a week in physicians' offices.
"Our pharmacists take care of around 300 to 500 patients per clinic site," Brummel said.
She said Fairview has 24 MTM pharmacists practicing in the Minneapolis–St. Paul area, as well as a network of contract pharmacists in Duluth.
Since its inception, the MTM program has provided care for more than 15,000 patients and solved nearly 80,000 drug therapy problems, Brummel said.
About half of 13,325 patients who received MTM services from January 1999 through December 2011 had three or more drug therapy problems and one third had at least five problems.
Among these patients, 27% were found to need additional drug therapy and 27% needed a medication dosage increased, she said. Unnecessary drug therapy and inappropriately high dosages collectively accounted for 13% of drug therapy problems.
Brummel said MTM reviews that are done using claims data may capture the latter two problems. But without a face-to-face, comprehensive medication review like those done at Fairview, the vast majority of medication-related problems will go undetected.
Candidates for MTM services at Fairview include patients who are at high risk for or have a history of frequent hospitalization, people with poorly controlled chronic conditions, patients who take multiple drugs or receive care from multiple physicians, patients with a recent change in their health or medication status, and patients taking so-called high-risk medications.
Fairview's MTM pharmacists work under collaborative practice agreements and authorized protocols. Brummel said the pharmacists "can initiate, adjust, or discontinue multiple medications for around 20 chronic conditions" and can order and view laboratory test results.
Thus, Brummel said, "we're able to make a lot of changes effectively on our own without going back to the physician."
But, she noted, it took time for the MTM program to evolve into the comprehensive care program it is today.
The payment model has also evolved over time.
"When we first started this, no pharmacists could even bill for their services," Brummel said.
Now, she said, MTM services are paid for through a combination of mechanisms, including shared-savings arrangements with insurers and services billed incident to the provider. In addition, the state's Medicaid program and some local employers reimburse Fairview for MTM services.
"We also have worked with our commercial payers to be able to get some contracts with them. That's still probably our biggest gap," Brummel said.
Brummel said Fairview's MTM program has reduced overall health care costs, improved clinical outcomes in patients with diabetes or asthma, and earned high marks for patient satisfaction.
The MTM program has also resulted in more efficient use of resources at Fairview by routing some lower-risk patients to a pharmacist instead of a primary care provider.
Under the Pioneer ACO model, Fairview Health Services must demonstrate its value to CMS, which will use 33 quality measures to track performance. In general, CMS will evaluate the ACOs in the areas of patient experiences, care coordination and patient safety, preventive health care, and care for patients at high risk for serious outcomes.
Brummel said Fairview's MTM services are expected to play a role in reducing hospital readmissions, improving medication reconciliation and discharge planning, screening patients for fall risks, improving clinical outcomes in patients with targeted conditions, and improving preventive care through immunization and screening activities.
The Pioneer ACO model started this past January. During the first two years of the program, participating organizations are operating under what CMS calls a shared savings and losses model. Performance will be compared against a benchmark, with participants receiving a portion of the cost savings or absorbing some of the losses relative to the benchmark.
During the third year and for up to two additional years, qualifying Pioneer ACO participants will receive a monthly payment for each beneficiary. According to CMS, this payment replaces "a significant portion" of Medicare's fee-for-service payments and can be used to pay for services, such as telemedicine and phone consultations, that are not usually reimbursable under Medicare.