BETHESDA, MD 21 Dec 2015—Blue Cross Blue Shield of Michigan (BCBSM) has taken a well-established program for providing clinical pharmacy services in patient-centered medical homes (PCMHs) and used it as the basis for a statewide initiative.
"The real intent is to change the way that healthcare works in our state—where we transform the care not just for Blue Cross members but, potentially, for all people that live in the state of Michigan," said Laurie Wesolowicz, director of pharmacy services for the health plan.
The practice model was implemented in 2009 at the University of Michigan Health System (UMHS) by Hae Mi Choe, director of pharmacy innovations and clinical practices for the health system. Choe said the model places pharmacists in already-established PCMH settings to help patients manage diabetes, hypertension, and dyslipidemia.
She said published and unpublished data show that the pharmacists' care has resulted in significant reductions in glycosylated hemoglobin levels and improved other indicators of care for patients with diabetes, such as statin use and regular examinations for peripheral neuropathy.
"We've also made tons of therapeutic alterations to improve efficacy and safety and reduce drug costs. So we're very active in the therapeutic management of chronic disease," Choe said.
BCBSM in September 2015 announced the launch of the Michigan Pharmacists Transforming Care and Quality program, a collaboration with UMHS, to establish clinical pharmacy services in 10 participating physician group practices in the state. The health plan's goal is to expand the model to all 46 physician practices that participate in BCBSM by the end of the two-year project.
Choe said BCBSM's strategy is innovative because the insurer, instead of paying for clinical encounters, directly funds the physician practices to develop programs for pharmacists to provide clinical services.
"Pharmacists are just such a natural part of a patient care team that we really wanted to support this program," Wesolowicz explained. "Pharmacists know drug therapy better than any other practitioner. They have the skill set to really talk about the really important quality measures like medication adherence, drug safety, [and] drug interactions."
Choe's role as director of the initiative is to help the leadership of each physician organization identify a pharmacist who is a good fit for the group's culture, leadership structure, and politics. She said each of these pharmacists will be trained to become a "pharmacist transformation champion" for developing the clinical care model at his or her practice site.
For the rollout of the PCMH expansion, Choe required the initial physician groups to already have a clinical pharmacist performing some type of patient care for the group. In addition, she said, at least two large physician practices within the selected groups had to make a commitment to engage with that pharmacist in the expanded role.
Participating practices are also required to sign a collaborative practice agreement that gives pharmacists prescribing authority and clinical autonomy in their defined role.
Choe said the alternative—requiring the pharmacist to seek a physician's approval for every proposed intervention—would defeat the purpose of the model.
"Without the collaborative practice agreement that allows the pharmacist to exercise clinical judgment within the confines of what we've agreed upon, you're really tying that pharmacist's hands behind their back," she said.
She said the pharmacist transformation champions that have been recruited come from a variety of backgrounds, including some who did not complete an ambulatory care residency.
"If you have a really bright pharmacist who's very engaged and very interested in this area and is willing to . . . get their skills and education up to par, then it's possible to get them ready to do this type of job," she said.
Choe said the acceptance of pharmacists' services by the physician leadership at UMHS has exceeded her wildest expectations.
"When I first started with the medical homes, I had to go door to door and try to promote and sell pharmacy services, because I wanted each health center to fund the pharmacist's time for their clinical services and not just get the pharmacist's time for free," Choe said.
Now, she said, the health system talks to her before building new patient care areas to ensure that pharmacists will be part of the care team from the beginning.
"It's been wonderful to see that transformation within our health system where now it's an expectation" to have pharmacists on patient care teams, she said.
That is also occurring outside of UMHS, Choe said. She said a large Michigan physician organization that isn't affiliated with her health system contacted her last year about emulating her practice model in its offices. She was able to connect the physician group with a pharmacist who had just finished an ambulatory care residency and was then hired by the group.
"Now, she's the lead pharmacist for this big physician organization developing clinical programs, which is wonderful because this is exactly what she is trained to do. And they liked her so much they hired another pharmacist," Choe said.
Wesolowicz said some physician practices in Michigan have worked with pharmacists on the healthcare team and are eager to build on that experience. Other groups, she said, are "guarding their turf" and have not embraced the integration of pharmacists into their practices.
"We really hope, once we get this program launched and we measure outcomes, even some of those naysayers will see the value that the pharmacist can bring to their practice setting," Wesolowicz said.
BCBSM has committed to fund the PCMH program for two years. But Wesolowicz predicted that sustained support for pharmacists' clinical services will arise from incentive payments to participants in the health plan's Physician Group Incentive Program (PGIP) and other quality-improvement initiatives.
"A lot of those quality measures include medication-related issues," Wesolowicz said. "If the [PCMH] pharmacists make changes to affect the quality of care related to the PGIP quality measures, that physician organization receives greater incentives and people are getting better care and reaching better outcomes. So it's kind of a win-win all the way around."