Pharmacy News

Medicare Project Helps Put Pharmacists in Primary Care

[March 15, 2016, AJHP News]

Kate Traynor

BETHESDA, MD 01 Mar 2016—An ongoing Medicare demonstration program with a medication management component shows some hope of reducing healthcare costs through the use of team-based primary care services.

An analysis of first-year data from the Comprehensive Primary Care Initiative (CPCI), which started in the fall of 2012 and runs through this year, found that the cost savings to Medicare nearly equaled the $141 million in care-management incentives paid to the participating practice sites.

A report commissioned last year by the Centers for Medicare and Medicaid Services (CMS) called this finding "promising," since savings weren't expected during the program's first year. But the report noted that the cost offsets varied by region and urged caution in interpreting the initial data.

The CPCI includes about 500 primary care practices in seven geographic regions. Each participating site receives per-member-per-month (PMPM) payments from CMS and other payers and may be eligible for additional shared-savings incentives.

Among the initiative's requirements are that all participating sites implement one or more primary care strategies—comprehensive medication management, integrated behavioral health services, or patient self-management support services—as part of CPCI's focus on population health.

Sites are encouraged, but not required, to implement all three of these strategies by the end of the demonstration project, according to CMS.

The most recent data from CMS indicate that nearly 100 CPCI sites have implemented comprehensive medication management services and 74 practices have brought at least one pharmacist onto the healthcare team to provide the services.

Clinical pharmacist Katherine O'Neal of OU Physicians, an internal medicine clinic affiliated with the University of Oklahoma School of Community Medicine in Tulsa, is one of those pharmacists.

"I am completely integrated into the clinic," O'Neal said. "I do medication reconciliation and daily prescription reviews and medication monitoring for all medications prescribed in our clinic, and I provide support for medication use and self-management."

She also works to resolve medication-related issues that occur during transitions in care and sees patients by referral to help them control chronic conditions such as diabetes, hypertension, chronic obstructive pulmonary disease, and dyslipidemia.

O'Neal is the internal medicine clinic's only pharmacist and is onsite 4.5 days per week. Her position is funded through the University of Oklahoma College of Pharmacy, where she holds the titles assistant professor and adjunct associate professor.

Nearly a quarter of the pharmacists working at CPCI sites are funded through an academic appointment, according to CMS. About half have been directly hired by the practice group, and 14% work under contract. Other sources fund the remainder of the positions.

According to CMS, all of the CPCI sites that focus on medication management provide medication reconciliation services, and most also address medication coordination during care transitions and medication review and assessment. Nearly half have collaborative drug therapy management agreements in place.

Jessica Binz, director of clinical pharmacy education at the University of Arkansas for Medical Sciences—West Family Medical Center in Fort Smith, said her practice site participates in several quality initiatives, including CPCI.

Binz practices under a collaborative drug therapy management agreement—known in Arkansas as a "written protocol"—and also works closely on medication-related issues with the transitions-of-care team.

"I do smoking cessation and medication management for smoking cessation as well," Binz said. "We have an interdisciplinary team that works with patients that are interested in stopping smoking."

Binz said the smoking-cessation program started last October and is going well. She said one of the positive trends is that her patients, many of whom have "issues with transportation," find ways to get to their follow-up appointments.

All of the Medicare beneficiaries in the practice—about 650 people—are considered part of the CPCI population, Binz said. Overall, according to CMS, the CPCI practice sites are responsible for the care of about 2.7 million patients, including more than 400,000 Medicare and Medicaid beneficiaries.

F. Alison Gray, ambulatory care pharmacist at the Little Rock Family Practice Clinic in Arkansas, said she was initially brought into the CPCI-participating clinic to help patients reduce their medication costs, mostly by increasing the use of generics and ensuring that prescribing is aligned with each patient's pharmacy plan.

After she found that the healthcare team was already doing a good job of keeping drug costs down, she turned her focus to warfarin management because it is "fairly straightforward" to implement and manage.

"Once I got that off the ground, then I moved on to diabetes education, which is really my passion," said Gray, who worked with the clinic's dietitian to develop a diabetes education program for patients.

"We have individual and group visits as well as a monthly support group that we have put together. And so far, it's been pretty successful. We've seen some pretty good outcomes with patients," Gray said.

Gray said she will be evaluating diabetes outcomes measures for CPCI. For warfarin-management patients, she is collecting data on their International Normalized Ratio (INR) values and examining whether patients are having their INR checked regularly.

Outcomes measures like these may help practice sites qualify for incentive payments from insurance programs that participate in the CPCI.

CMS initially identified 31 payers that covered a substantial portion of the practice sites' patients, agreed to contribute to PMPM payments, and, in some cases, offered pay-for-performance bonuses or other incentives to improve population health.

Marie Smith, assistant dean for practice and public policy at the University of Connecticut School of Pharmacy in Storrs, said the multipayer participation is an unusual cornerstone of the CPCI.

Smith explained that it's difficult for practice sites to disrupt their processes to participate in individual initiatives by different payers. She said having payers working in concert, as they do in the CPCI, minimizes this problem.

But she said it's the PMPM payments, which largely come from CMS, that have really boosted the CPCI by providing start-up funds for sites to hire the pharmacists and other staff needed to meet the program's milestones. She contrasted that strategy to shared-savings incentives, which are generally paid out only after outcomes have been assessed and long after the care is delivered.

Smith spent six months during 2013 on faculty leave at the CMS Innovation Center, where she focused on creating a road map for the integration of clinical pharmacy services into CPCI practice sites. She said the near-universal existence of state collaborative practice laws in 2012 gave CMS staff the confidence that pharmacists would be able to work effectively under the CPCI model without running afoul of scope-of-practice regulations.

CMS's implementation guidance for CPCI participants recommends that practices focusing on medication management include a clinical pharmacist on the healthcare team. According to CMS, the pharmacist should be involved in patient care either directly or by performing chart reviews and making therapy recommendations.

The pharmacist should also help the practice identify patients who are at high risk for poor health outcomes and would benefit from medication management. And, according to CMS, the pharmacist should participate in care team meetings and help develop processes to improve medication use and safety.

"It's an exciting time to be in primary care because there's so much experimentation going on," Smith said. "The new payment mechanisms, I think, are going to open up tremendous opportunities for pharmacists."


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