A Tidal Shift: Pharmacists and US Health Care Reform

Accountability and performance metrics are becoming a reality as pharmacists focus on quality of care. Pharmacists must anticipate and respond to the tidal shift.

The American health care landscape is shifting—and the pharmacy profession must shift with it. Health care delivery in the United States is both nuanced and enigmatic.

Our care delivery system has been vilified for its fragmentation, inaccessibility, and waste, while simultaneously praised for its innovation, skilled workforce, and resourcefulness. The changing landscape is full of both challenges and opportunities for pharmacy, which will only increase in the next 12 to 24 months as the hard work of fully implementing the provisions of the Patient Protection and Affordable Care Act (ACA) continues.

A Tidal Shift

As pharmacists, we must anticipate and respond to the tidal shift within the health care marketplace as a result of the ACA rollout. Federal and state governments, payers, and providers are increasingly reframing health care issues in terms of value, rather than strictly in terms of cost. This is reflected throughout the provisions of the ACA, with emphasis and incentives on improved quality and performance measurement serving as drivers of a new paradigm.

Providers and payers are rewarded for assuming population health risks and lowering overall costs while maintaining or improving quality. Emerging delivery models such as accountable care organizations (ACOs), and penal programs such as the Centers for Medicare & Medicaid Services (CMS) Readmissions Reduction Program, share common elements of care coordination requirements and data-driven quality measurement.

Pharmacy needs to answer these questions regarding our integration into the post-ACA environment:

What are the real implications and opportunities for pharmacists within the short and medium terms?

How can we best position ourselves to play a meaningful role in driving improvements in patient care within the evolving system?

In order for pharmacy as a profession—and pharmacists as individual practitioners—to deepen their collective contributions, there are several key steps that we should take.

Focusing on Value, Not Volume

The ACA includes several mechanisms that will lead to a substantial number of previously uninsured individuals becoming covered. A March 2010 Congressional Budget Office report indicated that the ACA will increase the number of insured non-elderly Americans from 83% to 94% by 2019. For elderly patients, the gradual closing of the Medicare Part D donut hole by 2020 will increase patient access and the use of pharmacies. The challenge lies in how we handle the increased volume of patients within our health care system—both at the primary care level with the shortage of physicians, and as pharmacists with the increase in the prescription volume. First, it is necessary to recognize that the emerging system is trending to reward value over volume.

As a profession, how do we ensure that there is value within the medication use system? Defining that value is critically important.

Measuring Value in Health Care

Value in today’ s health care system is measured through performance metrics. The National Quality Forum has nearly 700 endorsed measures that are used across health care settings. Each year, it reviews hundreds more for recommendation to various agencies within the Department of Health and Human Services. Pharmacy is far from exempt from performance measurement. The CMS has adopted several Pharmacy Quality Alliance measures generated using prescription claims data to calculate star ratings for Medicare D and Medicare Advantage plans.

As pharmacists, are you aware of the development of performance metrics that apply specifically to medication use and medication therapy management (MTM) services? Do you know how medication adherence is measured? Are you aware there are measures that look at how many comprehensive medication reviews are completed within the Medicare program for beneficiaries that qualify for an MTM benefit within their plan?

These measures will begin to shape how pharmacy practice continues to evolve. They are not only used by government agencies. In fact, some employers are already using performance metrics on appropriate medication use as an integral part of the way they evaluate the performance of both the pharmacies they run and the pharmacists they employ.

With the health care system, value is measured for nearly all providers. Doctors, hospitals, nursing homes, home health care agencies, dentists, and others are all directly measured. There are websites dedicated to public reporting of the performance of doctors, hospitals, nursing homes, and more. Pharmacies and pharmacists have thus far existed outside of this paradigm, but are unlikely to be able to do so for much longer. While it may yet be several years before pharmacies’ performance is publicly reported, as it is with other providers, the movement exists for performance to be measured across pharmacy providers in today’ s environment.

The Meaning of Accountability for Pharmacists

Within the health care system, accountability is moving front and center. Accountability for outcomes and performance as well as incentives for meeting certain high levels of quality care is becoming a reality. This accountability is being driven from many angles—by payers, employers, and also the federal government.

For pharmacists, however, there is a key step that we need to achieve before we can have direct accountability for our services and actions. This is a major rationale behind the collective effort amid national and state-based pharmacy organizations to pursue the recognition of pharmacists as health care providers as defined by the Social Security Act.

Why Become Providers?

If we truly want to optimize value in our health care spending, Medicare must include pharmacists’ clinical services that are provided in collaboration with physicians and other providers on the health care team. Recognition of pharmacists’ clinical services in the non-physician part of Medicare Part B would help to improve patient outcomes and assist physicians and other providers in effectively addressing the complex health care needs of patients.

This provider listing is not only used within Medicare Part B, but also by ACOs, state Medicaid programs, and other payers to determine payment policies and services covered. Achieving direct provider recognition of pharmacists would be a giant step forward in terms of being able not only to provide the clinical services that pharmacy has been offering, but also being able to be directly compensated for these services as well.

The change in provider status needs to accompany an accountability mind-set. That accountability extends beyond the 15-minute window when our patients are our customers. Pharmacists must take responsibility for their panel of patients, and think carefully about their contributions to managing the health of individuals and populations. Managing medication therapy includes taking responsibility for medication adherence, talking with patients about their therapy, addressing medication concerns, and making connections with patients who are not coming into the pharmacy when they should be.

Narrowing of Networks: Quality Means Marketability

Pharmacies that ignore the trend lines now run the risk of being increasingly cut out of the game. The narrowing of provider networks is already a prominent feature of the emerging health care landscape. Cost cutting within employer-based plans, increasingly managed care—heavy Medicaid programs, and the naturally narrower options within ACOs and Patient-Centered Medical Homes are becoming more pronounced features of the landscape. Within pharmacy, we see this paradigm unfolding as well.

Plans and payers have created preferred pharmacies—and they are a very prevalent reality in 2013. While the narrowing of preferred pharmacy networks to date has not been based on quality, we are seeing those dialogues beginning to take place in the market. Once quality becomes the determinant in creating networks based on performance against clinical measures, it will become the focal point in maintaining a pharmacy’ s marketability. Individual pharmacists, pharmacies, and the profession as a whole must include a focus on quality to remain viable within the new health care landscape.

Laura Cranston, RPh, serves as the executive director of the Pharmacy Quality Alliance, which is a multi-stakeholder organization established in April 2006 to improve the quality of medication management and use across health care settings with the goal of improving patients’ health through a collaborative process to develop and implement performance measures and recognize examples of exceptional pharmacy quality. Prior to her current position, Laura served as the executive director for the Institute for the Advancement of Community Pharmacy, an organization whose mission was to advance the practice of both independent and chain community pharmacy in the United States. Samuel F. Stolpe, PharmD, is associate director of quality initiatives at the Pharmacy Quality Alliance and an adjunct faculty member at Howard University. Dr. Stolpe collaborates on a number of research and demonstration projects exploring expanded roles for community pharmacists. He plays a key role in developing and implementing intervention strategies that improve medication-based performance metrics.