Accountable Care Organizations and Provider Status

Accountable care organizations (ACOs) are groups of health care providers (HCPs) or hospitals that work collaboratively to provide coordinated and high-quality care to their covered patients.¹ The United States is fighting the costs of health care, and experts estimate that more than 75% of all US health care expenditures are related to chronic conditions and medication use.² Pharmacists can be an ACOs’ secret weapon for providing high-quality care regarding medication use.

The US health care system spends close to $300 billion annually due to misuse of medications and more than $150 billion annually because of adverse events (AEs).² Pharmacists can optimize appropriate medication use and positively affect patient care. They can conduct medication therapy management (MTM) services for ACOs, including drug therapy management clinics (eg, clinics on HIV, hepatitis C, or anticoagulation), comprehensive medication review, medication reconciliations, drug utilization reviews, identification of gaps in care, and prescription drug adherence clinics.³ When pharmacists have worked in these capacities, patient outcomes have consistently been shown to improve. For example, pharmacists have been able to significantly improve glycated hemoglobin levels, low-density lipoprotein cholesterol levels, blood pressure readings, medication adherence, patient knowledge, and patient quality of life, while reducing AEs via MTM services and other related clinics or utilization reviews.⁴

Although pharmacists have been validated to reduce drug expenditures, hospital readmissions, lengths of stay, and emergency department visits,^3,4 they have not been consistently incorporated into team-based health care models of various ACOs and have not been recognized as reimbursable health care providers.⁵ Without consistent provider status recognition, pharmacists nationwide will not be able to provide the comprehensive services discussed here.^2-6 For example, pharmacists cannot submit claims to insurance companies for various services; therefore, there is no documented record of their participation in improving patient outcomes.

Currently, 38 states designate pharmacists as HCPs in their state code, but much work is needed to clarify the definition of “provider” and make it consistent with other health care professions. Only California and Washington state define pharmacists as HCPs throughout their state code and Medicaid policies.^2-6 In several other states, legislation has been introduced to consistently include pharmacists as providers in the state code or Medicaid policy.⁵ Pharmacists, nationwide, must uphold their legislative duties and get involved in their state’s health care policies (Online Table).

Table: Top 3 Interventions for Promoting Pharmacists as Health Care Providers

1. Visit pharmacist.com, accp.com, and ashp.com, and search for “provider status.”

These websites provide comprehensive information and resources regarding provider status. For example, these organizations have prepared letters that you can send to your representative or local elected official.

2. Identify and speak with your elected officials.

Opening a line of communication with your representative can provide an opportunity to voice your concerns. Your representative may become your advocate when other members of government or officials are debating provider status. To find out who your local and state officials are, visit opencongress.org.

3. Identify and speak with local, influential health care providers (HCPs).

Pharmacists are requesting to be part of a team of HCPs; therefore, we need to learn to “pass the ball” and work with other HCPs. Reach out to local physicians, nurse practitioners, and physician assistants, and offer to speak with them about the services you provide. In addition, consider speaking with their representatives. When you communicate with them and develop a mutual understanding, they will be more likely to contact their representatives and support our quest for provider status.

^{Adapted from references 1-5.}

Mohamed Jalloh, PharmD, is an instructor at Creighton University in Omaha, Nebraska, and a community pharmacist at Walgreens.

References

• Accountable Care Organizations. CMS.gov website. cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO/index.html?redirect=/Aco. Accessed November 11, 2015.
• Amara S, Adamson RT, Lew I, Slonim A. Accountable care organizations: impact on pharmacy. Hosp Pharm. 2014;49(3):253-259. doi: 10.1310/hpj4903-253.
• Role of pharmacists in Accountable Care Organizations. AMCP website. amcp.org/WorkArea/DownloadAsset.aspx?id=9728. Accessed November 29, 2015.
• Chisholm-Burns MA, Kim Lee J, Spivey CA, et al. US pharmacists' effect as team members on patient care: systematic review and meta-analyses. Med Care. 2010;48(10):923-933. doi: 10.1097/MLR.0b013e3181e57962.
• Provider status: what pharmacists need to know now. Pharmacist.com website. pharmacist.com/provider-status-what-pharmacists-need-know-now. Accessed November 28, 2015.
• More states address pharmacists’ provider status recognition. Pharmacist.com website. pharmacist.com/more-states-address-pharmacists-provider-status-recognition. Accessed November 28, 2015.