Accountable Care Organizations: Pharmacy on the Front Lines

Specialty pharmacy is at the forefront of providing the team-based care and patient counseling now being sought in the developing accountable care organization model.

The accountable care organization (ACO) model is being developed in the United States by experts across the health care spectrum. These experts agree that there is a need for providers of health care to work together to help slow the cost curve and improve quality. One of the main criticisms of health care today is of the traditional fee-for-service payment system, in which reimbursement is based on the individual service provided, resulting in poor coordination of effort among all the caregivers for a given patient.

Studies suggest that moving patients from uncoordinated care to coordinated care, with interventions and coordination across providers, could reduce the cost of care significantly. This process is evidenced in integrated systems such as Kaiser Permanente, where all the stakeholders work together on behalf of the patient. However, this model has been difficult to replicate in other parts of the country due to the fee-for-service method.

The ACO concept began through the realization that physicians who are tied to a particular hospital or health system often function as a network, and their patients tend to stay within this network for most of their health care. The thought is that you can formally organize these networks and hold these systems accountable by assessing the quality of care provided. The more improvement in care that is demonstrated by a network, the better the payment that can be derived from the payers.

The Affordable Care Act (ACA) enacted in March 2010 authorizes the Centers for Medicare & Medicaid Services to contract with ACOs to provide health care to Medicare beneficiaries under a shared savings program that began in January 2012. Discussions about the ACO model have primarily been in the world of Medicare; however, there is growing discussion about the concept for other health care sectors, including Medicaid and private insurance. This can only lead to more improvement of the ACO concept in general.

Over the past decade, several studies have demonstrated that pharmacists participating in team-based care models have made positive contributions to patient care and safe medication use. Pharmacists are well trained in the proper use of medications and are well positioned in the health care system to help optimize appropriate medication use, reduce medication-related problems, and improve health outcomes.

However, the pharmacist has not really been viewed in this light or utilized in this manner until recently. In particular, pharmacists based in community practice and properly trained in specialty disease states such as HIV, hepatitis C virus (HCV), and oncology are at the front lines of managing side effects, counseling the patient, and increasing overall adherence to therapy.

Specialty pharmacists in community settings are already actively involved in communicating with prescribers and patients to improve quality and appropriateness of care. Incorporating pharmacists within the ACO health care team will be essential to achieving the required quality improvement benchmarks set forth in the ACA.

It should also be noted that specialty pharmacy in the community setting can provide valuable data to all stakeholders on the health care team. I believe this data would be particularly valuable to the managed care organizations and the pharmaceutical manufacturers. In both cases, the data collected at the patient level could yield valuable insights into the behavior of patients on specific therapies.

For example, from the plan point of view, the data gathered can be used to build a disease management initiative that would be effective in dealing with a transient HIV population. Typical letterbased programs may not be effective in that population; the more effective adherence model would include the use of texting and in-person group meetings at the pharmacy to drive the need for compliance.

Another example, this time from the manufacturer’s point of view, involves the collection of the reasons for discontinuation of therapy by patients on a new and novel HCV therapy. Data collected in the real world will often offer manufacturers insight into the behavior of a particular therapy that was not realized during controlled trial settings.

Pharmacy has made great strides in elevating its position as a true member of the health care team over the last several decades. In my view, the community pharmacist trained in the delivery of specialty pharmacy services is in a unique position to deliver great value to the accountable care organization model as it develops. SPT

About the Author

Nicodemo “Nick” Calla, RPh, JD, is vice president of industry relations for the Community Specialty Pharmacy Network.