Medication Management: Integrating the Pharmacist as the Champion

Pharmacists should solidify their place within the patient-centered medical home. Here is an early model that achieves better health outcomes through comprehensive medical management and a team-based approach.

I have worked in the pharmaceutical industry for more than 20 years. At my core, I am a pharmacist by training, and have long had a passion for exploring ways to integrate pharmacy practice into care teams with a goal of improving outcomes and lowering the total cost of care.

For me, this quest began in the mid-1990s working in state government affairs for GlaxoSmithKline (GSK) in the Pacific Northwest on pharmaceutical care initiatives with local pharmacy associations and schools of pharmacy. As I moved into the US Public Policy group at GSK, my role transitioned to educating policy makers on the results and benefits of the Asheville Project (www.nbch.org/The-Asheville-Project-Case-Study) and eventually, to support a collaboration with the American Pharmacists Association Foundation to replicate the Asheville model through the Diabetes Ten City Challenge.

We haven’t been alone at GSK. Many leaders in the profession have worked tirelessly to elevate pharmacy practice as part of care coordination models. But challenges to date around payment for services, scope of practice, and a lack of technology needed to implement effective comprehensive medication management solutions have slowed the progress. However, to use an old cliché, there is light at the end of the tunnel. Today, the movement toward a value-based health care system in the United States represents an incredible opportunity for pharmacists, and most of all, for patients.

The United States health care delivery system is currently designed to focus on episodic care and acute illness. Most health care reform experts have articulated the need to improve the health care delivery infrastructure to enable better proactive management of chronic diseases and prevention services. However, implementing a better health care delivery system is interdependent on achieving payment reforms that align incentives to clinical outcome improvements, as well as connecting the care delivery infrastructure with health information technology, which facilitates the sharing of information and provides the needed quality data mining necessary for payment.

Improving the health care delivery system is a key, interdependent component of overall health care reform. One way to do this—coordinating the delivery of health care through a Patient Centered Medical Home (PCMH)—is gaining popularity among public and private payers as well as policy makers. The medical home model is gaining momentum because of its value proposition for the patient, physician, and payer by improving outcomes while lowering costs.

The medical home model is gaining strong political support as well. The 2010 Patient Protection and Affordable Care Act (ACA) contains several provisions relating to the PCMH. Most notable is the creation of the Center for Medicare and Medicaid Innovation (CMMI), which is piloting broad payment and delivery system reforms across the country. CMMI has launched 2 large demonstration programs, the Multi-Payer Advanced Primary Care Practice (http://innovation.cms.gov/initiatives/Multi-Payer-Advanced-Primary-Care-Practice/) and the State Innovation Models Initiative (http://innovation.cms.gov/initiatives/state-innovations/), both of which have a significant PCMH component.

In addition to the federal activity, most states understand the value of the medical home and several are currently implementing pilot programs. According to a recent Health Affairs (http://archive .pcpcc.net/2012/11/6/health-affairs-article-half-states-are-implementing-patient-centered-medical-homes), 25 states have enhanced provider payment systems to encourage implementation of the PCMH within their Medicaid program.

Unfortunately, of all the great care coordination work being done across the country, very few of these initiatives have included clinical pharmacists on the care team. Appropriate use of medications is a key element of a coordinated care delivery system, and in my opinion, pharmacists are the best suited to lead the effort to optimize therapy and help patients achieve their clinical goals.

Demonstrated Success with PCMH

Nowhere is the value proposition of the patient-centered medical home model more clear than at Community Care of North Carolina (CCNC), an organization with which GSK is proud to have a long history of collaboration.

CCNC (www.communitycarenc.org) began in 1998 in order to improve health care quality and save costs. The program now provides care to more than 1 million Medicaid recipients in North Carolina and has grown to encompass 14 networks, 4500 primary care physicians, and 1000 medical homes. According to a 2011 Milliman analysis, CCNC saved the state of North Carolina almost $1 billion between 2007 and 2010, primarily through lower emergency department and hospitalization utilization. The Healthcare Leaders Council awarded CCNC its Wellness Frontiers Award in April 2013 for implementing evidence-based care management programs that prevent disease and encourage wellness.

CCNC relies on patient-centered medical homes, population health management, case management services, and community-based networks to deliver care. The program provides each Medicaid recipient a case manager to serve as their coach to make sure they understand doctors’ orders and get to their appointments on time. CCNC has further developed their care coordination networks by adding several disease management initiatives, including asthma, diabetes, and congestive heart failure, as well as a chronic obstructive pulmonary disease pilot program.

Pharmacists began to work with CCNC on its medical home program in 2007 after it was noticed that there were patients with diverse medications who were prone to polypharmacy-related problems. It was evident that pharmacists could enhance clinical outcomes by providing medication management (pharmaceutical care) services while also managing drug costs. While medication cost savings are a convenient ancillary benefit to the program, the primary objective of CCNC pharmacy projects has not been to minimize medication costs, but rather to achieve therapeutic optimization to maximize health.

This is a subtle but important distinction since the former contributes toward the volume-based system we are moving away from while the latter allows for prescriber and patient-centered interventions such as coaching for adherence that in some instances actually increase medication costs, but ultimately improve care, when appropriate.

A team-based approach—pairing a pharmacist with the case manager—has been used so that an assessment of each patient can be made and points can be prioritized to inform the primary care physician before they see the patient face-to-face.

Throughout the CCNC networks, there are now more than 50 pharmacists who are the lead project managers and facilitators of pharmacy-related activities within a certain geographic boundary. They participate in activities such as developing proposals for new initiatives, reporting to the network leadership on existing initiatives, or presenting at local medical management meetings. The scope of activities in the CCNC networks offers a unique opportunity and challenge for pharmacists, and there is a growing need for more.

Pharmacist Role in Care Coordination

So where else are the pharmacists working within a PCMH environment? It seems obvious that one of the key areas of care coordination between a health care provider and the community is that of comprehensive medication management. To date, predictably, most pharmacists playing an integral “care coordination” role are located within the public integrated delivery systems, such as the Veterans Administration and Health Resources and Services Administration, as well as the private integrated delivery systems, such as Kaiser Permanente. Unfortunately, the “siloed” nature of ambulatory medicine has prevented significant uptake in pharmacist participation to date.

Fortunately, the Patient Centered Primary Care Collaborative (PCPCC) recognized this opportunity and organized a multi-stakeholder workgroup to formalize the role of the clinical pharmacist within the PCMH. That group published the second edition of “Integrating Comprehensive Medication Management to Optimize Patient Outcomes” in June 2012 for physicians, insurers, payers, and pharmacists to follow as they formalize the medication management relationship between a pharmacist and provider care coordinator.

Additionally, previously in 2009, Dr. Edwin Webb from the American College of Clinical Pharmacy authored a white paper entitled “Integration of Pharmacists’ Clinical Services in the Patient-Centered Primary Care Medical Home.” Dr. Webb references several recommendations of the Institute of Medicine’s “Quality Chasm” report, and based on those recommendations, he suggests pharmacist integration into the PCMH should be based on 7 essential principles. These principles emphasize the need for pharmacists’ clinical services in a patient-focused environment, as well as highlight the need for a flexible care delivery design that is focused on outcomes with access to HIT systems. The final principle calls for aligned payment policies to substantiate the medication management process.

Given the momentum to evolve our health care delivery and payment system to one that is proactive, coordinated, and connected, I cannot think of a better time for pharmacists to solidify their place within medical homes across the country. As pharmacists, we must step up if we are ever to demonstrate the critical role of comprehensive medication management in achieving better health outcomes and lowering overall health care costs. What an opportunity for us, and there is no time to waste—the patient is waiting.

Jon Easter, BSPharm, RPh, is senior director, delivery and payment reform, at GlaxoSmithKline (GSK). His primary focus is health care transformation and the health information technology (HIT) policy environment, where he works to maximize its value to enable better health care quality, enhance the US health care delivery system, and ultimately improve patient outcomes. At GSK, Jon has championed the company’s involvement in North Carolina First in Health, one of the nation’s leading patient-centered medical home projects. He was also directly involved with replication of the Asheville Project, a recognized model for care coordination to improve patient outcomes for chronic disease. Jon has spent 20 years in the pharmaceutical industry. In addition to his public policy experience, Jon has implemented patient registry systems within GSK’s care management division, covered the Pacific Northwest for the state government affairs organization, and spent several years as a sales representative and district sales manager.