Pharmacists in ACOs, Part 1: Accountable Care Basics Every Pharmacist Should Know

While trying to explain his work on quantum mechanics, physicist Richard Feynman famously quipped, “If anybody says they understand it, they don’t understand it.” The same could be said about the speed-of-light changes occurring within our nation’s health care system. In an effort to bring us all up to speed on these current changes, and share some pretty amazing opportunities ahead, this series, Pharmacists in ACOs, will give you a history, background, and implications of accountable care as it pertains to our profession.

Q: Start at the beginning: What is accountable care, and where did it come from?

A: The term accountable care refers to language within the Patient Protection and Affordable Care Act, commonly known as the ACA or Obamacare. More than 20,000 pages of related regulations have sprung from the original 974-page federal statute, covering everything from improving health care access to Medicare spending to revenue provisions. Accountable care is the idea that providers and health care systems should be rewarded or punished based on how well they provide their services (ie, that health care systems are financially incentivized to take into account their patients' outcomes. Accountable care’s goal is coined the “triple aim” and formally includes (1) improving patients’ experience, (2) improving the health of populations, and (3) reducing overall cost. Accountable care is often countered against the traditional fee-for-service model in which providers are paid for their volume of services, rather than for their services’ quality.

Q. If health care is being held accountable, how do we get graded?

A: The ACA's passage created several cost-containment methods called alternative payment models (APMs) that CMS can now use to incentivize health systems to produce better patient outcomes. You are probably familiar with the effects of the Hospital Readmission Reduction Program, which penalizes hospitals that have excessive readmission rates for certain conditions, such as congestive heart failure and chronic obstructive pulmonary disease. (Pharmacists have already shown that we can improve outcomes in this model, but that is a story for another time.) Or maybe you have heard of things called Bundled Payments or Patient-Centered Medical Homes. But, one of the major ways CMS "grades" health care systems is through an APM called an accountable care organization, or ACO.

An ACO is a group of providers, systems, and health care entities that partner to ensure delivery of quality care to a specifically defined population. Although some private sector ACOs also exist, most ACOs are highly associated with Medicare; however, all ACOs are graded against quality measures. These quality-improvement standards, of which 34 exist, adjust slightly from year to year, cover 4 domains related to patients’ satisfaction, safety, preventive health, and care for high-risk populations.

Each ACO’s standards are compared to national benchmarks established by CMS based on prior to the year to which they apply. Benchmarks are the performance standards ACOs must achieve in order to earn points. Each ACO’s final quality score is then used to determine the amount of savings it shares or amount of penalties it will owe to CMS.

Q: So who is being held accountable?

A: As health care professionals, we are all accountable, but some are more accountable than others. As of now, pharmacists and pharmacies are not likely to be incorporated into ACOs, but may be in the near future. Those in community pharmacies are mostly affected by accountable care under the Star Ratings they receive from Part D plans. The Star Rating System is deployed by CMS to measure how well Part D plans perform. Ratings are from 1 (worst) to 5 (best) and are calculated based on several categories, including quality of care and customer service. Community pharmacists are directly affected by star ratings by their patients’ use of preventive medications, adherence to certain chronic therapies, and the percentage of CMRs completed. The growth potential for pharmacists outside of dispensing roles is extremely wide, as we have the ability to affect those quality measures for ACOs, and many are related to the medication use process and preventive health screening. Of these 34 quality measures, pharmacists can directly influence 18, and arguably influence all 34.

Q: Wait a second, there’s a big election coming. Won’t all of this change? Could accountable care go away?

A: The plain and simple truth is yes—the Accountable Care Act will change, just as managed care, health maintenance organizations, pharmacy benefit managers, Medicare, Medicaid, and every other way we provide health care changes. As new and innovative methods for delivering care continue to be developed, the Accountable Care Act should change. However, the notion of accountable care in terms of value-based rather than volume-based care, as a method of improving our nations’ health care is never going away. The US health care system has turned a new leaf for over half a decade and too much change, success, and savings have occurred to go back to the old volume-based payment models that were crippling our national spending and health outcomes. A recent report from the Robert Wood Johnson Foundation estimates that the United States is on course to cut health care spending by $2.6 trillion by 2019. To put that amount in perspective, NASA could be funded at its current budget for 141 years with that kind of money. Yes, the ACA can and should be amended over time; but, no, pharmacists should not ignore accountable care.

Watch for the next 2 articles in this series. We will be discussing, more specifically, how pharmacists can influence accountable care through medication therapy management, annual wellness visits, chronic care management, transitions of care, and disease state management.

This article is published in collaboration with the Directions in Pharmacy CE Conference program.

Stephanie A. Gernant, PharmD, MS, is Assistant Professor of Pharmacy Practice Nova Southeastern University, College of Pharmacy.