Promise or Peril? Collaboration in Pharmacy

Coordination of patient care is a key goal of the accountable care organization model.

In the move toward a value-based system, collaboration among stakeholders is the name of the game. For hospitals and physician groups, the accountable care organization (ACO) model holds promise. An ACO, as defined by the Centers for Medicare & Medicaid Services, is a group of “doctors, hospitals, and other health care providers,” and, essentially, the goal of the ACO is clearly stated as one of coordinated, high-quality care. It is a system where shared risk and shared savings are meant to incentivize appropriate, value-based care. The concept is one many health care providers can get behind. As the medication expert, doesn’t the pharmacist belong in this collaborative value circle?

On the one hand, medication management is being hailed as the way forward, and improving medication adherence is on every pharmacist’s priority list. Programs, such as the star ratings, are meant to incentivize this way of thinking, and the message is getting through. On the other hand, community pharmacies are left to figure out how to get invited into the consortium while also running their businesses under the current, unsustainable reimbursement model that is based on prescription volume.

Directions in Pharmacy^® interviewed Bernie Vitti, executive director of business development, and Harry Thibodeau, chief operations officer of Pharma-Care, Inc, a New Jersey-based health care consulting company, to get an inside look at how pharmacists with boots on the ground are breaking into the value-based care market. What they told us amounts to this: hospitals and health systems can choose to either collaborate or consolidate, and many have chosen the latter.

Q: The first time you heard of an ACO, what was your impression, and did you think it would be important for your business strategy?Bernie Vitti: The idea behind collaboration is to have all of the stakeholders involved in the patient-centered process sharing information that delivers the best outcome for the patient. This has to include the pharmacy. The message brought to the ACOs is that we can help them simplify their population management and work within the framework of their guiding principles. Their response was you would have to be included in the same risk pool with us, and your payments may be delayed for up to 18 months. That sounds great, but unless I have a large revenue stream, committing those kinds of up-front dollars is a real challenge and near impossible.

At present, many ACOs are starting to align themselves with health plans and patient-centered medical homes, but they are missing the medication-adherence component. Therein lies the void left in making the value-based program work. The patient—physician relationship is seen as the most important part of the collaborative effort. Integrating the pharmacy into that relationship, however, increases the potential for positive outcomes, and we see it as true collaborative medicine.

Q: How do you see the ACO model evolving?BV: As we speak, ACOs are beginning to redefine themselves, moving toward an integrated health network environment. You have ACOs that are part of a large physician organization attached to a hospital or health system, and those that do not align themselves with a hospital or health system. Additionally, the health systems/networks are collaborating, merging, and/ or acquiring other hospitals to expand their reach. There is a large health system in New Jersey that has evolved into a large health network. As a result, most of the northern New Jersey landscape falls under their umbrella.

What we find so far is that the health networks haven’t given the pharmacist a chance to become part of the health care team. They have not realized the true value of pharmacists and what they bring to the collaborative team. In most cases, health systems include physicians, nurses, social workers, and care coordinators. If you are really a collaborative team, then the pharmacist must have a seat at the table.

Q: Where have you seen pharmacists incorporated under this model?Harry Thibodeau: ACOs are debating whether or not they should hire their own pharmacists. This model does not work unless they commit to sufficient staffing levels. If they are not hiring enough pharmacy staff, they are ultimately attempting to do more with less. This goes against the goal of improving quality. Some of the big chain pharmacies, which have the working capital to tolerate the reimbursement lag, have been able to participate by affiliating with health systems through collaborative agreements.

Q: What has the effect been on efforts to provide patient-centered, collaborative care?HT: The concept of accountable care is to push the risk down to the provider. The concept of the ACO is to get the providers to work together. Ultimately, it comes down to resources and where those resources can be found within the ACO. Organizations are incentivized to buy up other entities that would otherwise keep patients out of their revenue streams. When considering the push toward a patient-centered approach, one has to ask whether all these acquisitions and mergers are helping them achieve patient-centered care and improved quality, or are they just helping them leverage their contracts?

Q: What is the biggest barrier to community pharmacies, and where is the opportunity for pharmacists to have an impact?HT: Rather than working directly with the purchaser to provide value through a comprehensive medicationmanagement program, community pharmacists are forced to work through a third-party entity that is responsible for providing that value. Fundamentally, that is the biggest barrier.

BV: The opportunity for population management is on the employer side, where you are contracting directly with the purchaser. The employers, especially those that are self-funded, understand that dealing with the health plan and the third-party administrator is not going to be enough. They are starting to see the value that the pharmacist can bring to the table. They are looking at their costs and seeing that the return on investment (ROI) through direct face-to-face disease intervention programs is both a possible and practical approach to reducing costs.

Q: What is your population management approach with employers?

BV: All we are doing is providing a functional, value-based care design program. The effort hinges on 2 fundamental principles:

(1) Education. You need to have clinical experts meet face-to-face with the employees to educate them as to what the value-based program can provide. Have the clinical pharmacist work with those select employees, especially those that are moderate to high risk and are contributing 80% to 90% of total health care costs.

(2) Benchmarking. Demonstrate the results with data! Depending on the various value-based programs currently being delivered, the ROI is very similar. Employers usually begin to see results over an 18- to 24-month period of time. When the data are presented, it inevitably raises the question as to why things were not done this way previously.

Q: What advice do you have for clinical and community pharmacists?HT: The differences between a “clinical pharmacist” and a “community pharmacist” only exist within the limitations we place on ourselves. We hear from community pharmacists that they do not have the time, and some have said they have lost the skill set to engage in comprehensive medication management. Through proper reimbursement, the time factor fades. Through educational refresher courses and certificate training programs, confidence levels increase. Most community pharmacists know what an ACO is, but they do not have any involvement with them.

Community pharmacies are going to need to navigate these collaborative environments, especially given the emphasis on star ratings programs. The fundamental difference between the employer market and community pharmacy’s involvement with star ratings is that the star ratings are focused on process and outcomes through an intermediary. With employers, it is about total cost of care and a direct line to the purchaser.

As community pharmacists, you have got to break down the doors and educate the key decision makers. Let them know you have a program that can help them—and demonstrate it. This requires patience, perseverance, and persistence. You cannot crack the collaborative market in 6 months. On the health network side and the ACO side, we have work to do. Engagement with professional organizations, such as ASCP [American Society of Consultant Pharmacists], AMCP [Academy of Managed Care Pharmacy], APhA [American Pharmacists Association], etc, and your state pharmacy chapters, can only help to expedite this process. And it’s important to remember, there is strength in numbers!

Bernie Vitti is the executive director of business development at Pharma-Care, Inc, located in Clark, New Jersey. He received his master of arts degree from Seton Hall University. Bernie has been an intrepreneur at Pharma-Care, Inc, launching new and innovative value-based care solutions and medication therapy management program initiatives throughout the Northeast metro area.Harry A. Thibodeau, PhC, RPh, CCP (right), is the chief operations officer at Pharma-Care, Inc, with responsibility for the company’s day-to-day operating activities. He is a member of the American Society of Consultant Pharmacists (ASCP), the New Jersey Association of Mental Health and Addiction Agencies, the New Jersey Pharmacist Association (NJPhA), and the Governors Epilepsy Task Force for the State of New Jersey, and has served as a member of the government affairs committee for both ASCP and NJPhA.