The Impact of ACOs

If the biggest impact of the ACA will be on Medicare and one of the biggest changes in Medicare is the accountable care organization (ACO) model, then one could argue that ACOs will have the biggest impact on our health care system.

Everyone has heard the saying, “The only certainties in life are death and taxes.” Well, I think we can now add “Obamacare” as a life certainty. The Patient Protection and Affordable Care Act of 2010 (ACA) will change our long-held views on health care delivery, funding, and entitlement. This new law aims to provide complete and comprehensive medical coverage for all Americans.

One of the biggest impacts of Obamacare is on Medicare and Medicaid. The goal is to cut $716 billion in waste and reinvest it back into the system. The law addresses issues such as closing the Medicare Part D “donut hole” and providing better quality preventive services to all members. The law also expands Medicaid coverage to approximately 17 million of our nation’s poorest patients.

Therefore, if the biggest impact of the ACA will be on Medicare and one of the biggest changes in Medicare is the accountable care organization (ACO) model, then one could argue that ACOs will have the biggest impact on our health care system. An ACO is a health care organization characterized by a payment and care delivery model that seeks to tie provider reimbursements to quality metrics and reductions in the total cost of care for an assigned population of patients. The entity is accountable for organizing and aligning health care services to deliver seamless, coordinated care. Currently, there are 154 ACOs in the United States serving 2.4 million patients, and analysts predict a big growth year in 2013. The new law aligns incentives for the government and the ACO to share savings from Part A and Part B, but not Part D of Medicare. This is a very exciting proposition for value-based health care, where medications are an investment to save on Part A and Part B without being penalized.

At Elwyn Specialty Care, we are excited by the opportunity to showcase the value of personalized care—a service we have been providing to our patients for more than 10 years. We have partnered with local ACO providers to assist in the medication monitoring of specialty patients. Our mutual goal is to keep patients compliant and adherent, decreasing the rate of hospital readmission, and improving patients’ outcomes. This is not a one-size-fits-all solution. Patient selection, medication therapy management, compliance, and reporting are all variable components.

We developed a program where our pharmacists perform complete drug utilization reviews, including counseling patients on appropriate medication use, dosing, drug interactions, and common adverse reactions before the patient is discharged from the hospital. We ensure that each patient has an opportunity to discuss the medication management program with a pharmacist and answer any questions before they begin therapy. The medication is delivered and then follow-up calls/interventions begin within 7 days. The program is designed to identify challenges and barriers in adherence, discuss techniques and tips to improve adherence, and assist in side effect management and the removal of any other barriers to adherence.

The final component in this process is a critical one: providing assessment summaries back to the prescriber and/or health care team throughout the process. The major difference between Elwyn Specialty Care’s program and other specialty pharmacies is our complete approach to caring for the patient. We don’t care if it’s a $10,000 oncolytic or the baby aspirin that is going to prevent a myocardial infarction—we look at a cancer patient who has diabetes and cardiovascular disease and see 3 disease states that need to be managed. Our concept is to treat the “whole” patient by providing all the prescription and OTC medications needed to obtain the targeted outcomes.

What causes interference and impediments in executing a medication management program is restrictive networks from insurance providers and manufacturers. All members in health care should remember the common goal of helping our patients. When a health plan or pharmacy benefits manager mandates that a patient is to use a certain network or certain mail order pharmacy, this not only causes delays and paperwork for the patients and providers, but also doesn’t promote the concept of treating the “whole” patient. In theory, a hub-and-spoke limited distribution model may work well for medication delivery, but in the real world it poses problems and delays. These types of programs, built around providing services to patients, can sometimes cause a great deal of confusion. Selection to access of medication or coverage by the plan needs to be based on qualification and not managed care coverage.

If ACOs are the future of value-based medicine, then local specialty providers need access to medications and thirdparty plans. If our mutual goal is to provide the best possible care for our patients, then the financial and restrictive paradox needs to be removed from the equation. The truth is in the data, and ACOs will allow local care programs to prove they can provide better care by demonstrating measurable outcomes.

About the Author

Nicholas Karalis, RPh, is president of the board at Community Specialty Pharmacy Network and a pharmacist with Elwyn Specialty Care.