Value-based Care, Changing Payment Models During and Post COVID-19

Sandra Leal, PharmD, MPH, FAPhA, CDE, executive vice president, Health Plans and Payers Division of Tabula Rasa Healthcare & president-elect of American Pharmacist Association, discusses value-based care and changing payment models.

Alana Hippensteele: Hi, I'm Alana Hippensteele from Pharmacy Times. Before we get started, one of our top articles today is about men being at a greater risk of COVID-19 due to plasma concentrations that help the coronavirus infect cells. There's more of that on pharmacytimes.com.

Today I'm speaking with Sandra Leal, the executive vice president for SymphoniaRx and president-elect of the American Pharmacists Association on value-based care and changing payment models.

Sandra, I understand that you've been working to establish integrated clinical pharmacy services in a variety of programs. Why is the integration of these services so important?

Sandra Leal: So, I actually had a change in title, so I'm now the vice president for Tabula Rasa Healthcare, Health Plans and Payers Division, so that is actually something that has changed recently just because of the growth of our company and a lot of the work that I was doing in innovation is really now the work that I'm doing at Tabula Rasa to expand the clinical services of the model that we have, which has been a model that’s telephonic that does medication therapy management nationally, and what we do there is we really try to make sure that patients have the best outcomes with a medication that they're taking. So a lot of it is around medication safety, optimizing medication around the use of things that are, you know, complicated for patients. And we're seeing that, especially right now with what's happening with COVID-19, as we're doing outreach, people have a lot of questions, anxiety, stress. And so we've been trying to reach out to people when they've had barriers potentially coming in for services.

Alana Hippensteele: Yeah, absolutely. So, touching on the idea of value-based care, why do you think effective partnerships between patients and healthcare teams are necessary right now?

Sandra Leal: Absolutely. There is so much opportunity right now to really focus and integrate those two collaborations between the pharmacist, the patient, and the provider. It's really important to be able to address fragments in care right now. People are going to multiple places, they see care for multiple locations, and so what we try to do is really coordinate that care and make sure that everybody has that same information especially as it relates to the medication regimen. And we find that so many people are sometimes confused or don't even realize they have potentially duplicate therapy or that there are barriers that we can help overcome for that individual optimizing national guidelines. For example, making sure that people are taking the things that should be taken based on the guidelines for therapy, and so we really work closely with a health care team and that patient to make sure we have that best care possible and to try to resolve those identified problems that we're intervening on.

Alana Hippensteele: Absolutely, fantastic. How can health care teams work together more effectively to form partnerships with patients in the future?

Sandra Leal: It's really important for teams to be able to really leverage all of the benefits that they have around them. So one of the nice things that I've seen with a lot of the change in value-based models and patient-centered medical homes is that they're really trying to leverage the expertise and people practicing to the top of their license, so when I think about a patient-centered medical home, you know, definitely bringing in the nutrition counselor for those patients that need nutrition visits, bringing in the pharmacists to be part of that team before prescriptions are written, so that you actually have prescriptions that are appropriate, that are affordable, that will work for that individual patient. So you are essentially looking at the strengths of each partner on that team and leveraging that strength to be able to have the best outcomes for the individual, and that really helps of providers out, the physicians and the providers, because they're overwhelmed. There's just so many things that they have to do on a regular basis that if you don't leverage that, it's really hard to actually maintain effective outcomes for your entire panel of patients.

Alana Hippensteele: Yeah, absolutely. How are telehealth services able to support value-based care now and post COVID-19?

Sandra Leal: Well, telehealth is definitely, I feel like we have gained years in a month, you know, where we were leveraging telehealth it was kind of small before, there were some areas where it was excelling and behavioral health was one of them, but now what we're seeing is it, you know, by force, we had to embrace telehealth at lightning speed, and so that's been one of the benefits of- I don't want to say benefits, but one of the maybe positive outcomes we will see as a result of COVID-19. You know people embracing it, using it for the first time actually are saying oh wow this isn't as bad as I thought, and I've heard that from physicians that were reluctant at first to use it. Now that they have used it, they're actually appreciating it, and they're saying oh, you know, I can maintain some of this post-pandemic and actually be able to reach my patients. Now, the way that we've used it is really addressing what we call the air force ground force. We leverage our providers on the ground force and then we bring in telehealth as an air force model to do population health management to help supplement the ground force that sometimes is challenged with the volume of patients that they're having to see, so I feel that telehealth brings in a population health strategy. Especially as we're seeing, you know, groups consolidate how do you manage a population of 10,000 patients, 20,000 patients, a million patients. You can't do it one at a time. You can try, but then you have to make sure there's multiple touchpoints to reinforce some of those benefits and leverage both. Now I really want to emphasize it's not one or the other it has to be both together in order to have an effective way of managing population health now, and then definitely post-pandemic.

Alana Hippensteele: Yeah absolutely. So, in terms of telehealth services, would you say that teleservices with your patients was necessary for you before the pandemic as well? Was that something that you were involved in before?

Sandra Leal: Absolutely. So, we were using telehealth/telephonic outreach for patients to provide medication therapy management and even in our clinics for follow-ups, you know, chronic care management, for example. It's actually a telephonic follow up with patients to manage your chronic conditions in-between visits. So, we were already using it probably more than other practices. But what we constantly had to convince people about is that it's an effective strategy, it doesn't take away from the relationship with your patient, because I always had the argument that face-to-face is a hundred times better. And, you know, I'm not disagreeing that it's really good to do face-to-face. This is supposed to, again, help supplement, and help do touch points in-between visits, and then really, you know, everything is changing, technology is definitely, you know, it's a thing. People have their cell phones, you can connect with them wherever they are, so in my mind it's not trying to fight that, but how do you actually use it in a way to be effective. And it's not to replace a provider, it's to enhance the providers’ ability to stay connected with a patient and to hopefully get things resolved, and I think about it even in my own personal situation. I've been using a patient portal for my own health care, and it's incredibly beneficial to be able to message a provider, receive an email response, get a lab order through email without having to physically drive somewhere or physically go get it because all of that creates delays in me being able to actually get the care that I need. So, again, you know, enhancements to the opportunities we have today, and hopefully patients continue to embrace it, and we see a better outcome as a result of it.

Alana Hippensteele: Absolutely. So, in terms of payment models I understand that payment models are changing today. Have you seen more changes arise specifically due to the COVID-19 pandemic, and how are these payment models changing?

Sandra Leal: So, we've seen a lot of really great flexibility created because of COVID-19. So, I've been trying to work with telehealth legislation out there, and being a pharmacist, we're not one of the recognized providers. I was hoping that the flexibility would then, you know, also include pharmacists to be one of the recognized providers for telehealth, and unfortunately that has not happened yet, but what we are seeing is some restrictions lifted with telehealth in regards to sites that you could use it, you know, allowing it to QATs for example in rural health centers to have more flexibility, so there is a positive movement in allowing that flexibility. So I hope that really last post-pandemic because, again, if people embrace telehealth, we can deliver care, we can stay connected to people, especially those that that struggle with transportation, or those that are experiencing social determinants of health type of issues where this might become a point of entry and consistency in their care that prevents that fragmentation that's happening.

Another big issue is that we're seeing a lot of practices closing, you know, pharmacies have been closing in rural areas, hospitals have been closing, private practices, there's just been a lot of consolidation in the market. And so that's actually taken away an access point for individuals to be able to be connected to care, so this definitely provides that, and again it's not a solution you still want to maintain at that face-to-face if you can, but additional service opportunities, additional access points, I think are very critical to make sure that people have the continuity of care that they need, especially for chronic conditions, and we're seeing a lot of that today.

Alana Hippensteele: Yeah, absolutely. So how do you see payment models changing in the future? Do you see anything changing drastically?

Sandra Leal: I definitely see that there's a lot of innovation. Even in the way that we've been paying for value-based care, there's been a push to try to get people to think creatively about how to manage populations. Some of the incentives around risk and being able to be creative, I think that is definitely hopefully going to continue, because that is driving people to think differently and think about ways to utilize different practitioners, how to utilize technology, you know, doing remote monitoring kind of things. So I do feel like that's going to continue to evolve, and hopefully again with some of the regulations that have been, you know, softened a little bit that we can continue to pursue some of that creativity and being able to provide services in a way that do bring more value and hopefully, you know, bend the curve on the increasing cost of health care, because it is, it was going up exponentially, and so we do have to do something to be able to maintain that without, you know, bankrupting our healthcare system.

Alana Hippensteele: Absolutely. In terms of immunizations, why do you believe it's important for immunizations to continue during the COVID-19 pandemic?

Sandra Leal: Wow. So, I was just having a discussion yesterday with- I'm the president-elect for the American Pharmacists Association, and we were having this discussion about the pause right now on just usual vaccines because of COVID-19. Until the risk of not starting to think about what to do is going to put people at risk in a few months for kids that are not going and getting their usual vaccinations, and so I think it's very critical, immunizations not just for COVID-19. We're trying to come up with a vaccine for COVID-19, but then usual vaccinations are so important to be provided, and I know pharmacists have really stepped up to be an access point for vaccines again, not trying to replace pediatricians, but working in collaboration with pediatricians, having bi-directional communication to registry so that we all have that same information. We're not duplicating vaccines, but we're also not missing vaccine opportunities for children and for adults, in fact, to be able to really take that public health approach, so I just think it's really important for us to be constantly thinking about that, and then looking at opportunities to assess patients, to provide vaccine touchpoints, and to be able to reinforce how critically important they are, so that we can prevent, you know, incredible hotspots that we're seeing. And unfortunately, Arizona has been a hot spot for measles in the last year, and so this is something that if we don't, you know, really get a handle on it, we're going to continue to see these outbreaks happening.

Alana Hippensteele: Yeah. What do you think the impact of the current economic decline will be on medication adherence, and how can pharmacists intervene?

Sandra Leal: So, we've been trying to assess exactly what's happening with medication adherence. At first, we saw a lot of people trying to pick up their medication so that they had a stock of that in order to make sure that they could have it enough during the pandemic. But at the same time, as we've been contacting individual patients, a lot of them have been afraid to go to the pharmacies, or, you know, there's been a push to get medications mailed to them, there's been, you know, a lot of discussion around drive-throughs and, you know, people accessing their medications. So, we're still wanting to see what exactly the effect is going to be. I know for a fact that pharmacists are really trying to have those conversations with patients, and how critically important it is for people to continue to be adherent to their medication regimen, and COVID-19 provides a great opportunity to discuss that because people with the highest risk factors for COVID-19 are people who have chronic conditions, and I would imagine that if you're not controlled with your chronic conditions, your outcomes are potentially worse. So, you know, we're leveraging that information to say hey, let's continue care, let's make sure you're taking your medications, and we want to make sure your chronic conditions are under good control so that you don't become an even higher risk for COVID-19. So, this is an example today, but this is a constant discussion that we have, you know, pre-covid and post-covid and we're going to continue to reinforce how critically important it is for people to maintain their adherence and make sure they're taking medications the right way. And I want to really emphasize here's that it's not just about taking the medication, you know, it's about picking the right medication for the right conditions, and making sure you're not having safety issues, or you know ill-effects as a result of the medication. So, it's not just about adherence but taking the right medications, and that's where your pharmacist can really play a key role and outcomes related to adherence.

Alana Hippensteele: Yeah, absolutely. Thank you so much, Sandra, for taking the time to speak with me today. Now, let's hear from some of our other MJH life sciences brands on their latest headlines.