Value-Based Payment Models That Integrate Pharmacist Involvement

Health plans can provide cost data demonstrating medication cost trends, but clinical data are required from the health system to offer a comprehensive perspective. Pharmacists have an integral role in bridging this gap to ensure health systems achieve clinical, quality, and cost-of-care benchmarks.

During a session at AMCP Nexus 2020 Virtual, Brenden O’Hara, RPh, BCACP, clinical pharmacist of provider engagement initiatives, and Joseph Albright, PharmD, manager of clinical pharmacy programs, both of BlueCross BlueShield of North Carolina, discussed how interactions between health system and health plan pharmacists can improve clinical and quality outcomes in shared savings models.

Health care is expected to reach 19.4% of the national gross domestic product (GDP) by 2027. New drugs and technologies are contributing to this increased cost, and inpatient spending is the largest cost to the health care system (33%). “The majority of costs come from our sickest few,” Dr. Albright said.

“What do we do to bend the curve? How do we avoid that 20% GDP in 2027?” asked Dr. Albright. “The answer is transitioning to paying for value—paying for the results rather than a transaction.” The Centers for Medicare & Medicaid Services has been establishing quality or value-based programs for over a decade now.

Advanced payment models (APMs) have become increasingly popular, as they provide a variety of payment structures, engage providers in the design, and promote shared decision-making. APMs pay for medical care that financially awards clinicians for delivering high-quality, cost-effective care.

The pharmacist’s role in APMs includes formulary management, collaborative drug therapy management, transitions of care programs, population health efforts, immunizations, comprehensive medication management, and quality support adherence. “Plan and health system pharmacists can collaborate to support a variety of quality-based initiatives,” he said.

Pharmacists can impact total costs of care, such as with collaborative drug therapy management, telephone-based outreach and medication management, routine health maintenance screenings and immunizations, and medication safety initiatives.

Dr. Albright then gave an example of the Blue Premier value-based care program, a statewide program in North Carolina aimed at transforming health care that puts primary care first and ensures integration of mental and behavioral health. He said this program is helping them get off the “fee-for-service elevator” and transition to a more sustainable program. Revenue is delivered based on shared savings that are tied to quality measures to ensure cost reductions are not driven by lower-quality care, he said.

Dr. O’Hara then talked about pharmacist-centric work that BlueCross BlueShield of North Carolina is doing. Health plans and systems need to identify the role of the pharmacist in the health system and collaborate on information to support the work and decrease duplicate work. Pharmacists can identify patients/members who need higher touch for adherence and identify opportunities for closing Medicare Star/Healthcare Effectiveness Data and Information Set gaps.

High engagement in a health plan includes pharmacists leading the quality process. Data on quality metrics, fill data, formulary changes, and high cost claims are shared. In high engagement health systems, pharmacists are directly involved in quality improvement, and pharmacists are embedded in practices viewing reports on quality and taking actions.

He then gave an example of pharmacist engagement and outcomes via 2019 data. The plan had 536,000 members served. Colorectal cancer screenings increased by 3,041 additional members, and 13,412 additional members had controlled blood pressure. This resulted in an estimated $153 million cost savings and $85 million in performance payments made.

“We’ve set the groundwork that fee-for-service is not going to work, and there’s a lot we need to do to transition out of that so we can have a health system that we can manage. Pharmacists play a humongous role in that. We have a great knowledge base that can help with varied areas,” Dr. O’Hara said.

Pharmacists in all settings can have a role in improving outcomes. Health plan pharmacists in shared savings programs can help focus quality work, and engagement with all stakeholders is a key to success. “You have to have regular meetings, hold people accountable, and understand that you’re working together toward a shared [goal] of better outcomes for your patients,” he concluded. Presentation: M6 Value-Based Payment Models: Opportunities to Integrate Pharmacists from a Variety of Practice Settings.AMCP Nexus 2020 Virtual.