ACOs—A Model for Healthcare Reform

San Diego—Accountable care organizations (ACOs), included as part of the Patient Protection and Affordable Care Act, are groups of physicians, hospitals, and other healthcare providers who form an organization to provide coordinated quality care to Medicare beneficiaries, and share in any savings resulting from the alliance. It is estimated that 25 to 31 million Americans receive care from an ACO and 40% of Americans live in an area with at least 1 ACO.

Speakers at the AMCP meeting presented a Contemporary Issues session titled Accountable Care Organizations–2013 and Beyond: What You Need to Know Now. The session began with a presentation from Robert W. Dubois, MD, PhD, chief science officer at the National Pharmaceutical Council.

Dr. Dubois began by noting that ACO success is multifaceted and includes quality measures and data systems that result in shared savings. He highlighted the role of pharmaceuticals in a successful ACO, stressing that ACO success is dependent on consideration of medications. “Formularies need to be synchronized across sites of care, prescriptions need to be transmitted to pharmacies electronically, providers need to be able to access patient data electronically, providers should be alerted regarding gaps in recommended preventive care, the full episode of care costs have to be captured, and medication reconciliation should be performed,” he said.

In outlining what ACOs are currently doing well, Dr. Dubois cited electronic transmission of prescriptions, noting that 70% of ACOs responding to a recent survey indicated their group utilized electronic transmission of prescriptions. The percentages of respondents indicating that their group is currently utilizing other requirements for success were lower: 54% had the ability to view prescription and medical data in 1 system; 50% utilized formularies that encouraged use of generics; and 43% said their group can identify potential drug/drug, drug/disease, and/or polypharmacy issues.

He concluded his part of the session by citing areas that ACOs are currently not doing well, including usage of metrics to determine quality and fiscal efficiency of care, developing care protocols, involving clinical pharmacists in patient care, and engaging patients to encourage medication and therapy adherence.

The session continued with a presentation from Kristina Lunner, senior advisor, Leavitt Partners, LLC. Ms. Lunner’s presentation began with this definition of an ACO: “An entity that directly influences the provision of care and bears the financial risk of the measured health outcomes of a defined population.”

She said that at the end of the fourth quarter of 2012, there were 45 ACOs in the United States. As of the end of the first quarter of 2013, the number would increase to 428, according to the Leavitt Partners Center for Accountable Care Intelligence.

When Leavitt Partners asked ACOs what their top 5 needs were, the respondents cited (in descending order) data management, care management infrastructure, physician alignment, network development, patient engagement, organizational realignment, work force, and capital.

Because ACOs are what Ms. Lunner describes as “essentially risk-bearing entities,” she said that there are incentives for ACOs to (1) find and treat disease in the early stages to stop progression; (2) manage disease to avoid complications and disease progression; (3) identify gaps in care; (4) reduce hospital admissions; (5) optimize and synchronize best practices, such as formularies, within and across care settings; (6) transmit prescriptions electronically to pharmacies; (7) engage consumers; (8) measure and report quality measures; and (9) measure and calculate medical and pharmacy costs.

In summary, Ms. Lunner stressed that in the current healthcare environment, public and private payer roles are changing, provider roles are changing, and value is now part of the equation. She ended by saying these changes are creating both disruption and opportunities for the healthcare industry.

Marissa Schlaifer, MS, RPh, principal at Schlaifer & Associates, LLC, was the next presenter. Her presentation focused on ACO performance measures. She noted that many of the activities implemented by pharmacists in an ACO are directed at ≥1 of the 33 quality measures related to ACOs published by the Centers for Medicare & Medicaid Services (CMS).

Those drug therapy-related performance measures include better care for individuals (measure 12: medication reconciliation after discharge from an inpatient facility); better health for populations via preventive health (measure 14, influenza immunization; measure 15, pneumococcal vaccination), treatment of at-risk populations (measure 26, diabetes composite, aspirin use;  and measure 30, ischemic vascular disease, use of aspirin or another antithrombotic).

She continued by saying that pharmacists play an expanded role in advising prescribers regarding the relative effectiveness and value of their drug treatment options in an ACO, noting that in the ACO environment, pharmacists and other healthcare professionals accept greater responsibility for the ongoing management of medication therapy and outcomes measurement.

In conclusion, Ms. Schlaifer mentioned Walgreens ACOs. In January 2013, Walgreens became the first national pharmacy chain to be approved by CMS to participate in ACOs. Currently, there are Walgreens ACOs in New Jersey, Florida, and Texas. In each of those 3 ACOs, Walgreens has partnered with hospitals and physician groups.

The session concluded with a presentation from Mark Shinmoto, PharmD, director, pharmacy services at HealthCare Partners. Dr. Shinmoto concentrated on the successes of HealthCare Partners vis-à-vis ACOs.

He said the keys to success include robust data systems, an infrastructure that allows for good communication among all stakeholders, and alignment of incentives. He added that pharmacy is an important component of total care management (TCM), which needs to be embedded into the TCM team and be “measurable and scalable.”