AMCP: Innovative Care Delivery Options Can Reduce Health Care Costs

The successes and challenges of implementing 2 different care delivery models— accountable care organizations (ACOs) and a specialty pharmacy integrated delivery system—were discussed at a recent AMCP Nexus session titled “Innovative Delivery Models: What Lessons Can Be Learned?”

Greg Low, RPh, PhD, director, Massachusetts General Physicians Organization (MGPO)’s  Pharmacy Quality and Utilization Program, Massachusetts General Hospital, says the MGPO is a large 2412 physician multi-specialty medical group that is closely affiliated with the hospital.

Dr Low says ACOs are a way that organizations who are large enough to bear risk can accept responsibil­ity for the cost and quality of care for patients. Their prevalence is on the rise—the number of Medicare ACOs grew from 146 in 2012 to 423 in 2015, according to Pham HH et al (Medicare’s Vision for Delivery- System Reform-The Role of ACOs. New Engl J Med. 2015;373:987-990.).

During the session, Dr Low high­lighted both the recent cost-saving successes and criticisms of ACOs. For instance, the Centers for Medicare & Medicaid Services (CMS) found that in 2014, 20 Pioneer and 333 shared sav­ings ACOs increased quality measures over fee-for-service and were able to save $411 million (Medicare ACOs Continue to Improve Quality of Care, Generate Shared Savings, CMS Published online, August 25, 2015).

“Beyond cost savings we want ACOs to provide quality care and good outcomes for patients,” Dr Low says. “There are 2 frequent critiques; either that ACOs won’t work—that they won’t improve quality and save money—or that they’ll work but will concentrate on providers negotiating power so much that the providers will keep all of the savings.”

 ACO LESSONS LEARNED

Dr Low also highlighted some of the lessons that have been learned along the way. He says pharmacy is often the largest part of commercial trend, but a small part of the total expense for Medicare, par­ticularly when Part D is excluded.

He also says that while ACOs have great power over utilization, they have little power over pharmaceutical prices.

Primary care also has a much greater portion of the risk than specialty care providers and big data comes with its share of benefits and limitations.

In the years ahead, Dr Low believes there will be more specialty care mea­sures, quality measures with greater power, improved contracting to im­prove the drug-trend risk, and bio­similar medical management.

 SPECIALTY PHARMACY DELIVERY MODEL

JoAnn Stubbings, BS Pharm, MHCA, assistant director of specialty pharmacy services, University of Illinois Hospi­tal and Health Sciences System, also shared her experience with a health-system based pharmacy delivery model.

The University of Illinois Hospital and Health Sciences System is a 495-bed academic health center that offers outpatient services and typically encounters a total of 1 million patients each year.

 The health system created a fully-integrated spe­cialty pharmacy delivery model where embedded pharmacists are an integral part of a closed loop workflow. These pharmacists work in specialty clinics at the time of diagnosis to provide patient education and training, assist prescribers with product selec­tion, order labs and monitoring tests, and perform medication reconciliation and first dose monitoring.

Dr Stubbings says the health system also uses a Patient Access Center to assist with aspects such as:

• Insurance benefit verification

• Prior authorization

• Medicare Part D assistance

• Medication and copay assistance

• Medication adherence management

• Escalations to pharmacist

• Patient surveys

• Documentation and communication through the electronic health record

The model also uses a designated area for filling and dispensing specialty medications and a patient management program to aid in making sure medica­tions are used appropriately and effectively.

OUTCOMES

Dr Stubbings also shared during the session some of the specialty pharmacy delivery model outcomes that have been seen. For instance, patient satisfaction with specialty pharmacy services was higher for those in the University of Illinois Health specialty program. She told attendees that the model showed increases in revenue, number of prescriptions, and the number of active patients. Medication adherence also >90%.

“Health systems have integrated systems that allow for faster access to medications, fewer delays, and better overall adherence,” she says. “The patient care team at the health system, including the specialty pharmacy, is trusted, personal, interdisciplinary, comprehensive, and coordinated without any additional cost to the patient or insurance.”

PITFALLS AND LESSONS LEARNED

During the process, Dr Stubbings says several les-sons and obstacles were identified. She says some payer contracts can cause access issues because they may only allow one or a few specialty pharmacies, some distribution is restricted by manufacturers to certain specialty pharmacies, services are not always compensated, and the model is only scalable if the health system partners or serves retail patients.

Dr Stubbings concluded by highlighting the opportunities that exist for health systems to adopt specialty pharmacy programs. These opportunities include: improved outcomes, lower costs, opportunities for data and research, and partnership potential with employers, payers, or providers.—Jill Sederstrom