Pharmacists and Physicians Collaborating in Medical Homes

San Antonio—Since the introduction of the Patient Protection and Affordable Care Act in March 2010, the healthcare industry has placed more of an emphasis on collaboration among providers. Pharmacists could also help physicians with concepts such as the medical homes that promote teamwork and quality of care, according to speakers at the AMCP meeting who discussed their experiences during a session titled Managed Care Responses to Health Care Reform.

The CDHP Model

Stephanie Ross, PharmD, primary care clinical pharmacist at Capital District Physicians Health Plan (CDHP), Inc., said that CDHP noticed 5 years ago that there was a projected shortage in primary care physicians. The company, which is based in Albany, New York and has more than 4000 members, wanted to build a model that would increase reimbursement to primary care practices and help persuade more medical students to pursue a career in primary care. Thus, CDHP started a medical home pilot program that began in 2008 and lasted through 2010. It focused on patient-centered, comprehensive, coordinated care and emphasized quality and safety, according to Dr. Ross.

Verisk Health, a data analytics firm, found that CDHP’s medical home yielded a risk adjusted per-member per-month savings of $8, reduced admissions by 15%, and decreased emergency department visits by 9%. Dr. Ross added that if primary care physicians meet their goals and help save money and increase quality, they can earn approximately 40% more than they would in a traditional fee-for-service model.

CDHP also has a pharmacy medical home model that includes more than 30 community pharmacists in upstate New York who explain medications, promote effective care, address side effects, and simplify treatment regimens. They have helped improve the quality of care and reduce hospital admissions and readmissions. Dr. Ross mentioned that more than 80% of treatments involving medications and the more than 3.5 billion prescriptions that are written each year in the United States, so pharmacists can be valuable members of a coordinated care team. Pharmacists can help provide additional therapies for preventative or palliative care and aid with dose titration.

The SelectHealth Program

Alexander Bitting, PharmD, clinical pharmacy manager at VRx Pharmacy Services, mentioned another medical home model from SelectHealth, a health maintenance organization based in Salt Lake City, Utah. SelectHealth covers approximately 632,000 lives, including 84% commercial members, 15% in managed Medicaid and 1% in Medicare.

SelectHealth’s pilot program began in 2010 with 3 clinics. Now, there are 54 clinics (46 employed and 8 affiliated) with approximately 350 primary care providers. Similar to the CDHP medical home, SelectHealth’s program focuses on improving patient access to care as well as the quality of care and health outcomes. Physicians are reimbursed via fee-for-service, a monthly age and gender adjusted care management fee for imputed members at each site, and an annual quality incentive program.

Dr. Bitting mentioned a medical home collaboration between SelectHealth and Granger Medical Clinic, an independent group of 79 licensed physicians and providers. The activities included in the program include medication therapy management; disease management for diabetes, asthma, and chronic obstructive pulmonary disease (COPD); and immunization services. Dr. Bitting noted that common issues related to medications included drug costs, incorrect administration, and adverse effects. Although pharmacists can help in medical homes, Dr. Bitting said physicians are not always accepting of pharmacists, so he said it is important that pharmacists make an effort to develop and maintain relationships with physicians to prove their value.

CMS Hospital Readmissions Reduction Program

Richard Stefanacci, DO, chief medical officer at The Access Group, said that pharmacies could aid in the access to drugs as well as medication adherence, which are becoming more important in part due to the Centers for Medicare & Medicaid Services (CMS) hospital readmissions reduction program. The program is for readmissions related to myocardial infarctions, congestive heart failure, and pneumonia.

Beginning in fiscal year 2013, hospitals will have a 1% reduction in their Medicare payments if they did not meet a readmission requirement from July 1, 2008, to June 30, 2011. The penalties increase to 2% of payments in fiscal year 2014 for readmissions occurring from July 1, 2009, to June 30, 2012 and 3% of payments in fiscal year 2015 for readmissions occurring from July 1, 2010, to June 30, 2013. Dr. Stefanacci said that starting in fiscal year 2015, CMS has proposed to expand the conditions to include acute exacerbations of COPD and elective total hip and total knee arthroplasty.

Dr. Stefanacci discussed the importance of medication adherence to keeping patients healthy and decreasing costs. He said 25% to 30% of treatment failures are related to nonadherence and that 125,000 people die each year because of nonadherence. In addition, nonadherence to statins increased the relative risk for mortality by 12% to 25%, while nonadherence to cardioprotective medications increases the risk of cardiovascular hospitalizations by 10% to 40% and mortality by 50% to 80%. Further, Dr. Stefanacci said people who do not adhere to their heart failure medications have an increase in cardiovascular-related emergency department visits.

A way to deal with adherence issues is providing medications to a patient in the hospital before discharge, according to Dr. Stefanacci. By doing so, patients could receive instructions from their doctors, which could increase adherence. He also suggested that people who have difficulty visiting the pharmacy in person could have their prescriptions delivered to their homes. In addition, patients could benefit if they have immediate access to medications following their office visit. Physicians could enter the prescriptions in the patients’ electronic medical records (EMRs) and then send the patients to the pharmacy to pick up the therapies.

Dr. Stefanacci added that physicians’ offices could use patients’ EMRs to send them reminders on the telephone to refill their prescriptions or send them automated dispensing reminders. He cited a randomized, controlled study that found 42.3% of patients who received an automated call filled their prescription for statins within 1 to 2 weeks compared with 26% of patients who never received a call [JAMA Intern Med. 2013;173(1):38-43].

To meet the quality goals and keep costs from increasing too much, Dr. Stefanacci said it is important for physicians and pharmacists to collaborate. Although the relationships between physicians and pharmacists have not always been ideal, some progress has been made in recent years, according to Dr. Stefanacci.

“We are starting to break down the silos,” he said.