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Pharmacists Play Key Role in Helping Manage Cost in ACOs
San Diego, CA—“Pharmacists can affect medication utilization and expenditures within an accountable care organization [ACO],” said Dan Dauner, PharmD, MSPH, BCPS-AQ ID, pharmacy manager, Population Care Management Department, Essentia Health, during a session on impacting medication utilization and pharmacy expenditures in an ACO at the AMCP meeting.
The total cost of care (TOC) for an applicable population for a contract year is used by an ACO to negotiate a cost target with a payer. According to Dr Dauner, “78% of private payer TOC contracts include pharmacy expenditure” and that pharmacy can comprise up to 30% of TOC.
Pharmacists influence medication use and cost in an ACO by being involved in medication therapy management clinics, comprehensive medication reviews, medication reconciliation, drug utilization reviews, and prescription drug adherence programs.
For pharmacy care managers, a health-system level position within the Population Care Management Department, responsibilities include creating ambulatory care formulary, developing clinical decision support (CDS) functions within the electronic medical record, creating treatment protocols for high-cost medications within the specialty group, and assessing mediation utilization and cost-effectiveness.
CDS Functions
One tool to help change ambulatory prescribing patterns is the use of electronic systems designed to directly help physicians in clinical decision-making regarding medication use and dosage for a given patient. The need to alter prescribing patterns to manage cost is highlighted in reports by providers that lack access to medication cost data. “Providers are unaware of the difference in copays among tiers,” said Dr Dauner.
Inclusion of a CDS function can be used to enforce a formulary and recommend prescribing alternatives. Patient characteristics are used to generate recommendations.
Dr Dauner reviewed 5 studies that assessed the benefit of including a CDS function within e-prescribing programs. Three studies reported statistically significant differences in increased generic drug utilization with the addition of CDS function, and 1 of these studies also reported a significant decrease in medication costs. Two studies reported either no difference in increased generic drug use or decrease in medication cost.
Experience of Essentia Health
Dr Dauner described a program initiated at Essentia Health, an ACO, to address improving managing medication costs through e-prescribing. Under Essentia Health, all providers share the same preference list. An electronic function called dynamic alternatives (DAs) provides cost-effective options to expensive drugs. The program was used for a number of targeted medication classes, including angiotensin II receptor blockers, antidepressants, atypical antipsychotics, hypnotics, intranasal corticosteroids, long-acting beta agonist/corticosteroid inhalers, proton pump inhibitors, second generation antihistamines, statins, and triptans. For each medication class, 1 expensive brand and multiple generics were provided in the system.
Evaluation of the system showed poor DA acceptance rates, with only 7.6% acceptance of a cost-effective alternative medication. To improve DA usage, Dr Dauner said that his group will update protocols to include DA consideration during refills. He also said that patients will be switched to cheaper drugs if there is no medical reason against it, and he emphasized the use of collaborative practice agreements.
High Risk Medications
Another area where pharmacists and pharmacy care managers can play a role in an ACO is helping to improve high- risk medication (HRM) management. Dr Dauner emphasized that HRMs are important key medication-related measures in star ratings. Plans must receive at least 3 stars to be eligible for quality bonus payments and rebates under the Patient Protection and Affordable Care Act.
To manage HRMs, Essentia Health initiates a collaborative effort between population care management, pharmacy, and health plans. Dr Dauner said that pharmacists should review evidence-based guidelines with health care professionals, review claims data, chart review, and refer patients to health care professionals for review.
“Pharmacists can affect medication utilization and expenditures within an ACO outside standard services you normally see literature on,” said Dr Dauner.—Mary Beth Nierengarte
