Are pharmacists ready for value-based care?

February 13th, 2017 / By Steve Delaronde

U.S. pharmacists dispensed 4.4 billion prescriptions in 2015. The total cost was $310 billion. This represents 10 percent of the national healthcare bill. Drug costs are increasing and Americans are taking more prescription drugs now than ever.  While physicians and other prescribers ultimately control the volume of prescriptions that are written, it is the pharmacist that actually fills and dispenses the prescription. With 8 years of post-secondary education, licensure, and clinical experience, the pharmacist is in an optimal position to contribute to the Triple Aim of lower costs, better outcomes and a positive patient experience.

The pharmacy profession has gradually been shifting from a product-focused to patient-centered practice. The primary contribution of the pharmacist beyond filling, dispensing and counseling patients on how to take prescriptions is a service known as Medication Therapy Management (MTM). The purpose of MTM is to optimize drug therapy and improve outcomes through pharmacist-physician collaboration and engaging patients to take an active role in managing their medications. This is initiated by a pharmacist through an assessment of a patient’s medication therapy that categorizes and addresses four types of medication-related problems (MRPs).

  1. Indication – Drug is not necessary or additional drug therapy is required
  2. Effectiveness – Drug is ineffective or dose is too low to produce desired response
  3. Safety – Drug is creating an adverse event or dose is too high
  4. Adherence – Patient is not willing or able to take drug as intended

Source: Cipolle RJ, Strand LM, Morley PC. Pharmaceutical Care Practice: The Clinician’s Guide. 2nd ed. New York, NY: McGraw-Hill; 2004

MTM was officially recognized by the federal government when the 2003 Medicare Modernization Act required Medicare Part D plans to establish MTM programs to eligible beneficiaries. This includes Plan D enrollees with multiple chronic conditions that take multiple drugs and are likely to exceed an annual targeted medication cost threshold of $3,507 (2016 rate set by CMS).

As of January 1, 2017, selected Part D prescription drug plans can now offer innovative MTM programs in place of the standard CMS MTM model. These plans are given greater latitude in implementing program enhancements, as well as the opportunity to qualify for a performance payment in the form of an increased beneficiary premium subsidy if they achieve a 2 percent reduction in expected beneficiary fee-for-service expenditures net of model prospective payments. This will move Part D MTM into the shared savings models of physician practices and payers.

Studies have demonstrated the positive effects of pharmacist interventions on clinical outcomes, such as improved blood pressure control, improved diabetes self-care activities and reductions in medication-related adverse events. Total cost of care reductions have been suggested for some scenarios, such as lower treatment costs for patients with Type 2 diabetes.

The most critical medication-related issues are not necessarily related to non-adherence. The most significant issues actually relate to drug ineffectiveness – due to improper dosage, as well as the need for additional drug therapy. This was the finding in a 2011 study of Medicaid recipients in Connecticut, as well as a 2010 study of patients in a healthcare delivery system.  Both of these studies demonstrated overall cost savings. However, after factoring in the cost of delivering MTM services, the estimated return on investment for 9,000 patients over a 10-year period was a modest $1.29 for every $1.00 in MTM costs.

Including a pharmacist as a value-based healthcare delivery team partner is definitely worthwhile. Embedding the pharmacist in a group practice may be the best approach, but other models that engage independent community and retail pharmacists should be tested as well. Medication utilization will continue to increase as new drugs are developed, drug advertising and promotion intensifies, and the population ages. That means the opportunity to identify and control medication-related problems will grow, as well.

The direct costs of prescription medication, as well as the costs associated with inappropriate use, ineffectiveness, adverse events and non-adherence is substantial and growing. Identifying the optimal patient groups, health conditions, drug classes, interventions and targeted outcomes in value-based care arrangements is a necessary step to obtain the full benefit of the services that a pharmacist can provide.

Steve Delaronde is director of consulting for populations and payment solutions at 3M Health Information Systems.