The Work of Integrating Pharmacists into Value-Based Care Continues
As some of the most accessible healthcare professionals, pharmacists are uniquely positioned to help patients take charge of their health outcomes and also support patients’ social and financial well-being. The value-based care model is a significant development toward better outcomes in various respects for patients. It seeks to ensure that healthcare dollars are being spent in a way that prioritizes patient health, while rewarding the healthcare providers responsible for improving results, increasing cost savings, and decreasing hospitalizations.
The pharmacist’s mission falls directly in line with the mission of a value-based healthcare model in the following ways:
Helping patients access medications at lower costs
Keeping track of medication safety concerns
Talking through adherence issues or gaps in care
Managing multiple medication regimens
Addressing medication errors
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While the United States is known for its prowess in pharmaceutical and medical technology advances — aimed at helping patients combat disease and live longer, healthier lives — these innovations don’t necessarily always translate to better health outcomes for our communities. That’s because, by and large, the healthcare system in the U.S. operates more like a “sick-care” system.
Healthcare professionals, or HCPs, focus largely on diagnosing and treating patients once health issues come up, where preventive care tends to be put on the back burner. Although the U.S. spends about twice what other high-income nations do on health care, we have the lowest life expectancies and the highest infant mortality rates, among other issues like high chronic disease burden and obesity.
Value-based vs. fee-for-service models
In contrast to the traditional fee-for-service payment framework, value-based care is a healthcare model that ties payments for care delivery to the quality of care provided — rewarding providers for both efficiency and effectiveness. With traditional fee for service, less time and effort are placed into preventive care, or into following up with patients to ensure proper adherence to treatment regimens and addressing questions or concerns.
With value-based care, patient health outcomes are prioritized because HCPs must demonstrate that the service or procedure provided positively impacted the patient. It looks at specific measures such as reducing costly hospital readmissions, using health information technology tools, and implementing more preventive care.
Under these kinds of value-based care parameters, providers are rewarded for reducing the effects and incidences of chronic disease and helping patients live healthier. Ultimately, the mission of value-based care is to genuinely provide better quality of care for individuals and improve population health management strategies, while reducing healthcare costs.
Here are some of the ways providers and patients can benefit in the value-based care model:
Reducing the effects and incidence of chronic disease
Focusing more directly on preventive care and thorough follow-up
Involving patients more heavily in the healthcare decision-making process
For perspective, a 50% reduction in the diabetes incidence rate in Californians 51 years and older would produce $332 billion in social value between 2018 and 2050. This research highlights the gaps in care that currently exist and offers a way for pharmacists to step in and create actionable solutions to help serve our communities the way they deserve. By replacing fragmented, fee-for-service care with comprehensive, coordinated care using value-based models, we can step in a direction that truly prioritizes patient health outcomes.
Pharmacist-led value-based care initiatives
The fee-for-service model turns out to be a barrier to coordinated care in a team of HCPs, because it incentivizes individual clinicians to work in silos and perform separate services. In addition, fee for service does not encourage providers to focus on the most costly patients: those with higher chronic disease burdens, issues with polypharmacy, and those at greater risk of consistent emergency room admissions. Integrated care, supported by the value-based care model, is a response to the scattershot delivery of health and social services.
With America’s physician shortage getting worse and pharmacy schools pumping out more graduates, pharmacists can play a vital role in addressing these gaps in care. According to the Association of American Medical Colleges, there will be a shortfall of 21,400 to 55,400 primary care physicians in the U.S. by 2033. As some of the nation’s most vulnerable patient populations, like the geriatric or safety net populations, grow in number, they will be in need of professionals that can provide continued and consistent support with medication management of complex regimens, including reconciliation and adherence.
One pharmacist-led value-based care initiative looking to address these gaps and demonstrate what pharmacists can bring to patient health outcomes over the long run is the California Right Meds Collaborative. This project, launched in September 2019 by the USC School of Pharmacy, is a consortium of health plans, pharmacies, and academic and professional organizations in Southern California working to deliver high-impact, comprehensive medication management services, known as CMM, through a sustainable and value-based payment model.
Partnering with LA Care Health Plan, the Inland Empire Health Plan, and the Los Angeles County Department of Public Health, the California Right Meds Collaborative aims to build a network of pharmacies that provide high-impact CMM services aligned with population health priorities, and serve as access points for health and social services for the communities they serve.
Getting it done through government
Pharmacists have been advocating for themselves and their colleagues in healthcare to provide value-based care services like comprehensive medication management, especially for underserved and underrepresented communities that may be more impacted by social determinants of health. The California Right Meds Collaborative seeks to foster a more scaled and sustainable approach, and is a huge step in the right direction.
However, there are still legislative hurdles to be overcome regarding the reimbursement and expansion of pharmacist-led, value-based care services like CMM. In our most recent efforts in California, Assembly Bill 1131 outlined this value-based reimbursement strategy for MediCal patients who meet one or more of specified criteria, including being prescribed eight or more medications or biologics by multiple prescribers to treat or prevent two or more chronic medical conditions.
The bill would have the setting of reimbursement rates and rate billing codes for CMM services provided by a licensed pharmacist, who would be responsible for initiating, adjusting, or discontinuing medication. Unfortunately, this proposal, along with many similar bills that came before it, has not moved forward in the legislative process. This highlights the reality that government advocacy is an ongoing effort and can sometimes take years of persistence to get a bill passed.
Pharmacists are well equipped to come up with ways to better serve patients. But only with real collaboration and the investment of time, money, and work can the profession move forward. By being involved with consistent and persistent legislative advocacy within pharmacy organizations and professional associations, as well as by supporting studies that demonstrate the benefits of pharmacist-centered value based care services, pharmacists can play key roles in lowering the chronic disease burden in the U.S., controlling costs, and helping patients feel more supported in their journeys to better health.
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