While the ultimate impact of healthcare reform is still being debated, one trend is clear: Accountable care organizations continue to pick up steam. An ACO is a unique healthcare delivery model defined as a network of healthcare providers who share responsibility for coordinating high-quality care across a specific patient population. The concept is not new and, in fact, is based largely on integrated health system models that have been successful for many years. However, this model was only applied to public payer models as part of the Patient Protection and Affordable Care Act two years ago. Since then, numerous ACOs have launched, and many more are in development. In fact, as of the end of May, 221 ACOs had been identified across 45 states.1 In addition, in July, the Centers for Medicare and Medicaid Services announced the selection of 88 new ACOs, translating into coverage for more than 2 million seniors in 40 states and the District of Columbia under Medicare shared savings initiatives.
Both public and private ACO models have been formed to lower costs, improve care and create better health outcomes. The ACA-mandated Medicare Shared Savings Program first sparked ACO development, and commercial payers now are creating their own private-sector ACOs. CMS also introduced the Pioneer Program, which allows ACOs to contract with the federal government and commercial payers.
The current ACO landscape appears to feature physicians and hospitals as the targeted players in the ACO model. In response, the pharmacist community has voiced its concerns that ACO programs are undermining pharmacists’ role in integrated care systems. Since the introduction of the MSSP, pharmacy groups have urged CMS to actively include community pharmacists in ACO-data sharing.2 While pharmacist groups seek ways to become recognized as integral parts of ACOs, they emphasize their lack of control over prescription drug costs — so they are not perceived as liable for ACO costs tied to drug spending.3
Pharmacy stakeholder groups have emphasized the important role of community pharmacists in improving patient outcomes and lowering overall healthcare costs. Data suggest that pharmacists in integrated delivery structures help improve patient care by managing patients’ medications.4 In fact, many pharmacists already are integrated into medical homes across the nation.
Expanded role of pharmacists
ACOs will present some key opportunities to pharmacists — from increased collaboration with providers to expanded access to patient information and interaction. Under the ACO model, all caregivers should have greater access to patient health information, enabling them to assemble more complete and accurate treatment plans. As pharmacists tend to have one-on-one interactions with patients, they are well positioned to assist patients in identifying gaps in care, seeking out appropriate care and gaining patients’ buy-in for the new ACO structure.4 Given the focus on quality performance and cost reduction, there will be a need for pharmacists in post-discharge medication management as well. Currently, some pharmacists in integrated care systems provide follow-up phone calls to ensure patients are taking the correct medications and receiving appropriate lab tests post-discharge.
Community pharmacists will face some challenges when trying to integrate into ACO programs, as the current structure minimizes the role of pharmacists in the patient care process. Currently, the MSSP and Pioneer Program do not have an explicit role for pharmacists in ACOs. Pharmacists do have the opportunity to become part of an ACO via subcontracting. It’s important to note, however, that being an official component of ACOs would lead to more meaningful collaborations with other ACO providers and would allow pharmacists to influence ACO governance, help dictate patient treatment standards and pathways, and share in savings with other providers and suppliers.4
Value-based environment depends on a more holistic view to costs and outcomes. Pharmaceutical treatment costs must be examined in the context of the total treatment received or there is a risk that expenses related to their use could be targeted for cost reduction even though the efficient use of pharmaceuticals can lead to overall lower medical costs.5
In the absence of having a clearly defined role in the ACO, pharmacists may be left out of discussions regarding program structure and metrics. And because of the gap in pharmacy-based quality metrics in ACO programs, there’s no way to track pharmacists’ contributions toward the organization. As a result, pharmacists will need to actively engage and communicate their value to ACOs and may need to redefine their workflows to collaborate with physicians, nursing staff and other suppliers within ACOs.
Pharmacist groups should continue to engage in dialogue with payers/ACOs to encourage community pharmacist inclusion in ACO structures. In doing so, pharmacists can bring attention to their involvement in helping to control costs and improving patient care. Given the ongoing pressure from the pharmacy community to include pharmacists in the ACO structure, the role of pharmacists likely will expand over the next few years. In the absence of guidance from CMS and payers, it remains uncertain how pharmacists’ scope of practice will evolve, though we may see pharmacy-based ACOs and quality metrics emerge in the near future. Regardless, pharmacists will need to remain flexible as their roles may become increasingly primary-care focused under the ACO model.
Peyton Howell, MHA, is president of AmerisourceBergen Consulting Services and SVP business development for AmerisourceBergen Corp.
Leavitt Partners, Growth and Dispersion of Accountable Care Organizations: June 2012 Update. http://news.leavittpartners.com/newsrelease-cid-1-id-43.html
Yap D. Pharmacy to CMS: Explicitly include pharmacists in ACOs. American Pharmacists Association. http://www.pharmacist.com/AM/Template.cfm?Section=Pharmacy_News&template=/
CM/HTMLDisplay.cfm&ContentID=26185. Accessed March 8, 2012.
Stein M. Pharmacists Pursue Legislative, Contractual Strategies To Gain Key Role In ACOs. Daily News Updates from Inside Health Policy. https://healthpolicynewsstand.com/Inside-
CMS/Inside-CMS-03/01/2012/menu-id-316.html. Accessed March 1, 2012.
Pharmacists as Vital Members of Accountable Care Organizations. Academy of Managed Care Pharmacy. http://www.amcp.org/aco.pdf. Accessed February 16, 2012.
ACO Success Depends on Optimal Medication Management. The Pink Sheet. July 23, 2012