Emerging Business Models: Innovating Partnerships Between ...
Emerging Business Models: Innovating Partnerships Between Accountable Care Organizations and Pharmacists Stephanie A. Gernant, PharmD, MS Assistant Professor of Pharmacy Practice Genevieve M. Hale, PharmD, BCPS Assistant Professor of Pharmacy Practice Renee S. Jones, PharmD, CPh Director of Preceptor Development
Assistant Professor Tina Joseph, PharmD, BCACP Assistant Professor of Pharmacy Practice ACO Research Network, Services and Education ACORN SEED Matthew J. Seamon, Pharm.D., Esq. Chair, Pharmacy Practice Associate Professor HEALTHCARE TODAY MEDICAL ERRORS
ARE THE THIRD LEADING CAUSE OF DEATH in the US Heart Disease 611 k BMJ Publishing Group Ltd, 2016; Cancer 585 k Medica l Errors 251 k
COPD 149 k Motor Suicide Firearm Vehicle s 41 k s 34k 34k HEALTHCARE TODAY MEDICATION ERRORS COST THE US $20.6 BILLION ANNUALLY
NQF Quality Connections: The Power of Safety, 2010; (5) Yeaw J, J Manag Care Pharm 2009. ONCE UPON A TIME 1980s: HMO Health Maintenance Organization Capitation: a lump sum per patient to cover a given set of services Potentially compromised quality and patient choice Rizza, C. The history of hmos; a chronology of the development of health maintenance organizations. Americans for Free Choice in Medicine. 1995. AFFORDABLE CARE ACT Individual Mandate Employer Requirements Tax Related Reform
Health Insurance Exchanges Focus On Cost Containment While Improving Care US Department of Health and Human Services. Office of Population Affairs. Affordable care act. 200 Independence Av. S.W. Washington D.C. 20201. ACA CHANGED PAYMENT MODELS Fee For Service: (aka FFS) healthcare providers are paid for each service Pay for Performance: (aka: P4P, aka: Value Based Purchasing) financial incentive for achievement of optimal outcomes
Outcomes are called quality measures HHS wants 90% of Medicare payments on Value Based by 2018 U.S. Department of Health and Human Services. Available from: [http://www.hhs.gov/about/news/2015/01/26/better-smarter-healthier-in-historicannouncement-hhs-sets-clear-goals-and-timeline-for-shifting-medicare-reimbursements-from-volume-to-value.html] ACCOUNTABLE CARE ORGANIZATIONS ACOs: A group of providers, hospitals, and other healthcare organizations that tie reimbursements to quality indicators and reductions in the total cost of care for an assigned population of patients. Still capitation or shared savings, but must meet Quality Measures Note: ACO not necessarily Patient Centered Medical Home (PCMH) Centers for Medicare and Medicaid Services. CMS.gov. Accountable care organizations. Accessible from: [http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO/
ACOs GET GRADED Quality Measures = 4 Domains= 34 Measures Patient and Caregiver Experienc e Patient Safety Preventati ve Health At Risk
Populatio ns US Department of Health and Human Services. Office of Population Affairs. Affordable care act. 200 Independence Av. S.W. Washington D.C. 20201. Patient Safety ACO ACO ACO ACO ACO ACO ACO ACO #8 Risk Standardized, All Condition Readmissions #35 Skilled Nursing Facility 30-Day All-Cause Readmission Measure
#36 All-Cause Unplanned Admissions For Patients With Diabetes #37 All-Cause Unplanned Admissions For Patients With Heart Failure #38 All-Cause Unplanned Admissions For Patients With Multiple Chronic Conditions #9 Ambulatory Sensitive Conditions Admissions For COPD Or Asthma In Older Adults #10 Ambulatory Sensitive Conditions Admissions For Heart Failure #39 Documentation Of Current Medications In The Medical Record Preventive Health ACO #13 Screening For Fall Risk ACO ACO ACO ACO ACO ACO
ACO #14 #15 #16 #17 #18 #19 #20 Influenza Immunization Pneumococcal Vaccination Adult Weight Screening And Follow Tobacco Use Assessment And Cessation Intervention Depression Screening Colorectal Cancer Screening Mammography Screening
k n ACO #21 Proportion Of Adults Who Had Blood Pressure Screened In Past Two Years ACO #40 Depression Remission At Twelve Months ACO #27 & #41 (Composite) Diabetic Beneficiaries w/ HbA1cC in Poor Control; Diabetic Beneficiaries w/ Eye Exam MEETING QUALITY MEASURES: PHARMACIST SERVICES Disease State Management Pharmacists monitor, speak with and evaluate patients with chronic conditions such as diabetes, high blood pressure, high cholesterol, depression, pain or other disease states where optimizing medication therapy is a concern in between physician visits to more closely manage these illnesses Medication Therapy Management Pharmacists review patients medication profiles, and monitor for adherence, drug interactions, and side effects to ensure the medications safe and effective use Patient Education Pharmacists speak with patient directly about specific disease
states using verbal or written material. They can also teach patients about prevention, administration of devices (like inhalers or insulin) and healthy lifestyle management. Side Effect/Drug Monitoring Monitoring and communicating with patients who are on risky therapies on an intensive basis CONCERN: COLLABORATIVE PRACTICE AGREEMENTS Collaborative Practice Agreement (CPA) -Legal document between a provider and a pharmacist Centers for Disease Control and Prevention. Collaborative Practice Agreements and Pharmacists Patient Care Services: A Resource for Pharmacists. Atlanta, GA: US Dept. of Health and Human Services, Centers for Disease Control and Prevention; 2013. https://www.cdc.gov/dhdsp/pubs/docs/Translational_Tools_Pharmacists.pdf
CONCERN: HIPAA Treatment, Payment, Health Care Operations. A covered entity also may disclose protected health information for the treatment activities of any health care provideror the health care operations of another covered entity if both covered entities have or had a relationship with the individual and the protected health information pertains to the relationship. What is Treatment, Payment, Health Care Operations? Treatment is the provision, coordination, or management of health care and related services for an individual by one or more health care providers, including consultation between providers regarding a patient and referral of a patient by one provider to another. US Department of Health and Human Services. Office of Civil Rights. Privacy Brief. Summary of the HIPAA Privacy Rule. May, 2003. Accessible from: [http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/privacysummary.pdf]
CONCERN: MEDICARE CONCERN: PROVIDER STATUS The Social Security Act: Health care providers include all providers of services (e.g., institutional providers such as hospitals) and providers of medical or health services (e.g., non-institutional providers such as physicians, dentists and other practitioners) as defined by Medicare, and any other person or organization that furnishes, bills, or is paid for health care. US Department of Health and Human Services. Office of Civil Rights. Privacy Brief. Summary of the HIPAA Privacy Rule. May, 2003. Accessible from: [http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/privacysummary.pdf] CONCERN: HEALTH INFORMATION EXCHANGE (HIE) EHR Incentive Program- Carrot and Stick to integrate
Electronic Health Records (EHR) The eligible professional who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care should provide summary care record for each transition of care or referral. Eligible Professional Meaningful Use Menu Set Measures Measure 7 of 9. https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/ downloads/8_Transition_of_Care_Summary.pdf CONCERN: TEAM-BASED CARE AND INCIDENTTO-BILLING Chronic Care Management (CCM) 99490 For patients with chronic disease at risk of death/exacerbation Minimum 20 minutes/month Transitional Care Management Services (TCM) 99495 and 99496 Must have contact within 2 days of discharge Must coordinate with other healthcare professionals, assess adherence and medication management
US Department of Health and Human Services. Centers for Medicare and Medicaid Services. Medicare Learning Network. Transitional care management services. June, 2013 Accessible from: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Transitional-Care-Management-
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