Michigan Association of Health Plans

Pharmacist Integration is Essential to Implementing Value-Based Care Models

With the rise of value-based care models over the past decade, pharmacists can have a major impact on the total cost of care and success of models in health care systems, according to a session at the Pharmacy Quality Alliance 2021 Annual Conference

Paying for value means paying for results rather than a simple transaction, explained presenter Brendan O’Hara, RPh, BCACP, a clinical pharmacist with Blue Cross North Carolina. Projected national health expenditures anticipate that health care will have a 19.4% share of the national gross domestic product by 2027, with a majority of those expenditures going toward the sickest patients.

O’Hara reviewed several payment models, spread across 4 categories. The first category, he said, consists of the classic fee-for-service model, which he said is not sustainable. The second category involves a fee-for-service model that is linked to quality and value, whereas the third category is an advance payment model (APM) built on the fee-for-service model. Finally, the fourth category involves population-based payment.

Transitioning to these systems requires time, O’Hara said, as well as systematic changes throughout the entire health care system. Pharmacists in all environments—including community pharmacies, hospital pharmacies, and health plan pharmacists—can play an important role in these changes.

Pharmacists have a large impact on the total cost of care, O’Hara said, especially because they have a high-level view of the patient’s care and the total costs. Through working with high utilizers on collaborative drug therapy management and being involved with other providers, pharmacists can minimize costs while optimizing health outcomes, according to O’Hara.

Furthermore, some quality measures used by the Centers for Medicare and Medicaid Services can be directly impacted by pharmacists, including completion of a Comprehensive Medication Review, the statin use in persons with diabetes measurement, and medication adherence measures in many disease states. Measures in the Healthcare Effectiveness Data and Information Set are also impacted by pharmacists, such as the Asthma Medication Ration, diabetes and hemoglobin A1c control measures, and behavioral health measures.

Finally, O’Hara said high involvement from both health systems and health plans is essential in successfully implementing value-based plans. Signs of low health system engagement can include having pharmacists not directly involved in quality improvement; having pharmacists secondary to other teams and serving in solely a referral capacity; and not following through with opportunities to collaborate with the health plan.

This article originally appeared in the Pharmacy Times, read more here.

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