Are ACOs Ready to be Accountable for Medication Use?

BACKGROUND: Accountable care organizations (ACOs) have the potential to lower costs and improve quality through incentives and coordinated care. However, the design brings with it many new challenges. One such challenge is the optimal use of pharmaceuticals. Most ACOs have not yet focused on this integral facet of care, even though medications are a critical component to achieving the lower costs and improved quality that are anticipated with this new model. OBJECTIVE: To evaluate whether ACOs are prepared to maximize the value of medications for achieving quality benchmarks and cost offsets. METHODS: During the fall of 2012, an electronic readiness self-assessment was developed using a portion of the questions and question methodology from the National Survey of Accountable Care Organizations, along with original questions developed by the authors. The assessment was tested and subsequently revised based on feedback from pilot testing with 5 ACO representatives. The revised assessment was distributed via e-mail to a convenience sample (n=175) of ACO members of the American Medical Group Association, Brookings-Dartmouth ACO Learning Network, and Premier Healthcare Alliance. RESULTS: The self-assessment was completed by 46 ACO representatives (26% response rate). ACOs reported high readiness to manage medications in a few areas, such as transmitting prescriptions electronically (70%), being able to integrate medical and pharmacy data into a single database (54%), and having a formulary in place that encourages generic use when appropriate (50%). However, many areas have substantial room for improvement with few ACOs reporting high readiness. Some notable areas include being able to quantify the cost offsets and hence demonstrate the value of appropriate medication use (7%), notifying a physician when a prescription has been filled (9%), having protocols in place to avoid medication duplication and polypharmacy (17%), and having quality metrics in place for a broad diversity of conditions (22%). CONCLUSIONS: Developing the capabilities to support, monitor, and ensure appropriate medication use will be critical to achieve optimal patient outcomes and ACO success. The ACOs surveyed have embarked upon an important journey towards this goal, but critical gaps remain before they can become fully accountable. While many of these organizations have begun adopting health information technologies that allow them to maximize the value of medications for achieving quality outcomes and cost offsets, a significant lag was identified in their inability to use these technologies to their full capacities. In order to provide further guidance, the authors have begun documenting case studies for public release that would provide ACOs with examples of how certain medication issues have been addressed by ACOs or relevant organizations. The authors hope that these case studies will help ACOs optimize the value of pharmaceuticals and achieve the "triple aim" of improving care, health, and cost. DISCLOSURES: There was no outside funding for this study, and the authors report no conflicts of interest related to the article. Concept and design were primarily from Dubois and Kotzbauer, with help from Feldman, Penso, and Westrich. Data collection was done by Feldman, Penso, Pope, and Westrich, and all authors participated in data interpretation. The manuscript was written primarily by Westrich, with help from all other authors, and revision was done primarily by Lustig and Westrich, with help from all other authors.

The Central Role of Physician Leadership for Driving Change in Value-Based Care Environments.

BACKGROUND: In 2013, it was reported that about 1 of every 3 U.S. adults has hypertension. Of these 70 million individuals, approximately 50% have their blood pressure under control. Achieving hypertension control, especially in at-risk populations, requires a multipronged approach that includes lifestyle modifications and pharmacological treatment. As provider groups, hospital systems, and integrated delivery networks optimize their care processes to promote population health activities in support of the accountable care organization (ACO) model of care, managing hypertension and other chronic diseases will be essential to their success. A critical aspect of managing populations in an ACO environment is optimization of care processes among providers to increase care efficiency and improve patient outcomes. PROGRAM DESCRIPTION: Launched in 2013, Measure Up/Pressure Down is a 3-year campaign developed by the American Medical Group Foundation (AMGF) to reduce the burden of high blood pressure. The goal of the campaign is for participating medical groups, health systems, and other organized systems of care to achieve hypertension control for 80% of their patients with high blood pressure by 2016, according to national standards. The role of physician leadership at Cornerstone Health Care (CHC) and Summit Medical Group (SMG) in facilitating organizational change to improve hypertension management through the implementation of the Measure Up/Pressure Down national hypertension campaign is examined. OBSERVATIONS: Using patient stratification via its electronic health record, SMG identified 16,000 patients with hypertension. The baseline percentage of hypertension control for this patient population was 66%. Within 7 months, SMG was able to meet the 80% goal set forth by the AMGF's Measure Up/Pressure Down campaign. CHC diagnosed 25,312 patients with hypertension. The baseline percentage of hypertension control for this subgroup of patients was 51.5% when the initiative was first implemented. To date, the organization has achieved 72% hypertension control for at-risk patients and continues work towards the 80% campaign goal. The implementation of the Measure Up/Pressure Down campaign by CHC and SMG provides some valuable lessons. To further explore important aspects of successfully implementing the Measure Up/Pressure Down campaign in real-world settings, 6 key themes were identified that drove quality improvement and may be helpful to other organizations that implement similar quality improvement initiatives: (1) transitioning to value-based payments, (2) creating an environment for success, (3) leveraging program champions, (4) sharing quality data, (5) promoting care team collaboration, and (6) leveraging health information technology. IMPLICATIONS: The strategies employed by SMG and CHC, such as leveraging data analysis to identify at-risk patients and comparing physician performance, as well as identifying leaders to institute change, can be replicated by an ACO or a managed care organization (MCO). An MCO can provide data analysis services, sparing the provider groups the analytic burden and helping the MCO build a more meaningful relationship with their providers. DISCLOSURES: No outside funding supported this project. The authors declare no conflicts of interest. The authors are members of the Working Group on Optimizing Medication Therapy in Value-Based Healthcare. Odgen is employed by Cornerstone Health Care; Brenner is employed by Summit Medical Group; and Penso is employed by American Medical Group Association. Lustig, Westrich, and Dubois are employed by the National Pharmaceutical Council, an industry-funded health policy research organization that is not involved in lobbying or advocacy. Study concept and design were contributed by Lustig, Penso, Westrich, and Dubois. Lustig, Ogden, Brenner, and Penso collected the data, and data interpretation was performed by all authors. The manuscript was written primarily by Lustig, along with the other authors, and revised by Lustig, Penso, Westrich, and Dubois, assisted by Ogden and Brenner.

Using an Electronic Medication Refill System to Improve Provider Productivity in an Accountable Care Setting.

BACKGROUND: Even within fully integrated health care systems, primary care providers (PCPs) often lack support for medication management. Because challenges with conducting medication reconciliation, improving adherence, and achieving optimal patient outcomes continue to be prevalent nationally, it is critical that PCPs are provided the resources and support they need to provide high-quality, patient-centered care in an accountable care environment. PROGRAM DESCRIPTION: Sharp Rees-Stealy Medical Group uses a fully electronic medication refill system that allows for a centralized team to manage all incoming requests. Over time, 16 disease-specific protocols were created that allowed the pharmacy team to absorb approximately 80% of incoming refill requests for all enrolled PCPs. The refill clinic assessed all clinic information that a PCP would normally review in order to approve a refill. Tasks performed by the clinical pharmacists included medication reconciliation, dosage adjustment, and coordination of distribution from external mail order and retail pharmacies. OBSERVATIONS: In 2014, the number of tasks related to refill management reviewed by the refill/medication therapy management service totaled 302,592, resulting in 140,350 refill authorizations and multiple interventions related to medication use. Physicians have estimated that the service provides between 20 and 30 minutes of time savings per day. Assuming an annual PCP salary of around $200,000, 20 to 30 minutes per day would amount to $33 to $50 saved per day per physician. The savings is even higher when time savings from other clinical staff is included. IMPLICATIONS: The development of this electronic medication refill service has provided the following important lessons: (a) organizations rely on a leader or champion to push through process reforms--this program started with reluctant physicians first to determine best practices; (b) the lack of clinical pharmacist profiles within electronic health records (EHR) is a serious concern, since the creation of these profiles may not be easy or timely; and (c) PCPs working within an EHR environment will quickly embrace the idea of a service that can save them up to 30 minutes per day. With PCPs continuing to take on additional population health management tasks in accountable care organizations, pharmacists can provide workload offsets by meaningfully contributing to medication-related care.

Comparative effectiveness research in the U.S.A.: when will there be an impact on healthcare decision-making?

Five annual surveys of healthcare decision-makers potentially affected by comparative effectiveness research (CER) indicate sustained recognition of its importance and potential impact. Initial expectations of immediate CER impact have over time turned to stakeholder assessments of little short-term impact. In successive surveys, they project a continuous horizon of 3-5 years for CER to have a moderate or substantial improvement in decision making. The prominence of Patient-Centered Outcomes Research Institute in CER is highlighted by stakeholders, but greater emphasis on translating and disseminating research findings is needed, a role in which Agency for Healthcare Research and Quality is expected to contribute. Stakeholders, including patients, must be engaged throughout to ensure that findings provide the flexibility for decision makers to apply them to their patient populations.

Comparative effectiveness research in the USA: when will there be an impact on healthcare decision-making?

Five annual surveys of healthcare decision-makers potentially affected by comparative effectiveness research (CER) indicate sustained recognition of its importance and potential impact. Initial expectations of immediate CER impact have over time turned to stakeholder assessments of little short-term impact. In successive surveys, they project a continuous horizon of 3-5 years for CER to have a moderate or substantial improvement in decision making. The prominence of Patient-Centered Outcomes Research Institute in CER is highlighted by stakeholders, but greater emphasis on translating and disseminating research findings is needed, a role in which Agency for Healthcare Research and Quality is expected to contribute. Stakeholders, including patients, must be engaged throughout to ensure that findings provide the flexibility for decision makers to apply them to their patient populations.

Best practices: an electronic drug alert program to improve safety in an accountable care environment.

BACKGROUND: The accountable care organization (ACO), one of the most promising and talked about new models of care, focuses on improving communication and care transitions by tying potential shared savings to specific clinical and financial benchmarks. An important factor in meeting these benchmarks is an ACO's ability to manage medications in an environment where medical and pharmacy care has been integrated. The program described in this article highlights the critical components of Marshfield Clinic's Drug Safety Alert Program (DSAP), which focuses on prioritizing and communicating safety issues related to medications with the goal of reducing potential adverse drug events. PROGRAM DESCRIPTION: Once the medication safety concern is identified, it is reviewed to evaluate whether an alert warrants sending prescribers a communication that identifies individual patients or a general communication to all physicians describing the safety concern. Instead of basing its decisions regarding clinician notification about drug alerts on subjective criteria, the Marshfield Clinic's DSAP uses an internally developed scoring system. The scoring system includes criteria developed from previous drug alerts, such as level of evidence, size of population affected, severity of adverse event identified or targeted, litigation risk, available alternatives, and potential for duration of medication use. Each of the 6 criteria is assigned a weight and is scored based upon the content and severity of the alert received.  OBSERVATIONS: In its first 12 months, the program targeted 6 medication safety concerns involving the following medications: topiramate, glyburide, simvastatin, citalopram, pioglitazone, and lovastatin. Baseline and follow-up prescribing data were gathered on the targeted medications. Follow-up review of prescribing data demonstrated that the DSAP provided quality up-to-date safety information that led to changes in drug therapy and to decreases in potential adverse drug events. In aggregate, nearly 10,000 total potential adverse drug events were identified with baseline data from the DSAP initiatives, and nearly 8,000 were resolved by changes in prescribing.  IMPLICATIONS: Implications and additional thoughts from The Working Group on Optimizing Medication Therapy in Value-Based Healthcare were provided for the following categories: leveraging electronic health records, importance of data collection and reassessment, preventing alert fatigue utilizing various techniques, relevance to ACO quality measurement, and limitations of a retrospective system. RECOMMENDATIONS: While health information technologies have been recognized as a cornerstone for an ACO's success, additional research is needed on comparing these types of technological innovations. Future research should focus on reviewing comparable scoring criteria and alert systems utilized in a variety of ACOs. In addition, an examination of different data mining procedures used within different electronic health record platforms would prove useful to ACOs looking to improve the care of not only the subpopulations with specific metrics associated with them, but their patient population as a whole. The authors also highlight the need for additional research on health information exchanges, including the cost and resource requirements needed to successfully participate in these types of networks.

Are ACOs ready to be accountable for medication use?

BACKGROUND: Accountable care organizations (ACOs) have the potential to lower costs and improve quality through incentives and coordinated care. However, the design brings with it many new challenges. One such challenge is the optimal use of pharmaceuticals. Most ACOs have not yet focused on this integral facet of care, even though medications are a critical component to achieving the lower costs and improved quality that are anticipated with this new model. OBJECTIVE: To evaluate whether ACOs are prepared to maximize the value of medications for achieving quality benchmarks and cost offsets. METHODS: During the fall of 2012, an electronic readiness self-assessment was developed using a portion of the questions and question methodology from the National Survey of Accountable Care Organizations, along with original questions developed by the authors. The assessment was tested and subsequently revised based on feedback from pilot testing with 5 ACO representatives. The revised assessment was distributed via e-mail to a convenience sample (n=175) of ACO members of the American Medical Group Association, Brookings-Dartmouth ACO Learning Network, and Premier Healthcare Alliance. RESULTS: The self-assessment was completed by 46 ACO representatives (26% response rate). ACOs reported high readiness to manage medications in a few areas, such as transmitting prescriptions electronically (70%), being able to integrate medical and pharmacy data into a single database (54%), and having a formulary in place that encourages generic use when appropriate (50%). However, many areas have substantial room for improvement with few ACOs reporting high readiness. Some notable areas include being able to quantify the cost offsets and hence demonstrate the value of appropriate medication use (7%), notifying a physician when a prescription has been filled (9%), having protocols in place to avoid medication duplication and polypharmacy (17%), and having quality metrics in place for a broad diversity of conditions (22%). CONCLUSIONS: Developing the capabilities to support, monitor, and ensure appropriate medication use will be critical to achieve optimal patient outcomes and ACO success. The ACOs surveyed have embarked upon an important journey towards this goal, but critical gaps remain before they can become fully accountable. While many of these organizations have begun adopting health information technologies that allow them to maximize the value of medications for achieving quality outcomes and cost offsets, a significant lag was identified in their inability to use these technologies to their full capacities. In order to provide further guidance, the authors have begun documenting case studies for public release that would provide ACOs with examples of how certain medication issues have been addressed by ACOs or relevant organizations. The authors hope that these case studies will help ACOs optimize the value of pharmaceuticals and achieve the "triple aim" of improving care, health, and cost.