Hosp Pharm 2014;49(3):253–259 2014 © Thomas Land Publishers, Inc. www.hospital-pharmacy.com doi: 10.1310/hpj4903-253

Original Article Accountable Care Organizations: Impact on Pharmacy Shilpa Amara, PharmD*; Robert T. Adamson, PharmD†; Indu Lew, PharmD‡; and Anthony Slonim, MD§

Abstract The Patient Protection and Affordable Care Act (PPACA) has considerably transformed the approaches being used to deliver health care in the United States. It was enacted to expand health insurance access, improve funding for health professions education, and reform patient care delivery. The traditional fee-for-service payment system has been criticized for overspending and providing substandard quality of care. The Accountable Care Organization (ACO) was developed as a payment reform mechanism to slow rising health care costs and improve quality. Under this concept, networks of clinicians and hospitals share responsibility for a population of patients and are held accountable for the financial and clinical outcomes. Due to high rates of medication misuse, nonadherence to therapeutic medication regimens, and preventable adverse drug events, pharmacists are in an ideal position to manage drug therapy and reduce health care expenditures; as such, they may be valuable assets to the ACO team. This article discusses the role of the pharmacist in the era of ACOs specifically and health care reform globally. It outlines pharmacy-related quality of care measures, medication therapy management (MTM) programs (which may provide  the foundation for pharmacist involvement in ACOs), and pharmacist functions in patient-centered medical homes (through which ACO services may be organized). The article concludes with a description of successful ACO models that have incorporated pharmacists into their programs. Key Words—accountable care organization, medication therapy management, Patient Protection and Affordable Care Act, quality measure Hosp Pharm—2014;49(3):253–259

BACKGROUND US Health Care: Cost-Efficiency Concerns The Patient Protection and Affordable Care Act (PPACA), signed into law in March 2010, represents one of the most significant pieces of health care legislation in recent US history. Enacted in an effort to expand health care coverage, the PPACA has extended Medicaid coverage to individuals with incomes up to 138% of the federal poverty level, created health insurance exchanges that make insurance affordable to those who lack access to public or employer-based coverage, and enforced regulations that prohibit insurance providers from denying coverage or charging higher premiums to individuals with pre-existing conditions.1 As such, the uninsured portion of the US

population is expected to decrease from 44.3 million in 2009 to 24.4 million by 2019.2 The PPACA also seeks to improve the costeffectiveness of US health care. The United States currently operates under a fee-for-service payment system, in which clinicians are paid based on the provision of individual services. However, since the increase of third party insurers, this model has resulted in suboptimal performance and has been associated with serious cost-efficiency issues. This situation has arisen in part because providers have little motivation to reduce costs, given that health care is paid for by a third party that is largely unable to distinguish between necessary and unnecessary services. Likewise, health care consumers who are not directly


Drug Information Specialist, †Vice President of Clinical Pharmacy Services, ‡Vice President of Corporate Pharmacy—Education and Research, §Executive Vice President and Chief Medical Officer, Barnabas Health Care System, South Plainfield, New Jersey. Corresponding author: Shilpa Amara, PharmD, Barnabas Health Care System, 1 Cragwood Road, Suite 3D, South Plainfield, NJ 07080; phone: 908-769-2487; fax: 908-769-2463; e-mail: [email protected]

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paying for services have little incentive to weigh costs against value.3 As a result, the United States currently spends more money per capita on health care than any other member of the Organization for Economic Cooperation and Development (OECD), an organization consisting of 34 countries throughout the world.4 Indeed, health care spending per person in the United States is double that in several other major industrialized countries. In 2010, the national health expenditure (NHE) of $2.6 trillion (or $8,402 per person) accounted for 17.9% of the US gross domestic product (GDP). This represented a 3.9% increase from 2009, during which the GDP spent on health care was already 40% to 80% higher than that of Canada, Germany, France, Australia, and the United Kingdom.5,6 Nevertheless, the United States ranked last among 16 industrialized countries for “mortality amenable to health care” and among the bottom 5 out of 23 countries for “healthy life expectancy” in 2009.6 These data indicate that despite rising health care costs, the quality of US health care remains substandard compared to other industrialized countries. Introduction of the Accountable Care Organization Consequently, the Accountable Care Organization (ACO) was proposed as a mechanism to slow rising health care costs and to improve quality of care for Medicare beneficiaries. ACOs focus on the total patient, providing guidance on healthy lifestyles through wellness programs (eg, smoking cessation, weight control, nutrition, and exercise) and providing beneficiaries with access to preventive and screening services before illness occurs. For those who are ill, ACOs aim to improve coordination of their patients’ health care across an entire continuum of providers. Specifically, under the ACO model, networks of physicians and other practitioners partner with hospitals to manage and improve health care quality, while reducing costs. Notably, ACOs are held accountable for the clinical and financial outcomes of care provided, and payers may incentivize optimal patient care by providing monetary rewards to organizations exhibiting exceptional performance. Specifically, payers may collect data on costs, utilization, and quality of care measures and compare these outcomes to predetermined benchmarks and target savings. ACOs that achieve target savings may be entitled to share in these savings, which are then distributed to all members of the ACO.7,8 Although ACOs were initially developed for Medicare beneficiaries, this model is also being incorporated into other health care sectors, including Medicaid, private insurance companies, and even large employers.9


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APPLICATION TO PHARMACY Value of Pharmacists in Patient Care Medications have a tremendous ability to control disease and positively impact morbidity, mortality, and costs, when used appropriately. Chronic conditions account for approximately 75% of all US health care expenditures, and medications play an important role in the management of these diseases.10 However, data indicate that only 33% to 50% of patients with chronic conditions currently adhere to drug therapy, often resulting in clinical deterioration and unnecessary hospitalizations.7 In addition, the US health care system currently spends an estimated $290 billion each year on unnecessary medical services resulting from misuse of medications11 and more than $177 billion annually on treatment of avoidable adverse drug events, many of which could be averted with enhanced medication management.9 As such, pharmacists have widespread opportunities to help patients manage drug therapy to achieve desired outcomes, improve compliance rates, avoid preventable adverse events, reduce hospitalizations/emergency room visits, and decrease health care expenditures.7 Pharmacists are uniquely positioned to optimize appropriate medication use and improve clinical outcomes. Because they can reach out to patients between physician visits, they can optimize therapy, identify gaps in care, and relay critical information back to prescribers. They may also be able to identify toxic effects and inadequate therapy earlier. Studies conducted over the past few decades have demonstrated that pharmacist participation in interdisciplinary organizations has positively affected patient care.7 Indeed, a systematic review evaluating patient outcomes from 298 studies examining the effects of pharmacist-provided direct patient care revealed favorable findings across various patient outcomes and disease states. Specifically, pharmacist management significantly improved hemoglobin A1C levels, low-density lipoprotein (LDL) cholesterol levels, blood pressure, medication adherence, patient knowledge, and quality of life, while reducing adverse drug events. Thus, incorporation of pharmacists into teambased health care models such as ACOs can help to improve patient care and decrease health care costs.12 Pharmacist time should be allocated to achieve the greatest return on investment. Specifically, protracted or in-person interventions and counseling should target high-risk patients who are most likely to experience poor clinical outcomes or utilize costly health care resources (eg, diabetes patients, polypharmacy patients, patients receiving high-risk medications).10

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Pharmacy-Related Quality Measures Pharmacists should provide leadership in ensuring that medication-related quality performance standards are met, so that the ACO may share in cost savings. The impact of pharmacists may even extend to performance measures beyond those that are medication-related, especially as they advance their role as

members of the interdisciplinary health care team.10 Indeed, pharmacists may impact 22 or more of the 33 total quality care measures, which are outlined in the box, Accountable Care Organization Quality Measures.13 Because community pharmacists often have close relationships with their patients, partnering with them can help improve results of patient experience

Accountable Care Organization Quality Measures Patient/Caregiver Experience • • • • • • •

Getting timely care, appointments, and information Physician communication Physician rating Access to specialists Health promotion and education Shared decision making Health status/functional status

Care Coordination/Patient Safety • • • • •

Admissions: Chronic obstructive pulmonary disease/asthma in older adults Admissions: Congestive heart failure Percent of primary care physicians who qualify for electronic health record program incentive payment Medication reconciliation following discharge Screening for fall risk

Preventative Health • • • • • • • •

Influenza immunization Pneumococcal immunization Adult weight screening and follow-up Tobacco use assessment and cessation intervention Depression screening Colorectal cancer screening Mammography screening Hypertension screening

At-Risk Populations • • • • • • • • • • • •

Diabetes composite: Hemoglobin A1C control Diabetes composite: Low-density lipoprotein control Diabetes composite: Blood pressure control Diabetes composite: Tobacco non-use Diabetes composite: Aspirin use Diabetes mellitus: Hemoglobin A1C poor control Hypertension: Blood pressure control Ischemic vascular disease: Complete lipid panel and low-density lipoprotein control Ischemic vascular disease: Aspirin/antithrombotic use Heart failure: Beta blocker therapy for left ventricular systolic dysfunction Coronary artery disease composite: Drug therapy for lowering low-density lipoprotein cholesterol Coronary artery disease composite: Angiotensin-converting enzyme inhibitor or angiotensin receptor blocker therapy for patients with coronary artery disease and diabetes or left ventricular systolic dysfunction

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surveys, which constitute an important quality measure. In addition, pharmacists can facilitate medication reconciliation following hospital discharge and can increase influenza and pneumonia vaccination rates. Furthermore, pharmacists can improve diabetes composite scores by helping patients optimize LDL, blood pressure, and hemoglobin A1C and by encouraging smoking cessation and aspirin use. The majority of diabetes targets are all or nothing; organizations that fail to satisfy these goals will not be credited with meeting the quality standards for the diabetes composite measure, which further substantiates the value of pharmacist involvement.14 Medication Therapy Management Programs Many organizations have already begun to implement pharmacy services via medication therapy management (MTM) programs, which are expected to be the basis for pharmacist activities under the emerging ACO model.7 MTM programs offer patients an annual, interactive, comprehensive drug review to assess therapy, improve adherence, and identify gaps in care. Pharmacists also provide ongoing medication monitoring and recommend follow-up interventions with prescribers as necessary. Specific MTM services are outlined in the box, Medication Therapy Management Services.15 Such services may be provided to hospitalized patients or those visiting a primary care practitioner, as well as through drug therapy management clinics (eg, anticoagulation clinics, psychiatric clinics, lipid management clinics), brown bag programs for post hospital discharge patients, or prescription drug adherence clinics. Regardless of setting, the ultimate goal of these services is to optimize medication management and reduce hospital readmissions. One 2009 study evaluating the impact of pharmacist-initiated MTM services delivered

Medication Therapy Management Services • Perform comprehensive drug reviews via interactive consultations • Assess medication efficacy • Prevent and manage adverse drug events • Identify drug interactions • Identify gaps in care • Monitor drug therapy for chronic conditions • Promote health and wellness • Encourage immunizations • Recommend follow-up with physicians


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through community pharmacies over a course of 7 years revealed that these programs resulted in a remarkable $7.1 million in cost savings.16 Notably, reimbursement for MTM services is currently restricted. However, the PPACA contained provisions indicating that, pending the approval of the Medication Therapy Management Empowerment and Medication Therapy Management Benefits Acts, pharmacists may be reimbursed for providing MTM services under the ACO model.17,18 Provision of Services Through Medical Homes Coordinating patient care will likely require ACOs to organize services through patient-centered medical homes, which are team-based health care delivery models that provide comprehensive and continuous primary medical care to patients, with the goal of maximizing health-related outcomes. Given the essential role of medication management, particularly among patients with multiple chronic conditions, pharmacists are expected to play an integral role in medical homes. Specifically, they will ensure that patients receive appropriate drug therapy at optimal doses and will help to prevent and manage adverse drug events, thereby reducing costs.9 Furthermore, pharmacists in medical homes can empower and educate patients regarding drug therapy and stress that proper use and adherence reduces readmission rates. They can also help to coordinate care by providing physicians with pertinent drug-related information and ensuring that everyone on the team has complete knowledge of each patient’s drug therapy. Finally, through use of electronic medical records, pharmacists can obtain real-time clinical information and monitor drug therapy for the entire patient population, while offering clinical support and delivering information to physicians and other members of the ACO network.11 Next Steps Appropriate education and training are necessary to prepare pharmacists to operate under the ACO model. As such, pharmacy school curricula must be evaluated and restructured to enable students to practice effectively as members of an ACO. Specifically, additional training may be needed in physical assessment, medication reconciliation, communication skills, and use of informatics. Training may also be incorporated into pharmacy staff development programs in health systems.10 Once training and credentialing have occurred, pharmacists should determine how performance

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metrics (ie, financial, process, outcome, satisfaction) are obtained within an ACO, as this may help them procure financing for pharmacy services within the organization. Pharmacists may then enter into collaborative drug therapy management agreements and begin providing services to targeted patients. They may also wish to collaborate with quality improvement personnel to identify gaps in care, thereby enabling them to prioritize their efforts to achieve the most significant clinical and economic benefits.10 ACOs in Current Practice Because the Centers for Medicare and Medicaid Services (CMS) has not included savings in pharmaceuticals or improvements in quality related to drugs in the Medicare Shared Savings Program, most currently operating ACOs do not yet include pharmacists. However, there are several that have begun to incorporate pharmacy into their interdisciplinary model. Fairview Health Services, a health system based in Minneapolis, Minnesota, was one of the organizations selected to participate in the CMS pioneer ACO model. Pharmacists in this system spend 2 days each week working on site at primary care practices, where they provide eligible patients (eg, with poorly controlled chronic conditions, with polypharmacy concerns, with a recent change in health status, taking high-risk medications) with comprehensive MTM services. These pharmacists work under collaborative practice agreements and are authorized to autonomously modify therapy for approximately 20 chronic conditions. Since its inception in 1997, the MTM program has provided care to over 15,000 patients and has resolved nearly 80,000 drug therapy issues, the majority of which would have gone undetected in the absence of this service. Thus far, Fairview’s MTM program has reduced health care costs, improved clinical outcomes in patients with diabetes and asthma, and has improved resource utility by freeing up primary care providers and enabling them to use their time more efficiently.19 Cigna Medical Group (CMG), a multispecialty medical group practice in Phoenix, Arizona, is another ACO that has incorporated pharmacists into its practice. The network includes over 50 pharmacists who work in conjunction with physicians and take proactive measures to minimize clinical complications and reduce hospital admissions. These pharmacists operate an anticoagulation clinic where they monitor patients receiving warfarin therapy, review medical literature to inform physicians about new

medications, and contact patients to discuss drug therapy and adherence. Findings suggest that these pharmacists have made a significant contribution to patient care, as CMG physicians have put approximately three-fourths of their therapeutic recommendations into practice.20 The Norton ACO in Kentucky runs a pilot program aimed at cutting readmission rates for congestive heart failure (CHF). Pharmacists arrive at the patient’s bedside after the nurse finishes the workup and look for omissions or errors that the patient may have made when speaking with the nurse. The pharmacist also evaluates angiotensin converting enzyme (ACE) inhibitor dosage and offers counseling to patients upon discharge. Pharmacist involvement has helped to identify 1.5 medication discrepancies per patient, which demonstrates that pharmacists can play an important role in reducing health care costs and improving quality of care.21 Baylor Health Care System has incorporated pharmacists into their ACO by building on chronic disease management programs and medical homes. Patients receive preventative health screening, coordinated home and community services, instruction on how they can manage their chronic conditions, psychological and social management of chronic care, weight management, and smoking cessation programs. Baylor also operates a medication assistance program for indigent patients at high risk for hospital readmissions. As part of this program, pharmacists help patients apply for free medications from pharmaceutical manufacturers.9 The Carillion Clinic in Virginia is another prominent example of an ACO with pharmacist involvement. Pharmacists focus on patients with complicated medication profiles and provide ongoing maintenance for difficult chronic patients requiring intensive therapeutic management (eg, poorly controlled diabetics, end-stage CHF patients). Finally, CIPA, a physician group practice in New York, has built an ACO that allows pharmacists to provide direct patient care and work in collaboration with other health care professionals. Currently, pharmacists work closely with 20 of CIPA’s direct patient care providers, who can contact the pharmacists with questions and receive medication information newsletters.9 Several other organizations (eg, Tucson Medical Center, Vermont Community Health System) have also begun to incorporate pharmacists into their ACO networks, and pharmacy involvement is expected to continue to increase with ACO growth and expansion.9,21

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CONCLUSION Representing one of the most important pieces of health care legislation in recent US history, the PPACA was enacted to improve health insurance access and to improve the cost-effectiveness of patient care.1 Because the traditional fee-for-service payment system has resulted in overspending and substandard care, the ACO model was proposed as a strategy to slow rising health care costs and to improve the quality of patient care.3-7,9 Under the ACO concept, networks of clinicians and hospitals are brought together into an organized system in which all members share responsibility for patient care and are held accountable for all financial and clinical outcomes. ACOs incentivize optimal patient care by allowing organizations that meet quality standards to share in any cost savings they achieve.7 Pharmacists are positioned to play an important role on the ACO team. Current rates of medication misuse, nonadherence, and avoidable adverse events remain unacceptably high.7,9,11 Because pharmacists can reach out to patients and share valuable information with other clinicians, they are in an ideal position to manage multiple aspects of patient care, improve health care quality, and decrease overall health care expenditures.7 Many organizations have implemented pharmacy services via MTM programs, which have achieved significant cost savings.16 These programs are expected to be the basis for pharmacy involvement in the emerging ACO model.7 To ensure that they are qualified to participate in ACO programs, pharmacy schools should restructure curricula to provide prospective pharmacists with appropriate training. Moreover, practicing pharmacists should strive to enter into collaborative practice agreements, where they can provide services to targeted patient populations.10 Several organizations have already begun to incorporate pharmacists into their ACO networks, and pharmacy involvement is expected to continue to increase with ACO growth and expansion.9,21 ACKNOWLEDGMENTS The authors have no conflicts of interest and did not receive any funding for this work. REFERENCES 1. Henry J Kaiser Family Foundation. Focus on health reform. http://www.kff.org/healthreform/upload/8023-R.pdf. Accessed November 29, 2012.


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2. Sisko AM, Truffer CJ, Keehan SP, et al. National health spending projections: The estimated impact of reform through 2019. Health Aff (Millwood). 2010;29(10):1933-1941. 3. Crippen DW. United States—academic medicine: Where have we been? In: Crippen DW, ed. ICU Resource Allocation in the New Millennium: Will We Say “No”? New York: Springer Science and Business Media:101-106. 4. Mazer M. United States—academic medicine: Where are we going? In: Crippen DW, ed. ICU Resource Allocation in the New Millennium: Will We Say “No”? New York: Springer Science and Business Media:189-195. 5. Centers for Medicare & Medicaid Services. National health expenditure data: Historical. http://www.cms.gov/ Research-Statistics-Data-and-Systems/Statistics-Trendsand-Reports/NationalHealthExpendData/NationalHealth AccountsHistorical.html. Accessed November 29, 2012. 6. The Commonwealth Fund Commission on a High Performance Health System. Why not the best? Results from the national scorecard on U.S. health system performance, 2011. h t t p : / / w w w. c o m m o n w e a l t h f u n d . o r g / ~ / m e d i a / F i l e s / Publications/Fund%20Report/2011/Oct/1500_WNTB_Natl_ Scorecard_2011_web.pdf. Accessed November 29, 2012. 7. Academy of Managed Care Pharmacy. Pharmacists as vital members of accountable care organizations. http://www. amcp.org/aco.pdf. Accessed November 29, 2012. 8. Financial perspectives. In: Flareau B, Bohn J, Konschak C. Accountable Care Organizations: A Roadmap for Success. Virginia Beach, VA: Convurgent Publishing, LLC:161-188. 9. Daigle L. ASHP Policy Analysis. Pharmacists’ role in accountable care organizations. http://www.ashp.org/doclibrary/advocacy/policyalert/aco-policy-analysis.aspx. Accessed November 13, 2012. 10. American Society of Health System Pharmacists. Report of the 2012 ASHP task force on accountable care organizations. Am J Health Syst Pharm. 2012;69:e56-66. 11. Medication homes play vital role in the ACO. Pharm MD. http://www.pharmmd.com/news/articles/2011/medication-homes-play-vital-role-in-the-aco/. Accessed December 3, 2012. 12. Chisholm-Burns MA, Lee JK, Spivey CA, et al. US pharmacists’ effect as team members on patient care: systematic review and meta-analyses. Med Care. 2010;48(10):923-933. 13. Accountable care organizations 2012 program analysis. Quality performance standards: Narrative measures specifications. December 12, 2011. http://www.cms.gov/medicare/ medicare-fee-for-service-payment/sharedsavingsprogram/ downloads/aco_qualitymeasures.pdf. Accessed January 16, 2013. 14. National Community Pharmacists Association. Summary of accountable care organizations (ACO) final rule. http:// www.ncpanet.org/pdf/leg/nov11/summary_aco_final_rule. pdf. December 4, 2012.

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15. Centers for Medicare & Medicaid Services. Prescription Drug Benefit Manual. Medication therapy management and quality improvement program. https://www.cms. gov/PrescriptionDrugCovContra/Downloads/Chapter7.pdf. Accessed December 3, 2012. 16. Smith, M. Patient centered medical home and accountable care organizations—their growing roles today under health care reform. Presented at: Academy of Managed Care Pharmacy 2010 Educational Conference; October 14, 2010; St. Louis, MO. 17. What Obamacare means for community pharmacists. http://pharmacy.about.com/od/Community/a/WhatObamacare-Means-For-Community-Pharmacists.htm. Accessed January 17, 2013.

18. Barlas S. Pharmacists want to become part of accountable care groups. P&T. 2011;32(2):63. 19. Traynor K. American Society of Health-System Pharmacists. Fairview MTM services support accountable care. http:// www.ashp.org/menu/News/PharmacyNews/NewsArticle. aspx?id=3770. Accessed December 4, 2012. 20. Edlin M. Without a team of pharmacists, your ACO will  be incomplete. Managed Healthcare Executive. http:// managedhealthcareexecutive.modernmedicine.com/mhe/ article/articleDetail.jsp?id=741517. Accessed December 4, 2012. 21. Barlas S. Pharmacists want to become part of accountable care groups. P&T. 2011;36(2):63. J

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Accountable care organizations: impact on pharmacy.

The Patient Protection and Affordable Care Act (PPACA) has considerably transformed the approaches being used to deliver health care in the United Sta...
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