A S H P r e P o r t
Report of the 2012 ASHP Task Force
on Accountable Care Organizations
Am J Health-Syst Pharm. 2012; 69:e56-66
This article will appear in the January 1, 2013, issue of AJHP.
A
ccountable care organizations (ACOs) are groups of health care providers (e.g., physicians, hospitals, health systems) that are jointly held responsible for improv-ing the quality of care and reducimprov-ing costs (or the rate of growth in costs) across the health care continuum, including the ambulatory care, in-patient, and long-term-care settings. The Patient Protection and Afford-able Care Act (generally known as the Affordable Care Act) enacted in March 2010 authorized the Centers for Medicare and Medicaid Services (CMS) to contract with ACOs to provide health care to Medicare ben-eficiaries under the Shared Savings Program beginning in January 2012.1The goals of the Shared Savings Pro-gram are threefold: improve care for individuals, improve the health of the population, and reduce the rate of growth in health care expenditures. Several models for reimbursement have been explored involving the payment of bonuses to such health care groups as incentives for achiev-ing CMS goals for performance and cost savings.2 Shared risk is part of
some models. Assessment of quality
An audio interview, which supplements the information in this article, is available on AJHP’s website at www.ajhp.org/site/misc/ podcasts.xhtml.
Copyright © 2012, American Society of Health-System Pharma-cists, Inc. All rights reserved. 1079-2082/12/0000-0e56$06.00.
DOI 10.2146/ajhp120516 outcomes ensures that cost savings are not realized at the expense of the quality of care provided.2 Pioneer
ACO programs, which are demon-stration projects established by the Center for Medicare and Medicaid Innovation, have been established at selected health care facilities.3
Start-ing in October 2012, CMS began to reward hospitals that provide high-quality care for their inpatients through the new Hospital Value-Based Purchasing (VBP) Program.4
CMS will reduce diagnosis-related group payments for excess readmis-sions for certain conditions (pneu-monia, acute myocardial infarction, and heart failure in fiscal year 2013, which began October 1, 2012, and chronic obstructive pulmonary dis-ease, coronary artery bypass graft surgery, percutaneous transluminal coronary angioplasty, and other vas-cular conditions in fiscal year 2015, which begins October 1, 2014).5
ACOs may be administered through private health insurance plans or state Medicaid agencies instead of CMS. The goals of these ACOs are the same as those of ACOs administered by CMS (i.e., improved health outcomes and reduced health expenditures).6 The extent to which
ACOs have been established by CMS, Medicaid, and private insurers var-ies widely, with some ACOs in the
early stages of planning and others further along in the implementation process. Most Medicaid ACOs are in an early stage of development, partly because of the challenges associated with meeting state and federal leg-islative and regulatory requirements and the needs of low-income and chronically ill patients.7 An
initia-tive is underway by the Center for Health Care Strategies, a nonprofit health policy resource center whose mission is to improve the health of these patient populations, to help state Medicaid agencies design and implement ACOs.8 As states devise
strategies to implement the Afford-able Care Act, state health officials are likely to collaborate with federal health officials to facilitate Medicaid ACO implementation.9
The ACO model of health care delivery promotes continuity of care, which requires communication among health care professionals. The implementation of ACOs contributes to health reform by ensuring that patients are treated in the most con-venient and cost-effective location, avoiding unnecessary hospital ad-missions and readad-missions, requir-ing collaboration among physician groups and hospitals, focusing on chronic and preventive care, refer-ring patients internally (i.e., within the ACO where services are most
cost-effective), providing for smooth transitions in care, minimizing costs, and providing value. Considerable cost savings are often realized by avoiding referrals to health care pro-viders outside a health system.
In 2010, U.S. health expendi-tures reached nearly $2.6 trillion, representing a more than 10-fold increase since 1980.10 In 2008, one in
eight hospitalized surgical patients and one in five nonsurgical hospi-tal patients were readmitted to the hospital within 30 days.11 Chronic
diseases (e.g., hypertension, heart disease, stroke, cancer, diabetes mel-litus, pulmonary disease) account for roughly 75% of health care expenditures in the United States, and medications play an important role in the management of chronic diseases.12 Inappropriate medication
use is a major factor contributing to U.S. health care costs. In the late 1990s, approximately $2 billion in hospital costs alone were attributed to preventable adverse drug events affecting inpatients each year in the United States.13 Recent data suggest
that the rate of adverse drug events in hospitals may be 10-fold higher than was previously thought, affecting one in three hospitalized patients.14 In the
ambulatory care setting in the United States, the estimated cost of drug-related morbidity and mortality was $76.6 billion in 1995; by 2000, this cost exceeded $177 billion.15,16 The
pharmacist’s role in improving health outcomes, reducing the need for hos-pitalization or rehoshos-pitalization, and reducing health care costs through medication therapy management (MTM), discharge planning, and other direct patient care services has been well documented.17-19
Pharma-cist involvement in ACOs is less well established.
On June 29, 2012, ASHP con-vened the ASHP Task Force on ACOs in Bethesda, Maryland, to make recommendations on how best to help its members integrate pharmacy services into the ACO
model. The Task Force provided insight into the medication-use process in ACOs, made recommen-dations for implementing ACO mod-els, identified opportunities for and barriers to pharmacy involvement in ACOs, anticipated future evolution-ary changes to ACO models and the impact on health care reform, and made suggestions for possible ASHP actions to assist members with ACO-related issues.
The ASHP Task Force on ACOs comprised individuals with admin-istrative and clinical experience with ACOs in various academic and non-academic settings, including sev-eral individuals involved with pioneer ACOs. A complete roster of Task Force members is provided in Appendix A.
This report summarizes the dis-cussions of the Task Force and will be used as part of ASHP’s strategic planning process by the ASHP Board of Directors and ASHP staff.
New paradigm
The ACO is an integrated patient care model that emphasizes payment for quality of care instead of quan-tity of care (i.e., pay for performance instead of a fee-for-service model). Implementation of the ACO model of health care delivery requires a change in mindset among health care providers and patients. In the past, the health care provider was the fo-cus of the health care delivery model, with competition among members of various health professions for roles and responsibilities in the health care delivery process. Compensa-tion was provided for specific ser-vices. The ACO model involves a new patient-centric approach in which pharmacists and other health care professionals focus on how they can best use their expertise to meet pa-tient needs. To allay concerns about the potential adverse impact of ACO implementation on scope of practice and livelihood, health care profes-sionals should seek to assume roles and obtain compensation as valued
members of a team that provides patient care instead of securing pay-ment for specific services.
The new paradigm associated with ACOs requires a change in the health-system leadership culture from one in which personnel have narrowly defined responsibilities, often based on departments (i.e., silos), to one in which the health care team has shared responsibil-ity for patient outcomes. Specific tasks should be delegated to team members who are best equipped to assume the responsibility based on their education, training, and expe-rience, regardless of departmental affiliation.
It is in pharmacists’ best inter-est to collaborate with other health care professionals and build effective working relationships. Developing these relationships early in the proc-ess of establishing an ACO can help avoid contentious debate and conflict about scope of practice as ACO plan-ning proceeds. Pharmacists should focus on assuming roles and respon-sibilities with the greatest impact on patient safety and outcomes and be willing to relinquish their involve-ment in other roles and functions with comparatively less impact.
Health-system administrators need to recognize pharmacy services as core patient care services instead of ancillary services, as has often been the case in the past. Health-system administrators should be en-couraged to help pharmacy admin-istrators redesign pharmacy services as part of a “system of care” model in which budgets are allocated based on the disease, condition, treatment, or other intervention so that ap-propriate pharmacy resources can be deployed across multiple settings within the system of care.
Automation and technology (e.g., electronic communication among pharmacists, other health care pro-fessionals, and patients; robotics for dispensing; cloud computing for data sharing) should be used to
improve the efficiency, accuracy, and convenience of patient care services in ACOs. These technologies are particularly helpful in rural areas where geographic distances between patients and health care profession-als are large. Pharmacy technicians contribute to efficiency in providing pharmacy services, so pharmacists should seek to optimize the use of trained pharmacy technicians, al-lowing pharmacists to spend more time providing direct patient care services.
Patients in ACOs need to assume greater responsibility for their own health care. Providing incentives for patients to adhere to their drug therapy plan or removing barriers to adherence (e.g., eliminating copay-ments and other value-based insur-ance design strategies to promote the use of cost-effective services) can facilitate this process.20 The
ambula-tory care patient population should be targeted in strategies to motivate and empower patients to assume greater self-care responsibilities be-cause of the large size of this patient population and the high costs as-sociated with institutionalization for avoidable health problems.
Pharmacists are recognized as medication-use experts and should provide leadership in ensuring that medication-related ACO quality-performance standards are met. Pharmacists also should take a lead-ership role in addressing medication-related performance measures used in CMS’s Hospital VBP Program. ACO performance ties in with VBP performance, though the latter re-lates more narrowly to the acute care hospital setting than the former. The ACO and VBP performance standards and measures represent opportunities for pharmacists to demonstrate their impact on patient outcomes. The impact of the phar-macist could extend to performance standards beyond those that are medication related (e.g., patient sat-isfaction), especially as pharmacists
advance their role as members of the health care team.
A goal of implementing ACOs is to provide high-quality population-based care, and the transition from a fee-for-service model to population-based care has led to a change in in-centives focused on providing quality patient care instead of a high volume (i.e., quantity) of services. This shift in incentives has already begun to break down barriers between health care professions (i.e., eliminate silos) because of alignment of incentives among members of these profes-sions. Shared accountability (i.e., shared risk) for patient outcomes and health care costs is needed to provide quality care and reduce waste. Integrating the pharmacy profession
Many health-system pharmacists practice in acute care settings. The Pharmacy Practice Model Initiative put forth by ASHP is focused primar-ily on the inpatient setting, as well as ambulatory care and clinic settings in health systems.21 As health-system
pharmacists become involved in ACOs, they need to think beyond the walls of their institutions and in broader terms about health systems as part of the health care continuum. This continuum includes the am-bulatory care or home setting, acute care hospitals, clinics, physicians’ offices, and long-term-care facili-ties, such as rehabilitation facilifacili-ties, skilled-nursing facilities, and nursing homes. Nonacute conditions need to be considered along with acute con-ditions when developing strategies to provide pharmacy services in ACOs.
Most health care consumers ob-tain care in the ambulatory care set-ting, where the continuity of care is often interrupted because of a lack of infrastructure and mechanisms for health care professionals to fol-low patients after they leave health care institutions (e.g., hospitals, rehabilitation and long-term-care facilities). Although many
commu-nity pharmacists are active in disease screening and monitoring programs, immunization programs, MTM services, and other advanced patient care activities, community pharma-cist participation in patient counsel-ing and other patient care activities often is hindered by a large workload (i.e., high volume of prescriptions). A lack of access to complete patient data and compensation for patient-oriented services beyond the most basic functions involved in filling prescriptions also may limit the extent to which patient care can be provided in this setting. Community pharmacists need to become engaged in the patient care process to a greater extent and network with pharmacists across the care continuum to meet the goals of ACOs. Strategic partner-ships and alliances between health-system pharmacists and community pharmacists are needed.
Various pharmacy associations were originally established to meet the unique needs of pharmacists practicing in specific settings, such as hospitals, community pharmacies, long-term-care facilities, and man-aged care organizations. These phar-macy associations will need to col-laborate in helping members become involved in ACOs due to the need for communication during care transi-tions (i.e., medication reconciliation) and other pharmacist interventions across the care continuum.
Pharmacy education and training The curricula at pharmacy schools and colleges need to be evaluated and reworked to prepare students to practice effectively as members of the health care team in ACOs. Health-system pharmacists should col-laborate with the academic thought leaders who are responsible for professional training to ensure that students are equipped for the new practice roles required in ACOs. Additional training of students is needed in physical assessment, medication reconciliation, and
com-munication skills. The creation of a business case to obtain funding for pharmacy services as part of an ACO could also be part of the pharmacy curriculum. Experiential programs should place students in a variety of practice settings across the health care continuum to provide students with a broad view of the patient care services needed in ACOs. Pharmacy faculty who coordinate experiential programs for pharmacy students should establish partnerships with health care professionals at diverse practice sites to ensure that stu-dents are exposed to an integrated health care model and develop the skills needed to function effectively in these settings. Interprofessional collaboration among the faculty at pharmacy, medical, nursing, and other health care professional schools is needed to prepare students to as-sume effective roles on health care teams in ACOs.
The use of informatics (e.g., clini-cal decision-support programs with alerts, follow-up medical appoint-ment and medication administra-tion scheduling programs) is a vital component of education. Pharmacy schools and colleges should consider working with information system vendors to train students in the use of these systems.
Simulation centers with computer-based programs have been estab-lished for training students and staff in medicine, pharmacy, nursing, and other health professions in clinical decision making. These programs illustrate a team-based approach to addressing patient cases. Many of these cases (e.g., emergency sce-narios) cannot be taught in a real-world setting because of the need for prompt decision-making and the serious consequences of mistakes. Good patient cases that illustrate common scenarios encountered in pharmacy practice within ACOs need to be developed for use in these simulation centers. The technologies used for pharmacy student education
and training also may be useful for pharmacy staff development pro-grams in health systems.
Challenges and opportunities Integrating pharmacy programs into the ACO model of care presents many challenges, including diffi-culty with (1) identifying high-risk patients who stand to benefit most from pharmacy services designed to improve outcomes and reduce costs, (2) planning, coordinating, and com-municating among hospitals, clinics, physicians’ offices, and community pharmacies (i.e., across the health care continuum), (3) measuring the quality (i.e., clinical) and financial impact of the pharmacist, and (4) communicating effectively with pa-tients and influencing their medica-tion- and health-related behavior. Many of these challenges represent opportunities for pharmacists to devise innovative solutions to meet ACO goals.
Prioritizing patients for phar-macy services. To obtain the greatest return on investment in pharmacists as members of the health care team in ACOs, it is important to allocate pharmacist time and efforts wisely. Although a minimum standard of care should be provided to all patients, pharmacist interventions should target high-risk patients who are likely to experience poor health outcomes or use costly health resources. For example, high-risk pa-tients could receive face-to-face dis-charge medication counseling from a pharmacist and follow-up contact by a pharmacist after discharge instead of written information from a nurse with no follow-up. Risk stratifica-tion is needed to identify high-risk groups of patients, but risk analysis is a complex process. The criteria to use in risk stratification are not entirely clear because of a lack of scientific data. Patients with certain complex chronic diseases or conditions com-monly associated with poor out-comes (e.g., diabetes mellitus) are
one group that should be prioritized for pharmacy interventions because these patients are responsible for a disproportionately large investment of health care resources and costs.22
Other groups to target for pharma-cist intervention are less well-defined but could include patients receiv-ing certain high-risk drugs with a low therapeutic index and patients receiving a large number of medi-cations.23 Point-based risk-scoring
systems have been developed for use in the inpatient setting, but their ap-plicability in other settings is limited. Some risk-stratification systems are homegrown, and others are commer-cially available. Lack of an evidence base, reliance on empirical data, and lack of validation for criteria used to identify high-risk patients are prob-lems associated with some of these systems. A relevant set of criteria for risk stratification (e.g., certain condi-tions known to be associated with a high rate of hospital readmission at a particular facility) and workable methods for applying the criteria are needed. For example, several days before hospital discharge, a trained pharmacy technician could screen for patients meeting the criteria for a high risk for readmission and schedule patient discharge medica-tion counseling with a pharmacist, follow-up telephone calls with the pharmacist, and a follow-up patient visit with the primary care provider. Mechanisms for communicating with patients after they make the transition to another care setting are needed for such follow-up. Automa-tion of risk-stratificaAutoma-tion systems across the health care continuum would improve efficiency, but auto-mating systems is a challenge.
Coordinating and communi-cating across the health care con-tinuum. Avoiding fragmentation of care is vital for optimizing patient outcomes and preventing avoidable problems that result in the use of costly health resources (e.g., hospi-tal readmission). Discharge
plan-ning, medication reconciliation, and communication among health care professionals about other aspects of patient care at the time of transition between care settings contribute to the continuity of care. These proc-esses are particularly important for patients who are at a high risk for poor outcomes because of chronic diseases, use of large numbers of medications, or lack of a support net-work at home. Pharmacists should collaborate with care coordinators to avoid fragmentation of care.
Difficulty sharing patient infor-mation across the health care con-tinuum is a major barrier to the suc-cessful incorporation of pharmacy programs into ACOs. Pharmacists in some settings (especially small community and rural health care facilities) often have limited access to patient information beyond what is provided in the prescription. Infor-mation about the diagnosis, comor-bid conditions, immunization his-tory, laboratory data, vital signs, and other physical examination results is often not available in these settings. Communication between health-system pharmacists and physicians in the community about the health status of patients discharged from the hospital often is difficult. Con-nectivity among central and remote patient care locations to facilitate communication among health care providers is often lacking, especially when patients seek health care from providers outside health systems. Pa-tient privacy and confidentiality, sys-tem security, and identity theft also are concerns. An integrated patient care system requires support from an integrated information system.
Health information technology is available, and the Pharmacy e-Health Information Technology Collabora-tive (a group of pharmacy organiza-tions, including ASHP) has defined a minimum data set and functional pharmacy practitioner electronic health record (PP-EHR) capabili-ties.24 However, the limited extent
to which health information system vendors have accommodated phar-macy needs and a lack of standard-ization of pharmacy software appli-cations are problems.
Establishing collaborative drug therapy management agreements between pharmacists and physi-cians is vital to optimizing the use of pharmacists to meet ACO goals. The lack of quality-improvement tools to monitor and evaluate the effect of pharmacist interventions on patient care as part of these agreements is a potential barrier to the successful incorporation of pharmacy services into ACOs. A quality-improvement tool that is part of an integrated system is needed. Such systems can facilitate scheduling of patient care visits with multiple health care providers in different settings (e.g., a pharmacist and dietitian) to opti-mize convenience for and satisfaction of the patient.
Physician acceptance of pharma-cists in collaborative drug therapy management agreements may vary, depending on physicians’ perceptions of and confidence in the training, ex-perience, skills, and abilities of the pharmacist. Marketing of the scope, depth, and value of pharmacy train-ing (especially residency traintrain-ing) may improve physician acceptance of pharmacists in collaborative drug therapy management agreements. Nevertheless, assurance of pharma-cist competence through certification or other credentialing beyond licen-sure may be needed to gain physician and payer acceptance of pharmacists in collaborative drug therapy man-agement agreements. Some health systems have developed formal an-nual staff-credentialing programs, with peer evaluation of performance. This credentialing process leads to designation as an advanced-practice pharmacist, analogous to advanced-practice nurses with specialized edu-cation, knowledge, skills, and clinical roles. In 2011, the Council on Cre-dentialing in Pharmacy (a group of
13 organizations, including ASHP) published guiding principles for postlicensure credentialing of phar-macists.25 This document encourages
the implementation of credentialing and privileging processes in all phar-macy practice settings based on the patient care responsibilities of the pharmacist. The complexity of care provided by pharmacists practicing in ACOs may vary, and new models for credentialing and privileging of pharmacists in ACO models are needed. The Council currently is working on a follow-up report with model credentialing programs that might be helpful.
Liability may be a concern for pharmacists entering into collab-orative drug therapy management agreements. Pharmacists should consult with institutional legal advi-sors and risk-management personnel about these concerns.
Measuring pharmacists’ quality and financial impact. Pharmacists often are able to convince physi-cians and nurses of the value of pharmacist input into patient care but find it more difficult to demon-strate their value to health-system administrators, payers, and other decision-makers. A business case needs to be made to convince health-system administrators and payers of the wisdom of investing resources in the use of pharmacists in ACOs to meet the goals of improving patient outcomes and population health and containing costs. This business case should be built on documented evi-dence of the impact of the pharmacist on patient adherence to drug therapy plans; prevention of adverse drug events, medication errors, and hospi-tal admissions and readmissions; and related reductions in costs. The large potential return on investment should be emphasized in the business case.
Pharmacy staff members need to examine what the health-system leadership uses as performance met-rics. In addition to financial metrics (e.g., the number and cost per day of
readmissions, cost of drugs), proc-ess metrics (e.g., the tasks involved in and amount of time required for patient care), clinical or quality outcome metrics (e.g., culture and susceptibility test results), and satis-faction metrics (e.g., patient surveys, physician consultations) are often used. Understanding which metrics are used in the institution can help pharmacists prioritize their efforts to demonstrate a favorable effect on ACO performance.
An integrated care map or flow chart should be developed illustrat-ing core service lines (i.e., which health care professional performs which functions) and identifying high-risk diseases and conditions that represent opportunities for intervention to improve outcomes. The role of the pharmacy service (i.e., who, what, how, when, and how often) in providing care for patients with these diseases and conditions should be defined. This approach has been followed in the inpatient setting for traditional services (e.g., pharma-cokinetic consultations, with dosage adjustments made for patients with renal impairment). Pharmacy servic-es that are new as a rservic-esult of the VBP Program and the ACO model in the inpatient setting include preadmis-sion medication histories and recon-ciliation, provision of early inpatient education, medication reconciliation at the time of discharge focusing on factors that promote medication ad-herence in a real-world setting, and postdischarge patient follow-up.
Templates or other tools are needed that yield qualitative and quantitative clinical and financial data based on valid metrics. Metrics are needed to capture the impact of pharmacist interventions on hospital readmission rates. Cost data are par-ticularly valuable for ensuring that pharmacists are not omitted from ACO plans for providing patient care services. The net cost of treatment after taking into consideration re-source consumption should be
ascer-tained. Standalone tools are available but are inadequate.
The health-system and pharmacy leadership may have limited famil-iarity with the performance metrics required by ACOs and CMS’s VBP Program, including the weighting of the VBP Clinical Process of Care Measures (e.g., acute myocardial in-farction, heart failure, pneumonia, Surgical Care Improvement Proj-ect) and Patient Experience of Care Measures (i.e., Hospital Consumer Assessment of Health Care Providers and Systems). An understanding of pay-for-reporting and pay-for-per-formance requirements and the four domains of quality measures for pio-neer ACOs (patient/caregiver experi-ence, care coordination/patient safety, preventive health, and at-risk pop-ulations) is needed. Health-system pharmacists should partner with hospital-based regulatory or quality-reporting-department personnel to stay abreast of federal, state, and other (e.g., Joint Commission) performance measurement requirements.
Large volumes of data are gener-ated in large health systems, and quality-improvement personnel may require pharmacist input to identify which data are most useful. Pharmacists should collaborate with quality-improvement personnel to ensure that data selected for analysis yield information that is relevant and useful.
Predictive models are needed to identify gaps in care where pharma-cist interventions could yield sub-stantial benefits in improving patient care. Identifying such gaps would al-low pharmacists to prioritize their ef-forts and optimize results from lim-ited resources. Software programs are needed to facilitate the identification of patient care issues and streamline the pharmacy workload.
The pharmacy services provided to selected high-risk patients in an ACO often exceed what are provided for low-risk or non-ACO patients, because focusing limited resources
on the subset of patients most likely to experience poor outcomes that are costly is efficient and wise. In many health systems, care is provided to some patients in an ACO model and to other patients using a fee-for-service model. The approach to demonstrating the financial impact of pharmacists when integrating pharmacy services to support the VBP Program and reduce hospital readmissions is similar to that used when justifying pharmacy services for an ACO.
Communicating with patients and influencing patient behavior.
Inabilities to communicate effec-tively with patients and influence their medication- and health-related behavior can present a barrier to achieving ACO goals. These goals require that patients gain an under-standing of their disease or condition and its management and adhere to the treatment plan. Standardized terminology and content are needed in patient education to provide this understanding and prevent the con-fusion that can arise when different (sometimes conflicting) messages are received from more than one health care professional. Collaboration among practitioners in hospitals, physician offices, managed care or-ganizations, and community, mail-order, and home infusion pharma-cies is needed to provide a consistent message to patients and avoid the confusion and nonadherence that can result from mixed or conflicting messages.
Face-to-face counseling may be helpful for patients with complex needs (e.g., a new diagnosis of dia-betes or another complex disease, a need to learn how to use inhalers or other complex devices for treatment or monitoring of chronic diseases). Face-to-face counseling sometimes can be provided effectively for pa-tients at remote locations using mod-ern technology (e.g., Intmod-ernet-based audio and video communication). However, face-to-face counseling is
not essential for all patients. Patients should be stratified based on their educational needs to prioritize the use of counseling resources for pa-tients with the greatest need.
Providing patient education pro-motes adherence, which may be measurable in an integrated system by using prescription-refill data and calculating the medication pos-session ratio (percentage of time a patient has access to prescribed medication) or proportion of days covered (number of days all pre-scribed drugs are available out of the number of days of follow-up).26
However, it can be difficult to as-sess adherence across the care con-tinuum. Programs to promote ad-herence are needed, but developing such programs is time-consuming.
Providing patient education does not always translate into behavioral change that promotes health goals because of a lack of motivation or other barriers to change. Some patients need to be provided with incentives to overcome these bar-riers and make necessary changes. Incentives should be framed in the context of a patient’s personal values, needs, and goals (e.g., a wish to avoid ill health, disability, hospitalization, and premature death for the sake of loved ones). Because human behav-ior is complex, multiple strategies involving more than one member of the health care team may be needed to overcome barriers to change. In-terprofessional collaboration may be needed.
Motivational interviewing—a col-laborative, patient-centered form of guidance used to elicit and strength-en motivation for and commit-ment to change in the patient—is an important technique and skill that pharmacists need to develop and use to help patients achieve health goals.27 Pharmacists need to
avoid what patients may perceive as lectures about medication use. Patients need to be empowered and positioned to succeed as they prepare
for and make changes. Education alone is often insufficient to achieve behavioral change. Nevertheless, education is an important compo-nent of motivational interviewing to elicit the desired behaviors. The timing of this education can be critical. Education and follow-up reinforcement should be provided at a time when the patient is most receptive and likely to retain the in-formation presented, not at a time when he or she is distracted by pain, other discomfort, or concerns about imminent discharge from a hospital or another care transition. Ideally, patient education is provided in the ambulatory care setting to preempt the need for hospitalization. In the acute care hospital setting, education might be provided early in the course of the hospital stay as well as near the time of discharge and after the tran-sition to another care setting (i.e., in the home or a rehabilitation or long-term-care facility).
Most pharmacists are experi-enced in establishing a rapport with patients and educating them about drug therapy, but training in moti-vational interviewing skills is needed for many pharmacists. Motivational interviewing has been incorporated into the curriculum at some pharma-cy schools and colleges, but oppor-tunities are needed for practition ers who graduated years or decades ago to obtain practical experience and develop skills and confidence in mo-tivational interviewing.
Patients should be encouraged to set therapeutic goals. The in-volvement of family members and caregivers should be encouraged. Various patient-led support groups (e.g., Mended Hearts for patients with heart disease and their families and caregivers) have been created and can serve as models for success-ful approaches to increasing patient, family, and caregiver involvement in the health care process and commit-ment to achieving health outcomes. Pharmacists and other members of
the health care team should work with patients, family members, and caregivers to establish therapeu-tic goals, perhaps by developing a contract outlining the goals and responsibilities of the patient. The success of such efforts usually hinges on establishing an effective personal relationship between the pharmacist and the patient and building patient trust in the pharmacist.
Technology may be used to facili-tate the setting and achievement of health goals. For example, devices are available that allow the patient to monitor and share with his or her health care provider information about diet, exercise, body weight, sleep patterns, and other variables associated with favorable health outcomes.
Other challenges. Access to medi-cations can be an issue because of formulary restrictions and prior-authorization requirements (among other factors). Sorting through the complex formulary restrictions and prior-authorization requirements of a large number of health plans is time-consuming and costly for health care providers. Pilot proj-ects have been established in health systems using specially trained pharmacy technicians to anticipate and resolve problems with prior-authorization requirements before a patient is discharged from the hos-pital so that access to medications is not a problem in the ambulatory care setting.
Creating a standardized prescrip-tion drug benefit and formulary for ACOs would address the medication-access problem, but a standard ben-efit cannot be required for Medicare and Medicaid beneficiaries who by law must be given a choice of plans and benefits. Modifying prescrib-ing is another potential solution. Increasing the use of evidence-based prescribing would reduce the need for prior authorization.
Pharmacists in health systems are sometimes asked to participate in the
preparation and administration of costly, large-molecule, biotechnolo-gy-derived, injectable drug products obtained from specialty pharmacies (i.e., through restricted drug distri-bution systems), a practice known as “white bagging.” The health-system pharmacist cannot be certain about the integrity of products obtained from sources other than manufactur-ers and wholesalmanufactur-ers. Storage condi-tions may have been compromised, and there are no mechanisms to establish and track the product’s pedigree (i.e., origin and subsequent sales transactions) and accommodate product recalls.28 Personal and
insti-tutional liabilities are associated with the use of these products, and the institution may bear the cost of ad-ministering the drug. White bagging is not consistent with the integrated health care model in ACOs because of the resulting fragmentation in the patient care process; the relationship between the patient, physician, and pharmacist; and the drug supply, preparation, and administration processes.
Opportunities for collaboration The need to provide integrated care across the health care con-tinuum in the ACO model creates a need and opportunities for health-system pharmacists to collaborate with pharmacists and other health care professionals outside health systems. The potential for improved health outcomes and reduced costs may justify placement of pharmacists in practice settings outside the health system. These pharmacists can be placed in clinics and other settings to provide MTM services, resulting in increased quality of care and reduced costs.
Patient education is often omitted for hospitalized patients discharged to a skilled-nursing facility or other long-term-care facility because the patient is under medical supervision in these settings. However, in recent years, the acuity of care in these
settings has increased, and some pa-tients are poorly managed, resulting in readmission to the hospital. Some health systems have placed staff in long-term-care facilities to address this problem by working with per-sonnel in these settings. The health care team should develop care plans and provide discharge education for patients leaving the hospital for skilled-nursing facilities and other long-term-care facilities because many of these patients eventually return home, where medication use and other aspects of patient care are not under medical supervision.
The ACO model provides oppor-tunities for collaboration with pay-ers. Health systems have established collaborative risk-sharing agree-ments with payers for the provision of MTM services. The most costly medications could be the focus of MTM services initially. Cost-savings data generated by such agreements can be used in a business case to justify incorporating or expanding pharmacy services within the ACO.
Collaborative agreements between health systems and private physician practices outside the health system could be established as part of an ACO. Such agreements have been explored for the provision of care management services in rural areas with sparse population densities.
Private payers have considerable flexibility and often are amenable to establishing contracts with health systems to provide health services for managed care beneficiaries or employee groups. Innovative ap-proaches have been used by private commercial health plans to provide services to large employers. In some cases, health clinics with pharma-cies have been established in the workplace to improve the health and productivity of employees, reducing the cost per member per month for the plan and the em-ployer. Pharmacists need to become involved early in the process of contracting for services.
Role of ASHP
ASHP has sought input about the role of pharmacists in ACOs from thought leaders in institutions across the country with experience in or knowledge of these roles. In June 2012, the Society approved a policy on the pharmacist’s role in ACOs (Appendix B).29 ASHP has provided
members with ACO-related infor-mation and products in a variety of formats, including publications (e.g., articles in the American Journal of Health-System Pharmacy, a January 2011 ASHP policy analysis on the pharmacist’s role in ACOs30),
con-tinuing-education and networking sessions at meetings, and a one-hour archived webinar on the Affordable Care Act and ACOs.31 Nevertheless,
many pharmacists are unaware of the need or how to become involved in ACOs. Assistance is needed with basic patient care skills (e.g., physical assessment), identifying care bundles (i.e., groups of evidence-based best practices that improve care to a greater extent than when each prac-tice is used alone), innovative tech-nology, and pharmacy practices at transitions of care for patients with specific diseases (e.g., pneumonia) or in certain care settings (e.g., skilled-nursing facilities). ASHP should continue to educate its membership about ACOs and how to incorporate pharmacy programs into the inte-grated care model.
Descriptive reports of successful strategies for the incorporation of pharmacy services into ACOs and related performance metrics would be useful. As part of its Medication Management in Care Transitions project, ASHP has partnered with the American Pharmacists Associa-tion to identify models of successful collaborations between inpatient and outpatient pharmacists that could serve as helpful examples for members seeking to improve the medication reconciliation and care transition processes and reduce hos-pital readmissions. A report
describ-ing these models was released in late fall 2012.
ASHP could serve as a clearing-house for information (e.g., how to negotiate collaborative drug therapy management agreements), best prac-tices, and tools for decision-making in ACOs. Assistance in the develop-ment of a business case to obtain financing for pharmacy services as part of an ACO would be helpful. Pharmacy managers need to under-stand how best to demonstrate the impact of pharmacist involvement in the patient care process. ASHP also might develop a white paper about issues related to ACOs.
ASHP might develop patient cases that illustrate the role of the phar-macist in improving patient health in ACOs for use at simulation cen-ters in training pharmacy students and staff. Medication reconciliation could be the focus of some of these patient cases, but training should extend beyond medication reconcili-ation to other aspects of patient care (e.g., MTM services) in an integrated model.
ASHP could identify and share with its members effective programs to promote patient adherence across the health care continuum, especially outside the hospital setting. Read-mission of patients with pneumonia is a current concern for many health-system pharmacists.
ASHP might assist members who need training in motivational inter-viewing skills by providing educa-tion about the approaches used and skills needed to motivate patients to make medication- and health-related behavioral changes. Referring mem-bers to resources for developing such skills would be a valuable service.
ASHP might convene an advisory group of pharmacy leaders and care managers to develop strategies for effective collaborative working rela-tionships within ACOs. Participants in such an advisory group could have a more powerful voice as members of a group than when working alone.
ASHP should continue to work with the Pharmacy e-Health Infor-mation Technology Collaborative to promote use of the PP-EHR as a model in national health informa-tion technology initiatives. ASHP also should work with this and other groups to address the concerns related to the lack of connectivity and inabili-ty to share patient information among practitioners in various settings across the care continuum. ASHP should establish a dialogue with health infor-mation technology companies about pharmacy issues and needs, including the standardization of pharmacy soft-ware applications.
ASHP can play an important role in addressing concerns raised about the need for credentialing to ensure the competence of pharmacists who enter into collaborative drug therapy management agreements in ACOs. As a member organization of the Council on Credentialing in Phar-macy, ASHP should work to resolve these concerns.
ASHP might work with the Ac-creditation Council for Pharmacy Education to suggest changes to pharmacy school and college ac-creditation standards related to the curriculum. These changes should reflect the role of pharmacists prac-ticing as team members in ACOs and offering primary and preventive pharmacy services to patients.
ASHP should advocate for the role of the pharmacist in ACOs through the residency accreditation proc-ess. Senior administrators in health systems typically meet with ASHP accreditation services staff during ac-creditation visits, and these meetings provide an opportunity for ASHP staff to leverage their considerable influence to encourage involvement of pharmacists in ACOs. ASHP should reevaluate and modify resi-dency accreditation standards to re-flect pharmacist roles in ACOs.
ASHP should work with other professional pharmacy organiza-tions; professional organizations
representing physicians, nurses, and members of other health professions; governmental leaders; and health-system administrators to address ACO-related issues, minimize inter-professional conflict, and improve collaboration among health care pro-fessionals in ACOs. Issues related to the scope of pharmacy practice and use of pharmacy technicians to free up pharmacist time for patient care services might be addressed by work-ing with the National Association of Boards of Pharmacy.
ASHP should establish a dialogue among and create a sense of urgency in pharmacy educators involved in schools and colleges of pharmacy and residency training programs to prepare the next generation of phar-macy leaders for their future role in ACOs. Incorporating pharmacy ser-vices into ACOs requires transforma-tion and innovatransforma-tion (e.g., new prac-tice and payment models, incentives) that are disruptive. A strategic plan needs to be developed to manage dis-ruptions associated with innovation. The ASHP Research and Education Foundation might consider funding research (e.g., demonstration proj-ects) to evaluate innovative practice and payment models.
ASHP might provide members with guidance about the marketing of pharmacy services in an integrated patient care model to the public. Requests for pharmacy services from patients in ACOs are envisaged. Next steps
The pace of change in health care delivery and financing that influenc-es approachinfluenc-es used by pharmacists involved in ACOs is rapid. The ASHP Board of Directors and staff will monitor these changes and develop strategies to help members position themselves within the ACO structure and incorporate pharmacy services to meet ACO goals.
Conclusion
de-livery requires an integrated approach and a new mindset among pharmacists and other health care professionals across the health care continuum. This integrated approach presents chal-lenges and opportunities for health-system pharmacists. To overcome these challenges, ASHP should continue to provide its members with education, identify resources, and collaborate with other professional organizations.
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Appendix A—Members of the ASHP Task Force on Accountable Care Organizations
Ernie Anderson Jr., M.S.
System Vice President of Pharmacy Steward Health Care
Brighton, MA
Joseph T. Botticelli, M.S. System Director of Pharmacy Bellin Health
Hayley Burgess, Pharm.D.
Director, Medication Safety and Systems Innovations
Hospital Corporation of America Nashville, TN
Hae Mi Choe, Pharm.D., CDE
Director, Innovative Ambulatory Care Pharmacy Practices
Clinical Associate Professor of Pharmacy Department of Clinical, Social, and
Administra-tive Sciences University of Michigan Ann Arbor, MI
William W. Churchill, B.S., M.S. Chief of Pharmacy Services Brigham and Women’s Hospital Boston, MA
Justine Coffey, J.D., LLM (Secretary) Director, Section of Ambulatory Care
Practitioners
Pharmacy Practice Sections
American Society of Health-System Pharmacists Bethesda, MD
Christene M. Jolowsky, M.S., FASHP
Executive Director, Applied and Experiential Education
College of Pharmacy University of Minnesota Minneapolis, MN
Brenda J. Nelson, Pharm.D.
Pharmacy Coordinator—Transitions of Care Allina Health
Minneapolis, MN Priyesh Patel, Pharm.D. Chief Pharmacy Officer
Providence Health and Services Oregon Portland, OR
Pamela Phelps, Pharm.D.
Director of Clinical Pharmacy Services Fairview Health Services
Minneapolis, MN William Seavey, Pharm.D. Clinical Decentralized Pharmacist Eastern Maine Medical Center Bangor, ME
James G. Stevenson, Pharm.D. (Chair) Chief Pharmacy Officer
University of Michigan Health System Ann Arbor, MI
David R. Witmer, Pharm.D.
Senior Vice President and Chief Operating Officer
American Society of Health-System Pharmacists Bethesda, MD
Appendix B—ASHP Policy on the Pharmacist’s Role in Accountable Care Organizations29
To recognize that pharmacist participation in collaborative health care teams improves outcomes from medication use and lowers costs; further,
To advocate to health policymakers, payers, and other stakeholders for the inclusion of phar-macists as health care providers within account-able care organizations (ACOs) and other mod-els of integrated health care delivery; further,
To advocate that pharmacist-provided care (including care coordination services) be appro-priately recognized in reimbursement models for ACOs; further,
To advocate that pharmacists be included as health care providers in demonstration projects for ACOs; further,
To encourage comparative effectiveness re-search and measurement of key outcomes (e.g., clinical, economic, quality, access) for pharma-cist services in ACOs; further,
To encourage pharmacy leaders to develop strategic plans for positioning pharmacists in key roles within ACOs.
