Community Pharmacy’s Role in Accountable Care
When the Affordable Care Act was passed, the expansion of insurance coverage to 30 million more Americans received most of the attention. But those involved in healthcare recognize that a key part of this legislation is an increased emphasis on accountable care, along with the creation of Accountable Care Organizations (ACOs). Accountable care has the potential to transform healthcare.
What’s Driving the Emphasis on Accountable Care?
The Centers for Medicare & Medicaid Services (CMS) is focused on what many refer to as the “Triple Aim” of better health, better care and lower costs. This Triple Aim is articulated in the context of:
- A fragmented, mistake-prone delivery system that leaves care coordination to the patient
- An increase in the prevalence of chronic diseases, especially as the population ages
- A fee-for-service payment system that rewards volume (higher costs) over quality (good health outcomes)
What Is Accountable Care and What Are ACOs?
“Accountable care” is a philosophy of making providers more accountable for the quality and cost of care of the patients they care for.
Accountable Care Organizations are new healthcare delivery entities charged with delivering accountable care and achieving the goals of the Triple Aim. The CMS rules for ACOs (published on October 20, 2011) as well as the numerous commercial payor initiatives afford significant flexibility in how accountable care is delivered, meaning no two health systems or ACOs are likely to deliver accountable care exactly the same. Still, ACOs will share important characteristics.
- Care for populations. ACOs will be responsible for managing the health of entire patient populations. The CMS regulations require an ACO to care for at least 5,000 patients.
- Care coordination. An expectation is that ACOs will change healthcare delivery from fragmented to coordinated. Care will be delivered in teams. An important aspect of care coordination is the patient-centered medical home (PCMH), led by primary care providers, and a “medical neighborhood,” which is the broader community of providers who will collaborate with a PCMH in managing the population’s health. The concept of a medical neighborhood can include specialists, hospitals, labs and other providers — even pharmacists.
- Quality reporting. Being a Medicare ACO requires reporting on 33 defined measures of quality.
- Technology integration. Care coordination requires that providers be able to easily (and securely) access and share patient information from wherever an individual receives care. ACOs will adopt health information technology that includes electronic health records (EHRs), personal health records (PHRs), health information exchanges (HIEs) and analytical tools.
- Revised financial incentives. ACOs will have incentives to improve care coordination, meet certain quality standards and lower the costs of care. ACOs will have some financial responsibility for their population, with some types of ACOs having an opportunity to receive “shared savings,” where they share in a portion of cost savings to CMS. Some private payors are already offering shared savings and other financial incentives for accountable care.
So, organizations focused on accountable care are creating new delivery models to care for populations that emphasize coordination, quality, IT integration and revised financial incentives. Accountable care has the potential to profoundly change healthcare delivery.
What Does Accountable Care Mean for Community Pharmacies?
Greater emphasis on accountable care has much potential for community pharmacists. Pharmacists are trusted community resources with expertise in areas such as medication therapy management and adherence, counseling patients, conducting screening programs, and administering immunizations. Each of these areas has potential value to organizations focused on accountable care.
Some ideas for community pharmacists to consider:
- Assess your capabilities. This is an important moment to define your organization’s unique and valuable competencies and capabilities, and to consider what capabilities you might want to develop. Consider capabilities that would be valued by groups that are prioritizing accountable care.
- Understand your local landscape. Do homework about your local market to understand which health systems are emphasizing accountable care. Are there organizations where you have existing relationships? Which organizations would be attractive partners?
- Innovate. This is a time to contemplate offering new services and experimenting with new business models. For example, could your pharmacy offer medication-management services in collaboration with home-care providers (as some pharmacies are doing)? Could your expertise be valuable as part of a disease-management program? Might there be an opportunity to develop and lead a program to educate recently discharged patients about their medications? What information and knowledge do you have that would be valuable to providers in this changing context?
Keep in mind that health systems will be focused on reducing readmissions and transitioning the delivery of care to the most appropriate, lowest-cost settings (like delivering an immunization in a pharmacy instead of a physician’s office).
- Understand the technology requirements. ACOs will require that their partners be technologically integrated to share appropriate patient and population information to enhance coordination and outcomes. Understand what this means and what steps your pharmacy might need to take.
- Build relationships. Working with providers that are focused on accountable care requires building collaborative, trusted relationships. It is important for community pharmacists to be proactive in making providers aware of the many capabilities a pharmacy has and why inclusion as part of a medical neighborhood can be beneficial for the provider and patients.
Perhaps most important for community pharmacists is to be aware of the growing importance of accountable care and to see this as a potential opportunity that requires innovation. Join the conversation and be proactive in charting a course to participate in this opportunity.
For more information about the potential role for pharmacists in accountable care, see a comprehensive white paper by RelayHealth® at: www.relayhealth.com/resource-library/white-papers/.