Leading By Example Melissa Somma McGivney, PharmD, FAPhA, FCCP Associate Dean for Community Partnerships; Associate Professor University of Pittsburgh Tripp Logan, PharmD Senior Quality Consultant - MedHere Today Consulting Vice-President Logan & Seiler, Inc. (L&S Pharmacy / Medical Arts Pharmacy) tlogan@medheretoday.com Disclosures Tripp Logan, PharmD Senior Quality Consultant / Partner at MedHere Today Consulting Target Audience: Pharmacists ACPE#: 0202-0000-17-038-L04-P Activity Type: Knowledge-based Clinical Pharmacist / Vice President, Logan & Seiler, Inc. (L&S Pharmacy / Medical Arts Pharmacy) The American Pharmacists Association is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. Learning Objectives 1. Describe the skills needed to lead practice change within an organization. 2. Describe how to use an environmental scan to identify organizational needs for improvement in patient care and outcomes. 3. Explain how to create a proposal or plan for pharmacy-based patient care service delivery. 4. Describe how to identify and work with key decision makers and stakeholders to gain approval and ongoing support for pharmacists services. 5. Explain the components of a business plan for a pharmacist s patient care service, including how to demonstrate return on investment. Begin with a vision Patients achieve optimal health and medication outcomes with pharmacists as essential and accountable providers within patient-centered, team-based healthcare. Adopted by JCPP January 2014 1
Our Patients Learn from SUCCESS APhA Focus Group August, 2014 Pharmacist leaders who have successfully implemented, replicated and sustained pharmacist integrated care models 14 panelists representing diverse areas of outpatient practice throughout the US Facilitated by: Anne Burns, Sarah Dombrowski, Melissa McGivney Outcome: 9 Blueprint Elements for Building a Successful Business Case 9 Blueprint Elements for Building a Successful Business Case 1. Articulate your practice model 2. Identify champions 3. Think TEAM 4. Understand the financial, quality, and risk model of the practice/system/payer 5. Develop the value proposition 6. Determine resource requirements 7. Engage key leadership 8. Develop the implementation 9. Implement and improve Articulate your practice model http://www.pharmacist.com/sites/default/files/patientcareprocess.pdf Blueprint element #1 Articulate your practice model: Utilizing resources beyond pharmacy National Governors Association: 2015 The expanding role of pharmacists in a transformed health care system - Training, Scope of Practice, Case examples, Collaborative Practice Laws CDC: 2013 Collaborative practice agreements and pharmacist patient care services: a resource guide for pharmacists Collaborative Practice Agreements, strategies, case examples National Association for County and City Health Officials: 2013 Building and Sustaining Strong Partnerships between Pharmacies and Health Departments at State and Local Levels Articulates opportunities for partnering to improve community health 2
Articulate your practice model: Utilizing resources beyond pharmacy American Academy of Family Physicians: 2012 Pharmacists (Position Paper) The AAFP supports arrangements where the pharmacist is part of an integrated, team-based approach to care. Patient Centered Primary Care Collaborative: 2012 The Patient Centered Medical Home: Integrating comprehensive medication management to optimize outcomes Outlines specific process of care and implementation Report to the US Surgeon General: 2011 Improving patient and health system outcomes through advanced pharmacy practice: A report to the US Surgeon General Provides evidence pharmacists are acting as providers today Envision YOUR Practice Community Pharmacy Geriatric Team Practice Employer Group Employer Group Family Medicine Practice A Tale of Two Professions Enhanced Pharmacy Services You don t have to do everything, JUST DO WHAT YOU DO WELL! Partners are looking for enhanced service providers, not ALL service providers Identify Champions Blueprint element #2 Pharmacist Champion Physician Champion Champion PARTNER 3
Establishing Collaborative Partnerships Foundation of Collaboration J Am Pharm Assoc. 2001;41:682 692. Community Pharmacy Champions: Internal Search For Champions External Search For Champions Think Current Pharmacy Staff Full Understanding of: Company Mission Impactable Metrics Patient Care Approach Patient Care Successes The Reason We Do What We Do Potential Partners That Currently Do or Easily Could Understand Our: Company Mission Impactable Metrics Patient Care Approach Patient Care Successes The Reason We Do What We Do TEAM Blueprint element #3 Understanding your team Environmental Scan #1 understanding how the work is accomplished Focused observation Process Mapping Brief interviews or focus groups Investing in Your Team: Invest in patient care management tools that fit your practice Trust in your pharmacy staff, they can do it Create an environment of efficiency If it doesn t fit don t force it What you believe in and what fits your model Listen to your team they can make or break your efforts! 4
Understanding the financial drivers Environmental Scan #2 Blueprint element #4 Brief interviews/meetings with key personnel Examples: Office manager, medical director, Director of Pharmacy, VP Clinical Services Seek to understand: Type of financial model of the practice/pharmacy Where compensation is currently occurring Where the most significant unmet need is (especially medication-related) Financial Model Overview Fee for Service Practice type payer opportunity Type of payer model and means of payment Shared Savings Federal Single Payer Mixed Payer Pay for Performance Capitated Capitated Capitated Shared Risk Fee for Service Pay for Performance Shared Risk Capitated 27 Used with permission from Sarah Dombrowski, PharmD Used with permission from Sarah Dombrowski, PharmD Pharmacist Payment Opportunities Fee for Service Part D Medication Therapy Management Annual Wellness Visits Transitions of Care codes Diabetes Self-Management and Education (DSME) Incident to Contracts with employer groups, state Medicaid, etc Shared Savings Pay for Performance Capitated 29 Used with permission from Sarah Dombrowski, PharmD Pharmacist Payment in a Mixed Payer Models Pharmacist Payment Opportunities Fee for Service Shared Savings Focus on decrease in high-cost utilization (prevention of ED visits, hospitalizations, re-hospitalization) Use of specialty referrals Savings often kept at system-level Pay for Performance Capitated 30 Used with permission from Sarah Dombrowski, PharmD 5
Pharmacist Payment Opportunities Fee for Service Pharmacist Payment Opportunities Fee for Service Shared Savings Pay for Performance Focus on metrics Patient outcomes (A1c, lipids) - HEDIS STAR Ratings (i.e. Avoidance of high risk medications) Appropriate medication use (ACE-I/ARB; formulary) Capitated 31 Used with permission from Sarah Dombrowski, PharmD Shared Savings Pay for Performance Capitated 32 Used with permission from Sarah Dombrowski, PharmD Focus on low cost options and avoidance of system utilization (ED visits, hospitalizations, re-hospitalizations) Blueprint element #5 VALUE Defining Pharmacy Quality & Value Pharmacy value is often being assessed based solely on prescription claims Claims do not always reflect pharmacy s true value Rx Claims Do Not Always Reflect Value Health Plan/PBM Quality Metric P4P *Percent of total HRM Rxs not associated with a submitted claim 6
Health Plan/PBM Quality Metric P4P Met / Exceeded 4 star EQuIPP goal for HRM *Percent of total HRM Rxs not associated with a submitted claim Evolution of Quality Based Pharmacy Payments Medicare Part D: Medication Therapy Management FFS Health Plan/PBM Quality Metric P4P Outcomes Based Health Plan Payments Part D Enhanced Medication Therapy Management Model Quality Based Payment Does Not Always Produce Value Evolution of Quality Based Pharmacy Payments PAYMENT Medicare Part D: Medication Therapy Management FFS Health Plan/PBM Quality Metric P4P DOES NOT Outcomes Based Health Plan Payments ALWAYS MEAN Part D Enhanced Medication Therapy Management Model PROFITABLE Quality Based Payment Does Not Always Produce Value Medicare Part D: Medication Therapy Management FFS Rx Dispensing vs Pharmacy Services Prescription gross profit: About $12.50 per prescription 15 prescriptions * $12.50= $187.50 gross profit MTM Pharmacist services: $2 per minute 1 hour MTM= $120 Approximately 50% greater profit dispensing prescriptions vs. doing MTM work Pharmacy Profitability What s Over the Horizon? Don Dietz, R.Ph, MS, Vice President; Pharmacy Healthcare Solutions Inc. American Society for Automation in Pharmacy 2014 Annual Conference; January 2014 *2014 NCPA Digest Sponsored by Cardinal Health Health Plan/PBM Quality Metric P4P What is a DIR fee? DIR is any form of price concession, received either by the Part D sponsor or by an intermediary contracting organization (a Pharmacy Benefits Manager, or PBM, for instance) with which the sponsor has contracted, from any source (including manufacturers, pharmacies, enrollees, or any other person or entity) that serves to decrease the costs incurred under the Part D plan by the Part D sponsor, either directly or indirectly. Thus, DIR includes discounts, chargebacks, rebates, cash discounts, free goods contingent on a purchase agreement, up-front payments, coupons, goods in kind, free or reduced-price services, grants, legal judgment amounts, settlement amounts from lawsuits or other legal action, and other price concessions or similar benefits.* *Final Medicare Part D DIR Reporting Requirements for 2015; Centers for Medicare & Medicaid Services memorandum; May 31, 2016 7
Standard DIR Example DIR Impact on Pharmacy Case Example of Quality Based DIR Fee Program Quality Measure Measured By: Quality Based DIR Example ACE/ARB ADHERENCE DIABETES ADHERENCE STATIN ADHERENCE Third Party Third Party Third Party STATIN USE IN DIABETES Third Party % HIGH RISK MEDS IN ELDERLY Third Party FORMULARY COMPLIANCE PBM This Example Was Produced For Case Demonstration Purposes Only Quality Based DIR Example High Quality Pharmacy Providers Medicare Part D Health Plan High Risk / Chronically ill Medicare Member Patient Attribution High Quality Pharmacy Provider 8
High Quality Pharmacy Providers Higher DIR FEES High Risk / Chronically ill Medicare Member Patient Attribution High Quality Pharmacy Provider Outcomes Based Health Plan Payments Part D Enhanced Medication Therapy Management Model Value Driving? We Shall See will test whether providing Part D sponsors with additional payment incentives and regulatory flexibilities will engender enhancements in the MTM program * ROI: Return on Investment Our experience has shown that if done correctly, this investment by CMMI should work *https://innovation.cms.gov/initiatives/enhancedmtm/ 9
Known Value Treatment of Chronic Disease cost US: $1.7 TRILLON/yr= $0.75 per $1 spent 1 More than 1.5 million preventable medication-related adverse effects cost: $290 billion/yr in avoidable costs 1 Pharmacist Return on Investment (ROI) Range: 12:1 to 1:1. Average: 3:1-5:1 2 1. http://www.pharmacist.com/sites/default/files/files/provider%20status%20factsheet_final.pdf 2. http://www.usphs.gov/corpslinks/pharmacy/documents/2011advancedpharmacypracticereporttotheussg.pdf ROI in YOUR Practice Silver Scripts SCRIPT Practices Who Students in Senior Centers Pharmacists in Family Medicine What Comprehensive Medication Reviews Comprehensive Medication Management Investment Student, faculty time Pharmacist salary Financial Return Quality Return State grant funding to senior centers Student learning; Senior patient care Limited fee for service Increased STAR ratings Physician retention Sustainability 14 years 7 years Growth Added 4 centers None to date Enhanced Service Litmus Test Successful Program What Makes A Successful Program? Good for Prescriber Good for Employers Good for Third Parties Good for Pharmacy Staff Good for Pharmacy Good for Patients Enhanced Services Must Begin with a Business Plan How much time will this service take to implement? Can I start small and scale? What is my target market? What will this cost in labor? What will this cost to implement? Will this service also provide advertising? What is the short term & long term program budget? Enhanced Services Must Begin There with is a a Business difference Plan between How much time will this service take to implement? Can I start small and scale? What is REIMBURSABLE my target market? What will this cost in labor? & What will this cost to implement? Will this service PROFITABLE also provide advertising? What is the short term & long term program budget? 10
Offer Services That Are Profitable and/or Marketable Profitable Marketable Adherence monitoring program with packaging Chronic disease management Transition of care with hospital Care coordination with mental health provider Immunizations Medication Therapy Management Clinical services (blood pressure, blood glucose) Enhanced Services Calculator Adherence Monitoring 100 29* Number of patients enrolled in program Additional Rxs per patient annually Increase in ADDITIONAL program-driven Rx volume *Armstrong T., Impact of the MedHere Today Program on Persistence and Adherence, A Descriptive Report; Pfizer, May 2011. 2,900 Developing your Value Proposition Quality: What quality indicators are critical to your organization? What quality indicators are not optimally being met? How can you uniquely address those quality indicators? Cost: All costs associated with providing the care Hedgehog Concept Collins, James C. Good to Great: Why Some Companies Make the Leap-and Others Don't. New York, NY: HarperBusiness, 2001. * http://www.ccnccares.com/ Pharmacy is an Investment, Not a Cost Center* **https://www.communitycarenc.org/media/related-downloads/treo-solutions-report-on-utilization.pdf ** https://www.cpesn.com/ Service Expansion and Growth Define projected benefits to patients Define projected benefits to payer partners Define projected benefits to the decision makers Define projected impact on key metrics that are areas of need Estimate start up costs in relation to ROI Fully Understand the Needs of Decision Makers / Stakeholders Service Expansion and Growth Define projected benefits to patients Define projected benefits to payer partners Show why it is important Define projected benefits to the decision makers Define to projected them, impact not on key why metrics it that is are areas of need Estimate start up costs in relation to ROI important to you Fully Understand the Needs of Decision Makers / Stakeholders 11
Community Opportunities Services that impact Transitions of Care (Med-rec, CMR, Care Plan Reinforcement, etc) Services that result in additional MTM opportunities Services that impact Mental/Behavioral Health & Substance Abuse (Opiods) Compliance packaging with strategic targets Services that impact Quality Measures Wellness programs 340B programs Who s looking for enhanced pharmacy services? Health Plans Providers and Provider Groups Hospitals & Health Systems Federal and State Programs Chronically Ill Patients & Caregivers Home Health Workers Mental Health Providers Pharmacy Benefit Managers Determine Resource Requirements Blueprint element #6 Resource Requirements Resource HAVE NEED Documentation - Clinical documentation - Scoring metrics documentation Tools to identify high-risk patients Space Support staff, scheduling Mechanisms to communicate regularly YOUR Practice Engaging Key Leadership Blueprint element #7 Community Pharmacy Employer Group Employer Group Geriatric Team Practice Family Medicine Practice Payer Health System Hospital Physician Practice Champions 12
Engaging Key Leadership Begins where the champions are SCRIPT UPMC St. Margaret $$ Collaborative Practice Agreement Physician Champion Payer Health System Hospital Physician Practice Champions More champions Community chain pharmacy: District and regional leadership Grant support Tell your STORY A LOT! Employer group: Director of Human Resources School of Pharmacy Stories from Patients UPMC needs Doctors like Dr. Jordan and Maria Osborne. These 2 people working together have my diabetes at a good level. It is very important to have people like her and her knowledge working with a busy doctor trying to save UPMC money and making patients feel important and well. Data Patient encounters (volume) Patient outcomes (disease specific) Quality outcomes Practice efficiency 13
Community Based Approach Sharing your Value through the system Printed Testimonials from Patients / Providers Video Testimonials from Patients / Providers Meaningful Data Reinforcing Testimonials Utilization of Existing Relationships Marketing Materials Highlighting Your Story Health Fairs, Wellness Classes, Newspaper Clippings, Annual Face to Face MTM Service Totals, Annual Transition of Care Totals, Etc. Practitioner level Practice level Hospital Health system Payer Develop the implementation Plan Blueprint element #8 Implementation Plan Your how to guide! Easily replicable to other practitioners Implementation Process - Key Items Pharmacist Integration Work Plan Timeline with SMART goals Standard Operating Procedures CPAs Created Performance Measurement Plan Marketing Plan Performance Improvement Plan Define Intervention Strategies Claims Based OR Patient Based Fill reminders Med sync Fill gaps in care Medication safety CMR Packaging Days supply DIR reduction Copay assistance Medication access Transition of care Health literacy/social Care coordination Transportation Formulary assistance Education Implement and Improve Blueprint element #9 14
Implement and Improve Communication Follow-up Measurement Make positive changes Document your changes Continuous quality improvement KEY POINTS: 9 Blueprint Elements for Building a Successful Business Case 1. Articulate your practice model 2. Identify champions 3. Think TEAM 4. Understand the financial, quality, and risk model of the practice/system/payer 5. Develop the value proposition 6. Determine resource requirements 7. Engage key leadership 8. Develop the implementation 9. Implement and improve You are a CHAMPION! Change begins with you where you are now! 1.Philosophy of care 2.Patient Care Process 3.Practice Management System 1. The JCPP Pharmacist Patient Care Process : A. Provides a framework for payers B. Ensures payment for services C. Outlines a consistent pharmacist process of care D. Forces all pharmacists to be the same 2. The value proposition consists of: 3. What is NOT accurate when describing a DIR fee? A. Philosophy of care B. Improved quality of care C. Cost of care D. Improved quality of care balanced with cost A. Some DIR fees are calculated using prescription drug claims B. DIR fees were created in an effort to provide an accounting of prescription drug rebates C. DIR fees are not all accountable at the POS D. DIR fees only impact pharmacies 15
4. When approaching a potential payer or practitioner partner, you should first: A. Provide a finalized list of services you would offer B. Listen to the perceived needs of the population C. Ask for payment of services D. Offer to start immediately before details are finalized 16