Pharmacists and Health Reform: Go for It!

Pharmacists and Health Reform: Go for It! Helene Levens Lipton, Ph.D. Key Words: pharmacist, clinical pharmacy, health reform, Patient Protection and Affordable Care Act, medication therapy management, MTM, accountable care organization, ACO, medical home, community health teams. (Pharmacotherapy 2010;30(10):967 972) Now is the time for the profession of pharmacy to reach out, speak out, and act out to assume leadership under health reform. The opportunities today are unprecedented for pharmacists. The March 23, 2010, Patient Protection and Affordable Care Act, and the regulations surrounding it that are being written, offer powerful venues to demonstrate the full breadth of the profession s capacity for promoting the nation s health. But the profession must act now or lose an historic chance to become inextricably woven into the fabric of our nation s health reform mandate. This editorial will explore the major pharmacistrelated provisions of the health reform law, the opportunities that the law presents for pharmacists, and specific strategies that pharmacists and their advocates can use to expand pharmacists roles under health reform. Five Driving Concepts of Health Reform Before addressing pharmacist-related provisions in the law, we need to understand the driving concepts underlying the legislation. First, highrisk patients, typically Medicare beneficiaries, are the focus of many reform measures. These patients From the Department of Clinical Pharmacy, School of Pharmacy, University of California, San Francisco, California. No financial support was received for the preparation of this manuscript. The manuscript was adapted from Dr. Lipton s keynote address at the American College of Clinical Pharmacy Spring Practice and Research Forum, Charlotte, North Carolina, April 24, 2010. The opinions expressed in this editorial are those of the author and do not necessarily represent the position of Pharmacotherapy or the American College of Clinical Pharmacy. Invited editorials are not peer reviewed. For reprints, visit http://www.atypon-link.com/ppi/loi/phco. For questions or comments, contact Helene Levens Lipton, Ph.D., University of California, 3333 California Street, Suite 420, San Francisco, CA 94118; e-mail: liptonh@pharmacy.ucsf.edu. are chronically ill, take many drugs, and are very much in need of pharmacists medication therapy management (MTM) expertise. Second, reform seeks to strengthen the role of primary care physicians. Third, funding is available for pilot projects and programs that divert the payment structure away from fee-for-service. Fourth, the law is outcomes driven, with incentives for health care providers and delivery systems to increase quality of care and decrease costs. The all-important fifth concept underlying the health reform legislation is an emphasis on transforming how health care is delivered, with teambased care acting as a driving force for quality improvement, cost containment, and outcomes assessment. The need for team-based care is based on several facts that we can no longer afford to ignore. The country s current shortage of primary care physicians will be exacerbated by nationwide trends: 78 million baby boomers will start enrolling in Medicare next year, the current cohort of elderly is living longer, and more than 32 million uninsured patients will start to receive insurance in 2014. 1, 2 By 2030, almost one half of all Americans will have one or more chronic conditions. 3 Thus, a big gap in the provision of primary care services will be created, and pharmacists have the expertise to help fill the gap. The stakes are high: if we fail to develop innovative team-based models of care, we fail to deliver on our national commitment to achieving universal access to care. Opportunities for Pharmacists Under Health Reform Legislation Reference in the law to the work and expertise of the pharmacist is both explicit and implicit and is most evident in five programs: MTM, the community-based care transitions program,

968 PHARMACOTHERAPY Volume 30, Number 10, 2010 medical homes, accountable care organizations (ACOs), and the Independence at Home (IAH) Demonstration Program. Each program is defined below, along with its major components, and whether and how pharmacists are mentioned in the legislative language describing the program. The fact that pharmacists may not be mentioned explicitly in some programs does not mean that they cannot participate fully. It does mean, however, that pharmacists have to be proactive to ensure their inclusion. Medication Therapy Management Professional pharmacy organizations define MTM as.a partnership of the pharmacist, the patient or their caregiver, and other health professionals that promotes the safe and effective use of medications and helps patients achieve the targeted outcomes from medication therapy. 4 Components of MTM include pharmacists assessing patients health status, providing drug therapy and consultation, communicating with patients and providers, and integrating MTM into broader health care delivery systems. Pharmacists roles in MTM are stated explicitly in the law as follows: provide grants or contracts to eligible entities to implement medication management services provided by licensed pharmacists, as a collaborative, multidisciplinary, inter-professional approach to the treatment of chronic diseases for targeted individuals, to improve the quality of care and reduce overall cost in the treatment of such diseases. 5 Individuals eligible to receive MTM services include those who have two or more chronic diseases, take four or more drugs, take high-risk drugs, and/or have undergone a transition of care or other factors that might create a high risk of drug-related problems. These broad eligibility criteria give pharmacists leeway to create MTM programs across diverse delivery systems such as community pharmacies, clinics, integrated delivery systems, and hospitals. Several studies demonstrate how MTM can improve patients adherence with drug regimens and clinical outcomes. 6, 7 The health reform legislation provides funding opportunities for pharmacists to conduct rigorous research examining the impact of MTM in a variety of settings. Specifically, the law provides funding for grants to pharmacists for the provision of MTM services for chronically ill patients. Community-Based Care Transitions Program Preventing hospital readmissions is a high priority in the new law. It is widely recognized that hospital readmissions are burdensome to patients and their families, and very costly. 8 Avoidable readmissions are often triggered by two factors: preventable complications (e.g., inappropriate drug prescribing) and poor care transitions from hospital to other care settings. During these transitions, communication and follow-up often break down and quality of care is compromised, resulting in readmissions. One initiative under health reform the communitybased care transitions program is specifically designed to facilitate effective transitional care services. The community-based care transitions program provides funding to eligible entities that furnish improved care transition services to highrisk Medicare beneficiaries. 5 This program targets Medicare patients at risk for hospital readmission or substandard transition to postdischarge care due to dementia, depression, cognitive impairment, or a history of multiple readmissions. Hospitals serving medically underserved populations, small community hospitals, and rural hospitals will be given priority for participation, as will hospitals participating in an eligible Administration on Aging program. Hospitals may elect to join the pilot program with community-based organizations or those that provide care transition services. Funding is authorized at $500,000,000 over 5 years (2011 2015). 5 Applicants to this program must show that they either initiate care transition services for high-risk Medicare patients within 24 hours before discharge, or conduct comprehensive drug therapy review and management. 5 Clearly, pharmacists engage in these two activities through drug reconciliation and MTM, but their role in the program is implicit, as this program only specifies requirements for services provided, not which health care professionals must provide the services. Medical Home The medical home is a model of comprehensive health care delivery and payment reform that emphasizes the central role of primary care. Medical homes have several core characteristics:

PHARMACISTS AND HEALTH REFORM Lipton 969 they are targeted toward chronically ill patients; emphasize team-based care to promote comprehensive and coordinated patient-centered services; rely on health information technology to facilitate coordination, increase efficiency, and potentially improve health outcomes; and call for payment reform that recognizes the added value provided to patients who have a medical home. 9 The medical home is not a new concept. Kaiser Permanente, Group Health of Puget Sound, and other large integrated delivery systems all have elements of the medical home, especially the commitment to team-based care. All have made improvements in patients quality of care and outcomes. What is new about medical homes is payment reform. There is growing recognition that fee-for-service is inherently limited for supporting team-based care and improving quality performance. In emerging medical home models, practices would receive per-person permonth (PPPM) payments, either in addition to, or in place of, fee-for-service payments. The medical home has widespread public and private support. There are currently 22 demonstration projects in 14 states evaluating the clinical and financial outcomes of medical homes. A major challenge confronting the medical home is that about 40% of physicians practice in settings with five or fewer physicians. 10 Physicians practicing alone or in small groups have limited capacity to employ pharmacists and other allied health professionals. Therefore, the health reform legislation provides funding to establish community health teams to support smallpractice medical homes. In community health teams, physicians with medical home practices coordinate their services with community-based agencies and professionals, including pharmacists, to provide needed clinical services to their patients. These coordination activities take extra time for physicians; as a result, physicians will be compensated for their efforts with PPPM payments, and the agencies and professionals in the community with whom they collaborate will receive payments as well. The promise of the community health team is its ability to create an infrastructure to provide call coverage for 24 hours, 7 days/week and employ pharmacists, nurses, social workers, and other health professionals to work with a defined group of physicians in the community. Beyond theory, North Carolina and Vermont are using variations of the community health team medical home model and achieving some impressive outcomes. 11 Pharmacists roles in the medical home are stated implicitly under the general discussion of medical homes: improve health outcomes through the implementation of activities such as quality reporting, effective case management, care coordination, chronic disease management, and medication and care compliance initiatives. 5 Under the section on community health teams, the pharmacist s role is stated explicitly: [community health teams] may include medical specialists, nurses, pharmacists, nutritionists, dieticians, social workers, behavioral and mental health providers (including substance use disorder prevention and treatment providers), doctors of chiropractic, licensed complementary and alternative medicine practitioners, and physicians assistants. 5 A recent article by leading health policy experts makes a compelling case for including pharmacists to play key roles as team members in medical homes. 12 In the health reform law, funding is allotted for the creation of a new Center for Medicare and Medicaid Innovation by 2011. 5 This center is charged with developing, implementing, and evaluating innovative team-based programs to improve chronic disease management and lower health care costs. The reform dedicates $10 billion through 2019 for innovative pilot projects (e.g., medical homes and MTM services). 5 Accountable Care Organizations An ACO is a local health care organization and a related set of providers that can be held accountable for the cost and quality of care delivered. They consist of providers that meet specific criteria and work together to coordinate care of Medicare fee-for-service beneficiaries. Examples of ACO models could include multispecialty group practices, networks of individual physician practices, and partnerships between hospitals and medical groups. Under the law, providers organized as ACOs that voluntarily meet quality thresholds can qualify for the Medicare shared-savings program, which allows them to share savings with the government, based on their ability to increase quality and decrease costs. 5 The ACOs will seek to align payments with improvements in care, providing new support to health care providers for bending the cost curve and improving patient health. The program is scheduled to begin no later than January 1, 2012. 5

970 PHARMACOTHERAPY Volume 30, Number 10, 2010 In the law, the pharmacist s role in the ACO program is implicit. The section on reporting requirements states the following: data may include care transitions across health care settings, including hospital discharge planning and post-hospital discharge follow-up by ACO professionals. 5 These professionals are defined as physicians, physician assistants, nurse practitioners, or clinical nurse specialists. Although pharmacists are not listed as ACO professionals, their knowledge and skills are invaluable in any program that aims to improve quality of care and decrease costs for the chronically ill. Independence at Home Demonstration Program The IAH Demonstration Program promotes the use of interdisciplinary teams of clinicians to provide home-based medical care and monitoring for chronically ill Medicare beneficiaries. Similar to ACOs, a shared savings model will provide incentives for practices that spend below set targets and have improved clinical outcomes. To qualify, preference will be given to IAH medical practices that are located in high-cost areas of the country, have experience in furnishing health care services in the home, and use electronic medical records, health information technology, and individualized plans of care. 5 The demonstration program will begin no later than January 1, 2012, and the law authorizes $5,000,000 each fiscal year between 2010 2015 for incentive payments. 5 Under the law, pharmacists are mentioned explicitly: [An IAH medical practice] is comprised of an individual physician or nurse practitioner or group of physicians and nurse practitioners that provides care as part of a team that includes physicians, nurses, physician assistants, pharmacists, and other health and social services staff as appropriate who have experience providing home-based primary care to applicable beneficiaries, make in-home visits, and are available 24 hours per day, 7 days per week 5 As a result, chronically ill Medicare beneficiaries who enroll in an IAH program will be eligible to receive at-home drug therapy monitoring and management by a pharmacist. The Opportunity Is Now Clearly, the health reform law offers many opportunities for pharmacists, but several major programs do not mention pharmacists explicitly. History has shown that even when pharmacists roles are mentioned explicitly, pharmacists are not necessarily guaranteed a seat at the table. Pharmacists have an amazing opportunity with the new health reform legislation to influence and expand their roles, but it will not be an easy win. It will take determination, political savvy, and action. Here are six immediate action steps that pharmacists can take nationwide: Step 1: Participate Aggressively in Drafting and Responding to Health Reform Regulations As a professional body with immense combined strength, and as individuals, pharmacists need to advocate for their inclusion in all of the health reform programs discussed above. Make pharmacists roles in these programs explicit by meeting face-to-face, and often, with key personnel in federal agencies (Centers for Medicare and Medicaid Services, Agency for Healthcare Research and Quality), before they draft regulations that will map out critically important details of program implementation and operation. After draft regulations are published, every pharmacist and organization has the opportunity to engage actively in the public comment process to revise the regulations. Step 2: Make Your Value Known to People with Influence Pharmacists can work with other powerful stakeholders such as provider organizations, federal agencies, and insurers to market the pharmacy profession as essential to successful health reform. For example, pharmacists should participate in meetings and forums where important reform issues are being discussed, such as the recent National ACO Summit in Washington, DC, where key health stakeholders convened in a national forum to network while discussing potential and future directions for ACOs. 13 Step 3: Reach Out to Multi-Stakeholder Groups to Advance the Profession and Promote Team- Based Care Pharmacists working in organizations interested in exploring the ACO concept, or those groups that are further along in the process of becoming ACOs, should consider joining the multi-stakeholder ACO Learning Network. 14 Directed by the Engelberg Center for Health Care

PHARMACISTS AND HEALTH REFORM Lipton 971 Reform at the Brookings Institution (Washington, DC) and the Dartmouth Institute for Health Policy and Clinical Practice (Lebanon, NH), this national collaborative provides support both to groups that are exploring the use of the ACO model and to those that are further along in the process of becoming ACOs. Of importance, pharmacists should ensure that people within ACOs who are developing new service delivery models are aware of the capabilities that pharmacists can provide. In addition, there will be opportunities for pharmacists to help design, implement, and evaluate new initiatives under the new Center for Medicare and Medicaid Innovation. By acting proactively, pharmacists can maximize participation in such initiatives. Step 4: Publish High-Quality Research Pharmacists need to conduct rigorous research to evaluate their impact on cost and quality outcomes in health reform programs in which they play a part. Although data from demonstration projects and scientific literature have documented the value of having pharmacists as care team members, 6, 7, 9 pharmacists roles and activities need to be assessed rigorously in the context of medical homes, ACOs, and other delivery system reforms. 12 Step 5: Use the Strength of Your Numbers Pharmacists can be more proactive by advocating through professional organizations, using the power of the group to bring about change. For example, investigate if your state practice act allows all of the services specified in the MTM grant program. If not, learn how you can change this situation, or find out how to get yourself nominated for the state pharmacy board. Another way to become involved is through the Patient Safety and Clinical Pharmacy Services Collaborative (PSPC), which is sponsored by the Health Resources and Services Administration. 15 This national collaborative is dedicated to achieving optimal health outcomes and eliminating adverse drug events through increased use of clinical pharmacy services for high-risk patients. A total of 110 teams, led by pharmacists and representing more than 350 organizations, are participating in this new initiative across the country. This collaborative is a platform for innovation and a test bed for widespread application of clinical pharmacy best practices. As part of the implementation of clinical pharmacy services, PSPC teams are already introducing programs under health reform such as MTM, medical homes, and community-based care transition models. Step 6: Take Ownership of Medication Therapy Management Pharmacists and their advocates must promote MTM. Under health reform, MTM services should be an integral part of medical homes and ACOs. Currently, they are not. All MTM services should be linked explicitly to prescription drug benefits in insurance exchanges, which are new marketplaces that will begin selling insurance to individuals and small businesses in 2014. Currently, they are not. Individual pharmacists and professional pharmacy organizations must speak out about the value of MTM and other clinical pharmacist services and how such services improve quality and generate cost savings that will be attractive for inclusion by ACOs, medical homes, and IAH medical practices. For example, pharmacists should work with insurance companies and health plans so that MTM services are an integral part of their health care benefit packages. Conclusion Health reform cannot meet its full potential without pharmacists. But only pharmacists can decide what the profession s roles will be under the new law. It is a defining moment for the profession, and the opportunities will never be greater for pharmacists to be in the lead with other professionals, as together, they move the nation s health care agenda forward. For this author, who is a health policy specialist and pharmacist advocate, it would be a great disservice to the nation s health if this opportunity were lost. My recommendation? Go for it! References 1. Institute of Medicine. Retooling for an aging America: building the health care workforce. Washington, DC: National Academy Press; 2008. 2. Centers for Medicare and Medicaid Services. Estimated financial effects of the patient protection and affordable care act, as amended. Available from www.cms.gov/actuarial Studies/Downloads/PPACA_2010-04-22.pdf. Accessed June 16, 2010. 3. Wu SY, Green A. Projection of chronic illness prevalence and cost inflation. Santa Monica, CA: RAND Health, 2000. 4. American Association of Colleges of Pharmacy. Medication therapy management services definition and program criteria. Available from www.aacp.org/resources/historicaldocuments /Documents/MTMServicesDefinitionandProgramCriteria04.pdf. Accessed June 16, 2010.

972 PHARMACOTHERAPY Volume 30, Number 10, 2010 5. Patient Protection and Affordable Care Act of 2009, HR 3590, 111th Cong. Available from www.govtrack.us/congress/ bill.xpd?bill=h111-3590. Accessed June 16, 2010. 6. Lee JK, Grace KA, Taylor AJ. Effect of a pharmacy care program on medication adherence and persistence, blood pressure, and low-density lipoprotein cholesterol: a randomized controlled trial. JAMA 2006;296(21):2563 71. 7. Pellegrino AN, Martin MT, Tilton JJ, Touchette DR. Medication therapy management services: definitions and outcomes. Drugs 2009;69(4):393 406. 8. Centers for Medicare and Medicaid Services. Application of incentives to reduce avoidable readmissions to hospitals. Fed Regist 2008;73(84):23673 5. 9. Lipton HL. Home is where the health is: advancing team-based care in chronic disease management. Arch Intern Med 2009; 169(21):1945 8. 10. Liebhaber A, Grossman JM. Physicians moving to mid-sized, single specialty practices: tracking report no. 18. Washington, DC: Center for Studying Health System Change; 2007. 11. Berenson R, Howell J. Structuring, financing and paying for effective chronic care coordination. Available from www. urban.org/url.cfm?id=1001316. Accessed June 16, 2010. 12. Smith M, Bates DW, Bodenheimer T, Cleary PD. Why pharmacists belong in the medical home. Health Aff (Millwood) 2010;29(5):906 13. 13. National Accountable Care Organization Summit. Overview. Available from www.acosummit.com/overview.html. Accessed June 23, 2010. 14. Accountable Care Organization (ACO) Learning Network. Overview. Available from xteam.brookings.edu/bdacoln/ Documents/ACO%20LN%20overview.pdf. Accessed June 23, 2010. 15. Health Resources and Services Administration. Patient safety & clinical pharmacy services collaborative 2: learning session #2 and breakout session A-2. May 13, 2010. Available from fda.yorkcast.com/webcast/viewer/?peid=051352aa2e8749249f9 61a9bb27c2344. Accessed June 18, 2010.