Park Nicollet: Pioneers in accountable care

CMS-designated Pioneer ACO helps pharmacists across the country provide team-based accountable care

A visitor to Park Nicollet Health Services might find Molly Ekstrand, BSPharm, AE-C, CDE, talking to a patient. She spends about 60 minutes on each initial visit to ensure that patients are using their medications safely and efficiently. The extra attention can be attributed to Park Nicollet’s success at incorporating pharmacists into the primary care team to provide optimal patient care under the accountable care organization (ACO) model.

Park Nicollet is a nonprofit, integrated health care system located in St. Louis Park, MN. It is one of the largest multispecialty clinics in the United States, providing more than 55 medical and surgical services within its 27 clinics, specialty, and hospital locations throughout Minneapolis–St. Paul, MN. Park Nicollet maintains an innovative culture and team-based approach to delivering high-quality personalized care.

Pioneering ACOs

In 2011, Park Nicollet was selected as a Pioneer ACO by the CMS Innovation Center. ACOs are groups of doctors, hospitals, and other health care specialists who work together to provide patients with coordinated, high-quality care. The Pioneer ACO Model is a CMS initiative designed to encourage the development of ACOs and provide more coordinated care at a lower cost. Several commercial plans have contracted with Park Nicollet in similar arrangements, making the model available even to patients not on Medicare. This approach achieves cost goals by avoiding duplication and errors. Teams must meet quality standards based largely upon patient outcomes.

Pharmacists play a significant role in ACOs by helping patients manage chronic conditions and working directly with medical teams to help control conditions and prevent adverse events. At Park Nicollet, pharmacists work with patients to assess, evaluate, and identify drug therapy problems. Shortly before CMS announced Park Nicollet as a Pioneer ACO, Ekstrand was hired to help integrate medication therapy management (MTM) with primary care teams.

“MTM allows us to provide superior care to our complex patients,” said Tim Rajtora, MD, Clinical Practice Director, Internal Medicine, at the St. Louis Park practice site. Recently, the team was able to assist a patient with atrial fibrillation who was failing warfarin by using MTM to simplify the patient’s drug regimen. “MTM can work behind the scenes or see patients before or after the clinician,” Rajtora commented. “MTM can really tease out when medications are working against one another. Pharmacy brings great value to the team.”

A long way in a short time

In less than 2 years, Ekstrand and her team have rapidly expanded MTM services. The program started with three pharmacists in 2 clinics; today, MTM is provided at 10 primary care clinics. Later this month, Park Nicollet will expand the services to a total of 13 clinics, a decision based on the regional and patient population needs of the health system.

Ekstrand told Pharmacy Today that she is “amazed at where we have come in such a short time. We have built an infrastructure that supports medication management services throughout the entire health system” in order to offer health care teams’ medication expertise.

The transition to ACOs opens the door for pharmacists to help patients directly. Park Nicollet emphasizes pharmacists as medication experts, and medications are the optimal first-line intervention for 88% of chronic medical conditions. According to the Institute for Healthcare Informatics (IHI), the United States spends $200 billion each year due to improper or unnecessary prescription drugs. Ekstrand said that patients are pleased to be referred to a pharmacist because they feel privileged to have extra information, attention, and care. Patients know the team works closely together and communicates often.

ACO vs. FFS

The ACO payment structure is a stark departure from the fee-for-service (FFS) model. Under FFS, services are paid for separately by each client, whereas ACOs reward improved quality and cost based on groups of eligible patients. A major critique of FFS is that there is no financial incentive to coordinate care and no data to support pharmacist services.

Ekstrand doesn’t think FFS does enough to support the work involved with MTM. “It’s been much easier for me in the health system, and especially with the ACO model, to align our medication management program and pharmacist contributions to the overarching system goals of improved quality and reduction in total cost of care,” she said.

In FFS, pharmacist fees may be difficult to obtain full reimbursement for as separately billed line items for a single Medicare patient with a single visit. Under the ACO model, however, there is greater incentive to use a pharmacist since the reimbursement model is based on quality outcomes for a group of patients and reduction of growth in all health care costs for that group. In an ACO, all providers are collectively responsible for patient improvement.

At Park Nicollet, Demetrius Chester (left) summarizes a medication action plan he developed with Molly Ekstrand, BSPharm, AE-C, CDE (right), to Gregory Lehman, MD.

Making an impact

While ACOs are less than 2 years old, many are watching their progress. Currently, 428 ACOs exist in 49 states, and the model is growing rapidly with commercial insurers as well. At the end of 2013, Park Nicollet and the other 31 Pioneer ACOs will complete their first year under a risk-based contract. These preliminary results will influence the future prevalence of the model.

“Thank goodness our health system has taken a leap of faith,” Ekstrand said. “Cost is hard to show a change in a short amount of time, especially with this large population.” She is confident that quality will improve. For example, a 68-year-old female patient at Park Nicollet felt overwhelmed by her medications and the health care system when she came to see Ekstrand a year ago. She had retired early, temporarily lost her health insurance, and suffered from depression. When the patient reentered the system, she received many prescriptions and needed numerous tests and follow-ups. Ekstrand began working with her to prioritize and simplify her medications and set medication-related goals, which she has achieved in the past year.

“Not only is she safer in terms of risk reduction, she is engaged and feeling more in control of her own health,” Ekstrand told Today. “She feels supported by her health care team.”

Take aim at improvements

Ekstrand advised pharmacists working with an ACO to follow Triple Aim, a framework developed by IHI and adopted by CMS to optimize health-system performance with better health, better care, and lower costs. Pharmacists can achieve these goals by realizing that the “total cost of care is about getting the right person to the right team member and working in collaboration,” said Ekstrand.

Employees at Park Nicollet credit their progress to shared responsibility. Ekstrand is “very hopeful” that pharmacists will have provider status in the future. Through ACOs, medical providers can build off each other’s strengths, leading to systematic use of pharmacist capabilities and safe and effective medication use for all patients.