Using medications properly in an ACO environment

Role of MTM considered by working group including pharmacists; Feldman advises pharmacy leaders on how to market services to ACOs

Medications are an investment, and pharmacists are the “enabler” in using the investment well. This is nothing new. But now, in value-based health care, there’s also an economic consequence if medications aren’t used well.

That, according to Marv Feldman, MSPharm, was part of the reasoning behind a by Robert W. Dubois, MD, PhD, Feldman, and colleagues that focuses on the role of medications in value-based environments such as accountable care organizations (ACOs).

“Drugs cost money, no doubt,” said Feldman, Managing Principal, Pharmacy Consulting Program, Premier health care alliance. “But oftentimes, they’re a lot less costly than … the alternative.” For example, generic antihypertensive drugs are a small investment for a person to avoid cardiovascular complications down the road and stay out of the hospital. “The finances are pretty obvious,” he said.

With higher-cost drugs such as those used in treating arthritis and oncology, “the financial-value equation becomes more difficult to clearly define, [though] we know it exists,” Feldman told But “the vast majority of patients receive pretty inexpensive medications. … A lot of the drugs we’re getting the greatest value from are the least expensive. As long as they’re used properly.”

Framework for medication use

The commentary proposed a framework for optimizing medication therapy in a value-based environment:

  1. Proactively consider medications an essential part of the full spectrum of condition management, and not just an expense or care silo.
  2. The role, impact, and characteristics of medication therapy management [MTM] will vary by condition, and a “one size fits all” approach will not yield optimal clinical or economic outcomes.
  3. Composite risk can be used to identify patients who are candidates for medication management strategies to watch for drug–drug, drug–disease, or polypharmacy concerns.
  4. In each circumstance where there are condition-specific incentives to achieve economic savings, there should also be a quality metric to detect underuse.

A working group comprising representatives from the National Pharmaceutical Council, American Medical Group Association, the Premier group-purchasing organization, and seven provider organizations developed the framework. The group included six pharmacists. “The members of the group largely are in health systems that are ACOs,” Feldman said. The mix of practitioner perspectives included acute care in their ACO and MTM in the ambulatory side of their ACO.

Value-based environments are emerging. At this stage, 154 ACOs are serving more than 2.4 million Medicare patients, according to the .

The health care reform law aligns incentives to properly use medications by providing that the government and the ACO share savings from Part A (hospital admissions) and Part B (physician services) but not Part D (drug spending). “These ACOs can spend more on drugs to save on Parts A and B and not be penalized,” said Twlug Senior Vice President of Government Affairs Brian Gallagher, BSPharm, JD. “Pharmacists are perfectly positioned and trained to maximize the benefits of the drug spend to obtain the most savings and boost revenues to the ACO.”

‘Marketing 101’

How can pharmacy leaders practicing in an ACO environment convince decision makers of the need for pharmacist services such as MTM?

“Pharmacists are a diamond in the rough who just go out and help patients while managing the most cost-effective use of medications. Yet many executives aren’t necessarily familiar with the important role they play,” Feldman said. “It’s like anything else. This is Marketing 101.”

First, define who the decision makers are.

“You’ve got to figure out: What are the hot buttons of those who are deciding which programs get resources and which don’t?” Feldman said. “And that’s probably a place where most pharmacy leaders don’t perform the proper due diligence. They just start talking from their perspective as a pharmacist and assume everybody else will understand their position.”

Then, based on the organization’s priorities, present the argument.

If the ACO is “primarily focused on clinical quality, then highlight the value pharmacists can bring in medication safety and outcomes,” Feldman said. But if the ACO is “more tuned in to financial results, then emphasize the critical utility pharmacists can deliver in reducing the incidence of needless 30-day readmissions by ensuring the patient understands the proper use of their medications upon discharge from the hospital and while being treated in your clinics.”

Finally, demonstrate how pharmacists can serve both interests. “Because the reality is good patient care is less costly than mismanaged care,” Feldman said.