Financial Models for Pharmacist-Provided Care:

Opportunities in Health Care Reform

Wayne W. Oliverwoliver@gingrichgroup.com

Center for Health TransformationTwitter: @wayne_oliver

Center for Innovative Pharmacy Solutions

Health Reform Goals ShouldHave Been …

Lower Costs

Improve Quality

Expand Coverage

In Reality, Health Reform Was …

Expanding CoverageHealth Insurance Reform

21st Century Personalized Intelligent Health

System Requires Transforming 4 Boxes

Financing to Enable300,000,000-Payor Insurance System

Effective, Efficient and Productive HealthDelivery System

Individual Rights, Responsibilities and Expectation

of Behavior

Maximize Cultural and

Societal Patternsfor a

Healthy Community

4. 3.

2. 1.

Health Reform (2012 and beyond) Not a “Bill” …. It’s Statute (Law of

the Land) Creates Some Opportunities Classic 1966 Epic Spaghetti Western

Film

The GOOD, The BAD and

The UGLY– Advance and Enhance the Good– Mitigate the Bad and – Eliminate the Ugly

The Impact on Pharmacy Profession

8

The Impact of Health Reform States must expand Medicaid programs 18 to 20 million expansion and expand

government control over healthcare financing and delivery.

Availability of prescribers? Physician payments under Medicare and Medicaid are well below the prevailing rates in the private sector. On average, physicians in Medicare are paid 81

percent of private payment. On average, physicians in Medicaid are paid 56

percent of private payment. Some sporadic access issues for patients in

Medicare, and major access problems for patients in Medicaid.

Implications or Opportunities?Short Term Future for

Pharmacists Older Medicare Population• MTM Services• Medical Home• ACO’s & Shared Savings

More Chronic Disease Other Disease States

• Alzheimer's, Cancer … How does pharmacy prepare?

Challenges for the Pharmacy Profession Creating Value

• Personalized medicine Issues with Interoperable IT Limited Resources for ‘New’ Programs

• Medicare/Medicaid have funding issues• Value-based benefit design

Keeping up with constant change• Expanding role of pharmacists• Internal Conflict in the Pharmacy Profession

– From Purveyor of Drugs to Respected Clinician– Better Positioning as “Medication Expert”

Health reform may create opportunities for pharmacists:

• Shortage of primary care physicians ACOs will push collaboration and

integrated “team” approach to care.

Care Coordination• Improve Quality, Reduce Costs• More appropriate utilization of care by

patients

Implications or Opportunities?The Impact of Health Reform

Health reform will create opportunities for pharmacists in a “traditional” role:

• Health counselors» Face-to-Face vs. Telephonically

• Wellness and prevention awareness• Immunizations• Medication Therapy Management (MTM)

» Mirixa: Private sector network of pharmacists

Payment reform could result in new non-traditional opportunities

• Pay-for-Performance

Advancing Pharmacy Profession

Value-based care will validate need for payment reform.

Pharmacists have a strong desire to utilize their clinical knowledge in providing direct patient care and interaction with the prescribers. 

Pharmacists in a unique position to assist in the coordination of care.

New Medicare expanded MTM opens more patients and more diseases.

Payment Reform Opportunities

Private Sector, Medicaid Managed Care MTM programs and other pharmacy based clinical services such as adherence programs and disease specific initiatives.

Clinical data captured through these pharmacy-based services will be important in the new care delivery models including patient-centered care.

• Advances in Primary Care• Patient Centered Medical Home

Payment Reform Opportunities

Clinical and administrative medication data will be on boarded to HIEs to support the new care delivery models. 

• Nebraska, Utah and Florida   Providing real value through

marrying clinical data with direct patient care.

Reducing hospital readmission rates. 

• Pharmacists as care coordinator• Communication and business process

Payment Reform Opportunities

HIT breakthroughs to create data rich information.

• Clinical data to drive best practices and evidence-based medical and pharmacy care creating an integrated “team” approach to care.

Health reform creates a “non-profit” Patient-Centered Outcomes Research Institute.

• Formerly called “Comparative Effectiveness Research” (CER) but term drew criticism of rationing.

• It will be financed through a Patient Centered Outcomes Research Trust Fund, with initial funding starting at $10 million this year, and reaching $150 million annually in Fiscal Year 2013, with additional revenues from insurance fees.

Health Reform Opportunities

Building a Sustainable Pharmacy Care Model

Fundamental Payment Reform: “Personalized medicine” and individually

centered pharmacy care models. Restoration of the traditional physician-

pharmacist-patient relationship. “Clinical” pharmacists are not just in clinical

settings. They are in community, institutional practices.

Building a Sustainable Pharmacy Care Model

Embracing an individually centered model of care: Coordinated care, advances in primary care, PCMH Alignment of provider and patient incentives Targeted Medication Therapy Management

– The CVS study estimated that 35% of patients don't take their medications as directed

– Consequences per every 100,000 :» 16 unnecessary heart attacks» 5 unnecessary strokes and» 7 unnecessary deaths

Creating Innovative Models State & Local Governments are the “Hotbed” of

Reform:• “Where the Rubber” hits the road• Medicaid Funding Pressures

– Expansion of coverage– Creative approaches

• Public – Private Partnerships:– Asheville Project– Ten City Challenge

Creating Innovative Models State & Local Governments are the “Hotbed”

of Reform:• Exploring unique new opportunities

– MTM “Clinics” at employer sites (plants)– Freestanding MTM Services in communities (Mirixa)– Adherence Clinics

» Compliant patients with high cholesterol patients have fewer hospitalizations by 9% and reduce costs per patient by as much as $944 during an 18-month period.

Accelerating Ideas that Work CHT 21st Century Intelligent Pharmacy

Project: Accelerate adoption of best practice Leading edge experts on patient safety,

improving quality, medication adherence, pharmacy practice innovation, pharmacy education, care coordination, pharmacy technology

http://www.healthtransformation.net

Center for Health Transformation

www.healthtransformation.net

Health Reform Reportwww.healthreformreport.com

Health Reform Resources

Wayne W. Oliver, J.D.Vice President, Center for Health Transformation

woliver@gingrichgroup.com Twitter: @wayne_oliver

Thanks!