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Majority of ACOs Lacking Infrastructure, Protocols to Optimize Medication Use

In a value-based environment, optimal use of medications is key for improving quality and managing costs. Yet when the National Pharmaceutical Council, the American Medical Group Association, and health care performance improvement alliance Premier Inc surveyed a group of accountable care organizations (ACOs) on their readiness to optimize pharmaceutical use, they came across a concerning discovery.

“Most ACOs do not yet have the infrastructure and protocols in place to optimize medication use,” explained Kimberly Westrich, vice president for health services research at the National Pharmaceutical Council. 

From Theory to Reality

In 2012, the Working Group on Optimizing Medication Therapy in Value-based Healthcare published a framework with 4 takeaways for successful medication management. These included (1) proactively considering medications an essential part of the full spectrum of condition management, and not just an expense or care silo; (2) understanding that the role, impact, and characteristics of medication therapy management will vary by condition, and a “one size fits all” approach will not yield optimal clinical or economic outcomes; (3) using composite risk to identify patients who are candidates for medication management strategies to watch for drug-drug, drug-disease, or poly-pharmacy concerns; and (4) using a quality metric to detect underuse in each circumstance where there are condition-specific incentives to achieve economic savings. 

Lack of Readiness Revealed

Researchers gauged ACO readiness for optimizing medication use in the real world via a survey of 46 ACO chief pharmacy officers, pharmacy directors, chief medical officers, and medical directors.

The survey revealed high readiness in several areas, particularly in the ability to transmit prescriptions electronically, the ability to integrate prescription and pharmacy data into one system, and the ability to create formularies that encourage generic use.

However, ACOs were found “not very ready” in a number of other important areas including the ability to quantify prescription cost offsets and demonstrate the value of appropriate medication use, the ability to implement processes to avoid polypharmacy and duplicate prescriptions, and the ability to include quality metrics for a broad variety of conditions.  

Just 15% of ACOs report having a strong ability to measure the cost-efficiency of medications, while nearly 60% of ACOs report having a strong ability to target drug-related interventions.

Nearly 4 years after the working group published its framework for success, pharmacy leaders still feel their organizations are largely unprepared to managed pharmaceutical care, according to the presentation. A follow-up survey launched a year ago has yielded similar results, Westrich said.

High-Performing ACOs 

Interestingly, early results from the survey shed light on capabilities highly correlated with an ACO’s financial success. When comparing high-performing ACOs with their lower-performing counterparts, researchers noticed higher-performing ACOs had better scores in several categories: pharmacist and physician access to integrated medical and pharmacy data, patient-reported outcomes tracking, regional health information exchange with pharmacy data, standardized medication risk stratification, and pharmacy notification when a physician cancels a prescription.

Capabilities with less apparent correlation with success include electronic prescriptions for non-controlled substances, patient education on alternatives, prescription dispensing before discharge, provider notification that another provider has prescribed a medication, and provider notification that a prescription has been filled or discontinued. On those measures, high-performing and low-performing ACOs scored similarly, according to Westrich.

On several measures—proactively following up with patients about medication use, regional health information exchange, and standardizing transitional care protocols—respondents said leadership and care team buy-in are a more critical constraint than budget limitations. 

The results are leading investigators to conclude that medication management is still not a high priority for most ACOs. In addition, leadership can have an enabling, or a stifling, impact on an ACO’s medication management practices. 

Best Practices Available

For success, ACOs must address gaps in their medication management strategies, Westrich emphasized.

“Medications cannot be viewed as a siloed expense item in a value-based environment. They need to be integrated so the cost offsets and quality benefits resulting from optimized pharmaceutical use can be recognized and measured,” said Westrich. “Our work underscores the value in taking an integrated view of the whole system. Viewing medications as a cost to be managed is short-sighted; there is great value in recognizing they are a tool to be leveraged.” 

The Fairview ACO’s comprehensive medication therapy management program, for example, shows how direct interaction with high-risk patients about their medications as well as enhanced communication between physicians and pharmacists can affect both outcomes and costs.

The Marshfield Clinic’s Drug Safety Alert Program provides lessons on leveraging electronic health records, preventing “alert fatigue,” and flagging issues related to quality measures.

A case study published just recently, meanwhile, illustrates how an electronic refill system at the Sharp Rees-Stealy Medical Group boosts provider productivity.

Through the examples of others, ACOs can learn how to begin to optimize medication use for better outcomes and lower costs. 

“There are many resources out there to help organizations learn how others have made this transition. Along with our partners, we have published 3 best practices to show how leading ACOs have been able to optimize medication use in their own systems,” Westrich explained. “There are also many partnerships with a focus on sharing knowledge—the American Medical Group Association and Premier each have ACO groups, Brookings and Leavitt Partners have an accountable care learning collaborative, and the American Journal of Managed Care has one as well, to name just a few.”—Jolynn Tumolo

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