Achieving Affordable Medication Management by Jim Notaro, RPh, PhD
As I speak to more and more executive officers at ACOs and PCMHs about Medication Management, I hear an interesting pattern of comments:
My care management priorities don’t include Medication Management
I feel pharmacists are too expensive to hire
I don’t know how to demonstrate a return on a Medication Management program
These are all valid comments, and present some of the obvious major barriers that accountable organizations face when implementing a Medication Management program. In many cases, accountable organizations are unsure of how they might capitalize, sustain, and scale a Medication Management program. As a result, these concerns can prevent program initiation. Some larger organizations “bite the bullet”, and hire a pharmacist, but have trouble scaling the Medication Management service such that it provides more value than the resources it consumes.
In the Part D world (where Medication Management services are required) we have been grappling with these issues since 2006, and I believe our experience has relevance in the accountable care world.
Medication use consumes approximately 30% of the care budget. In addition, it is a primary root of unnecessary emergency visits (hypotension, anticoagulation) and hospital admissions and re-admissions. If you don’t have a robust Medication Management program, you can hardly think of yourself as accountable.
Capitalizing Medication Management
When you start to think of implementing a Medication Management program, your stomach probably gets queasy at the thought of hiring a pharmacist. Pharmacists are a big “nut”. Typically a seasoned pharmacist will run in the $50-60 an hour range—throw in benefits, and you’re talking $130-150 K a year. A new grad will cost less, but they will require more of your time and guidance. That’s a lot of “moolah” to shell out for somebody. First of all, that’s only one person—how will you cover their off time?; health care is 24/7/365. Second, you haven’t even begun to add in the costs of infrastructure—office space, computer, etc. Third, how many cases can this pharmacist address per day?
Most accountable organizations, because they are not able to up-front the type of resources required for a Medication Management staff and infrastructure, will need to craft inventive ways to get started with Medication Management. Some organizations have developed relationships with schools of pharmacy that are willing to place faculty pharmacists in the organization, and either share or cover the cost of the pharmacist. While this option addresses the cost of a pharmacist, it creates a new barrier; it provides a faculty member who must also attend to faculty responsibilities, and cannot devote complete attention to the practice. Unfortunately the faculty option does not address issues of coverage and scalability.
Another option is to purchase incremental services from an organization dedicated to providing Medication Management services. This option allows you to purchase a Medication Management team on a fractional basis—addressing cost, coverage, and scalability issues.
Return on Investment
Demonstrating the value of a Medication Management program is not an inconsequential task—especially if you have not designed your Medication Management program to demonstrate value. What do I mean by this? For many Medication Management programs, the extent of the design is this: review a patient’s medication regimen to identify drug-related problems, and discuss these with the prescriber and patient. The problem with this design is it’s not focused or proscribed enough to provide value. Any value you get from a Medication Management program consisting of a general drug regimen review program will be accidental.
To ensure that your Medication Management program will create more value than the resources it consumes, you have to design it like a clinical trials protocol. Here are some key features you need to address:
Endpoints: Like a clinical trial, you have to start with the end in mind. What is value for you? Generally, value is divided into three categories: financial, clinical, and quality of life. What do you need to achieve lower drug spend? Improved STAR measures? Lower hospital re-admissions? Each of these value propositions can be achieved with a Medication Management program—but they will not have the same design.
Inclusion/Exclusion Criteria: Clinical endpoints give you the inclusion criteria for your Medication Management program. In the managed care world, reviewing a patient population to understand who meets the inclusion/exclusion criteria is known as IDENTIFICATION. Allowing patients to enter your program as they present to the office or are referred is a sub-optimal way of “mining” the value of your Medication Management program. The problem here is that patient records in most EHRs cannot be easily queried for patient identification. While many accountable organizations have access to more easily queriable claims data, they do not have the capacity for working with this data.
Minimum Data Set: Similar to a clinical trial, you need to determine what data to collect in order to demonstrate that you have or have not achieved your endpoints. More importantly, you need to collect this information AS A PART OF THE MEDICATION MANAGEMENT PROCESS and IN A REPORTABLE FORMAT. You can’t afford to waste resources combing through progress notes at the end of the month to produce your value reports (this is why you can’t use an EHR to do Medication Management, but more on that in a future blog!).
Process: Clinical trials proscribe the intervention process. They do not leave it up to clinical judgment. If you want your Medication Management program to produce value, then all pharmacists must be deploying the same intervention in the same way when certain conditions are recognized.
Medication Management programs that are designed to demonstrate value almost always do. Moreover, the benefit of optimizing medication regimens cannot only be immediately seen in the pharmacy budget, but cascades throughout the other care cost centers.
Clinical Support Services, Inc. is a care management company specializing in Medication Management. CSS provides Medication Management software and support for MCOs, ACOs, and self-insured employer groups. For more information about CSS and its offerings, contact firstname.lastname@example.org.
Jim Notaro, RPh, PhD, is a pharmacist and the Founder and President of Clinical Support Services, Inc. Jim has used his clinical and analytical background to design a unique care/Medication Management software infrastructure that can accommodate both administrative claims and structured clinical data. As a result of this experience, Jim has participated in a number of data management and data aggregation projects including: Aligning Forces for Quality, Beacon, Community Care Transitions Program, and the Comprehensive Primary Care Initiative. He is also an Assistant Professor in the Department of Health Services Administration at D’Youville College, Buffalo, NY, teaching graduate-level courses, and serving as thesis director.
For more information about CSS or Jim, visit our complete website: www.csshealth.com.