Advanced Clinical Pharmacy Services Integration in an Accountable Care Organization

In this session, Kelly Boesen, PharmD, BCPS, and Sandra Leal, PharmD, MPH, CDE, FAPhA, of the El Rio Health Center in Tucson, Arizona, described a sustainable business model for pharmacists practicing in an accountable care organization (ACO) environment.

An ACO is defined as a healthcare organization characterized by a payment and care delivery model that seeks to tie provider reimbursement to achievement of quality metrics and reductions in the total cost of care for an assigned population of patients. The organization consists of a group of providers and suppliers of services that work together to coordinate care for the Medicare Fee-for-Service (FFS) patients they serve. To become an ACO, the organization must serve at least 5000 Medicare FFS patients and agree to participate in the program for at least 3 years. The organization will continue to receive FFS, and if the organization achieves certain benchmarks, it will receive additional reimbursement (shared savings).

These benchmarks may include outcomes and quality measures pertaining to:

• Patient/caregiver experience (access to providers, timeliness of appointments, provider ratings)
• Care coordination/patient safety (performance of medication reconciliation, screening for fall risk, reduction of readmission for certain chronic conditions)
• Preventive health services (immunizations, body mass index [BMI] monitoring, depression screening, blood pressure [BP] screening)
• Focus on at-risk populations (patients with diabetes and cardiovascular disease)

The El Rio Health Center is a Federally Qualified Health Center (FQHC); in 2012, when it joined the Arizona Connected Care ACO, it served 79,637 patients. At the time, 4 clinical pharmacists were employed with the primary responsibility of providing collaborative drug therapy management for patients with diabetes and related comorbidities. As part of the ACO, areas and opportunities for extended pharmacy integration included:

• Population health management
• Enhanced patient experience through access, satisfaction, and outcomes
• Annual wellness visits (AWVs)
• Review of patient complexity and risk
• Formulary management
• Guideline implementation/review
• Targeting of safety events associated with medication use

As a method of revenue generation, the health center explored the inclusion of pharmacists in the administration of AWVs. AWVs are preventive wellness visits and are not routine physical checkups that patients may receive from a physician or other practitioner. (Medicare does not provide coverage for routine physical examinations.) There are 2 types of AWVs—initial and subsequent. AWVs involve a number of activities, including assessment of health risk and development of a personalized prevention plan of service. The following activities are conducted as part of AWVs:

• Review of medical and family history
• Review of list of current medical providers
• Measurement of height, weight, BMI, and BP, along with other appropriate routine measurements
• Detection of cognitive impairment
• Review of risk factors and establishment of list of risk factors
• Review of functional ability
• Establishment of a written screening schedule for next 5 to10 years
• Provision of advice and referrals to health education and preventive counseling services

Other elements may be included as determined by the Secretary of Health and Human Services.

Interventions that may occur in AWVs include, for example, identification of previously undiagnosed depression; coordination of meal services, resources for people with fall risk, and transportation resources; and optimization of medication therapy.

Medicare mandates that AWVs must be furnished by a health professional, meaning a physician; physician assistant, nurse practitioner, or clinical nurse specialist; or a medical professional (including pharmacists) or a team of medical professionals working under the direct supervision of a physician. It should be noted that physical exams and initial preventive physical examinations (IPPEs) for entry into Medicare must still be performed by a physician or similarly licensed provider.

From a coverage perspective, Medicare provides annual coverage of an AWV for beneficiaries who are no longer within 12 months after the effective date of their first Medicare Part B coverage period and who have not received an AWV within the past 12 months (ie, at least 11 full months after the IPPE or most recent AWV). Additionally, Medicare pays for only 1 first AWV per beneficiary per lifetime. However, patients may receive subsequent AWVs annually. Currently, initial AWVs are paid at $165 per visit, and subsequent visits at $110 per patient per year.

Based on the fee schedule for AMVs, the presenters noted that about 1000 visits per year were needed to sustain a pharmacist full-time equivalent (FTE) position and associated ancillary personnel resources, given the fact that facilities and shared services were available. In the case of the El Rio Health Center, Dr Boesen noted that she was the FTE staff member, demonstrating proof of concept.

Lessons learned during the process of setting up the AWV service included the importance of educating patients, providers, and staff about the value of the wellness visits and the activities entailed. Additionally, as with any business model, effective marketing was needed to recruit patients. The El Rio Health Center sent letters to eligible patients, provided flyers to Medicare patients, and mentioned the AMV program when patients were in the office to see other providers.

If considering a pharmacist-run AWV program, Dr Leal recommended doing the math to make sure such a program is feasible within your patient population, acquiring buy-in from administration, training providers regarding the appropriate documentation requirements, and ensuring that there is an appropriate space to perform the AWVs. Once the program has been established, it is a matter of recruitment, performance, and documentation.