Managed Care Responses to Healthcare Reform

The patient-centered medical home (PCMH) has many key goals and components. When paneled, the majority of AMCP 2013 Nexus attendees agreed that the PCMH is best described as “a practice model that organizes primary care practice operations and incentives to deliver patient-centered, coordinated, comprehensive care with the goal of improved quality and efficiency.” With health reform, and the emergence of novel practice models, managed care organizations are increasingly identifying ways in which pharmacist involvement can help to improve the quality and cost-effectiveness of patient care.

Stephanie Ross, PharmD, BCACP, primary care clinical pharmacist, Capital District Physicians’ Health Plan, Inc (CDPHP), says that 5 years ago, CDPHP recognized that primary care was in crisis. The predicament included a projected shortage of primary care physicians, and a model of care that did not offer competitive earnings to attract the interest of graduating students. This provided incentive for CDPHP to support enhanced reimbursement to primary care practices, as well as to make the profession more attractive for medical students. Dr Ross said that one of the reasons we need pharmacists to participate in the model home is that more than 80% of treatments involve some form of medication. Furthermore, an aging population with more comorbid/complex disease will require complex individualized treatment strategies.

Beyond the triple aim, pharmacists can collaboratively support high-quality and cost-effective care in a multitude of ways. Dr Ross suggests those include chronic use of PPIs/PPI step-down protocol, proper management of common acute care illnesses, hypertension treatment education, diabetes resources, and miscellaneous drug conversions. In CDPHP’s next phase of embedding the managing clinical pharmacist into primary care practice, they hope to focus on population management/population health, expand primary care clinical pharmacy services to more medical groups, and establish best practices among providers in the community including quality, satisfaction, and cost.

Alex C. Bitting, PharmD, VRx Pharmacy Services, relayed one provider’s feedback about the importance of pharmacy involvement with the PCMH. “Having a clinical pharmacist available on site has supplemented the care I am able to provide my patients. The pharmacist is able to take time to educate patients not only on medications prescribed, but also how the body responds to each medication,” said Erica Baiden, MD, family medicine. “I also appreciate having another pair of eyes to offer my patients quality and comprehensive care.”

Richard G. Stefanacci, DO, MGH, MBA, AGSF, CMD, chief medical officer, the Access Group, added that just as pharmacists play a critical role in medication adherence, the pharmacy can also play an equal role in medication access and management. The retail pharmacy can improve timing and location of delivery, as well as play a critical role in adherence through medication dispersing services.

Dr Stefanacci says what is critical for managed care organizations is the identification of both the “right patient and the right intervention.”