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- New Models: Community Pharmacy’s Role in an ACO!-  Bruce Thompson, RPh, MS"-  Director of Health System Pharmacy Services"-  Hennepin County Medical Center"

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Objectives

q Realize the benefits Pharmacy provides with outcome data."

-  Know the barriers Community Pharmacy needs to overcome to be a viable member of health system

•  Realize the current barriers and opportunities in transition of care."

•  Understand the opportunities for pharmacy in an ACO model."

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464 Bed Hospital DSH/Trauma Center. 60 Clinics – Primary Care, Specialty 2400 RX per day 20 RPh provide MTM Services

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It is Estimated That

- More than 2 Million individuals in the United States take Warfarin

- Over 24 Million prescriptions are dispensed each year

- How many prescriptions do you dispense each year?

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How do you monitor Warfarin Patients

-  How many patients do you know have had an INR within the last 4 weeks?"

-  How many patients do you know that the INR is in range for their therapy? "

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Patient Case

A patient with a history of atrial fibrillation is admitted to the hospital. The patient has been receiving: "

Warfarin 5mg every day for the past six months. The INR is high so the doctor writes a new prescription for the patient at discharge and explains that the new prescription is Warfarin 3mg only for Tuesday, Thursday and Saturday; (continue to take 5mg the other days)."

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Patient Case Result #1

-  Upon discharge the hospital gives the patient the discharge prescriptions, asks if they understand what is needed and discharges the patient. Within the 15-20 pages it instructs the patient to make an appointment with the anticoagulation clinic within 3-5 days"

-  The patient fills the prescription at their regular community pharmacy. The patient now takes the Warfarin 5mg every day and Warfarin 3mg on Tuesdays, Thursday and Saturdays. Thus 8mg three days a week."

-  Minimal interaction with the pharmacist."

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Patient Case Result #1

-  Ten days later, the patient has not gone to the anticoagulation clinic and presents at the Emergency Department with multiple bruises, nose bleeds and coughing blood."

-  His blood level is 3 times the safe level. The patient is given platelets, packed cells and an antidote for the warfarin overdose."

-  Patient is hospitalized for 8 additional days and survives. ""

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Patient Case #2

-  Upon discharge the hospital coordinates care with the anticoagulation clinic and the community pharmacy. Since this is a medication on the High Risk protocol, the pharmacist provides the patient education, explains the complex treatment and provides the patient with a calendar to assist taking the medications correctly."

-  Follow-up appointments are made for the patient and confirmed with the patient before they leave."

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Patient Case #2

-  Patient understands the importance of the medication regimen"

-  Patient receives follow up care at the anticoagulation clinic 5 days post discharge."

-  The community pharmacy has open access to the patient’s medical record to ensure the best therapy."

-  No Hospitalizations or ED visits in the following 6 months."

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What is the relationship between you and your Health System?

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Dispensing  without  MTM

Med  Rec                      (  If  accurate)

Transistions  without  MTM

Prescribing  in  a  Vacuum

CommunityPharmacy Hospital

HomeCareSNF

Clinics

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ACO needs to include Community Pharmacy in the plan.

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MTMComprehensive  

Med  Rec                      Transistions  with  MTM

Coordinated  Prescribing  

Accountable  Care  Organization

Pharmacy/            Health  Information                  Exchange

Alligned,  Efficient,  Incentive-­‐Driven  Model

CommunityPharmacy

Hospital Home CareSNF

Clinics

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Accountable Care Organizations

- Do you understand the ACO in your area?

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Hennepin Experience

ONE year pilot project with Minnesota Medicaid."- 8000 Patients,"- 46% had 10 meds or more"- HCMC Pharmacy provided: "

- Extensive med rec in hospital"- Coordinated medications on discharge"- MTM follow-up within 5 days of discharge"

- No involvement with PBM or cost control activities"

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Hennepin Experience - Outcomes

•  Admission rate reduced by 42%"•  Emergency Room visits decreased by 37% "- Reduced total cost of care by $2500 per

person!!

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Accountable Care Organizations

- Do you continue providing services as a “fee-for-service”? No Risk

-  Is your Community Pharmacy equipped to be at RISK with your ACO?

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Behind the scenes of the ACO

Pharmacy needs to know about the ACO Key Facts -  How many members are in the ACO?

-  What is the member utilization of prescription benefits?

-  What is the average prescription cost PMPM?

-  What is the generic dispensing rate?

-  Will the community pharmacy be allowed to dispense specialty drugs? Are there special rates/ considerations

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Behind the scenes of the ACO

Pharmacy needs to know how the ACO fits -  How many current ACO members use my pharmacy?

-  What is my cost to fill those prescriptions?

-  What is the current revenue for this business?

-  What services can I provide to provide additional value?

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Fee-for-Service or At-Risk

Honestly, ACO models are not ready for Community pharmacy to be at risk.

-  Information is controlled by PBM industry.

How do we change the model? Do we want to?

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Incorporate Community Pharmacy Services into the ACO

What services can you provide that will improve your value to the ACO?

- As the most visible health professional, Pharmacy has opportunities"

-  Increase involvement in High Risk areas."- Diabetes"- Anticoagulation"- Asthma""

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Medical Record

Pharmacy needs “write access” to the medical record"

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As ACO’s Mature

Total cost of care will incorporate community pharmacy performance. - Top performers will gain volume and market

share!

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Accountable Care Organizations

- Does the ACO understand the value your Community Pharmacy can provide?

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What is your Next Step?

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Is the ACO for You?!

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References -  http://en.wikipedia.org/wiki/Accountable_care_organization -  http://innovation.cms.gov/initiatives/Pioneer-ACO-Model/ -  http://www.npr.org/2011/04/01/132937232/accountable-care-organizations-explained -  http://www.amcp.org/aco.pdf -  http://www.drugstorenews.com/article/expanding-role-pharmacy-acos -  http://www.mtbc.com/learningcenter/index.php/aco-creating-a-strong-foundation-with-

a-ehr/ -  "Medicare "Accountable Care Organizations" Shared Savings Program - New Section

1899 of Title XVIII, Preliminary Questions & Answers". Centers for Medicare and Medicaid Services. Retrieved January 10, 2010.

-  Gold J. Accountable Care Organizations, Explained. Kaiser Health News, NPR. Jan 18, 2011. http://www.npr.org/2011/04/01/132937232/accountable-care-organizations-explained.

-  http://pnhpcalifornia.org/2010/10/the-history-and-definition-of-the-%E2%80%9Caccountable-care-organization%E2%80%9D/

-  http://www.beckershospitalreview.com/hospital-physician-relationships/implementing-acos-a-top-challenge-for-medical-groups-survey-finds.html

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References -  McClellan M, McKethan AN, Lewis JL, Roski J, Fisher ES (2010). A National Strategy to

Put Accountable Care Into Practice. 29. pp. 982=990. doi:10.1377/hlthaff.2010.0194. PMID 20439895.

-  Leavitt Partners, Growth and Dispersion of Accountable Care Organizations: June 2012 Update. http://news.leavittpartners.com/newsrelease-cid-1-id-43.html"

-  Yap D. Pharmacy to CMS: Explicitly include pharmacists in ACOs. American Pharmacists Association. http://www.pharmacist.com/AM/Template.cfm?Section=Pharmacy_News&template=/"

-  Stein M. Pharmacists Pursue Legislative, Contractual Strategies To Gain Key Role In ACOs. Daily News Updates from Inside Health Policy. https://healthpolicynewsstand.com/Inside-"

-  CMS/Inside-CMS-03/01/2012/menu-id-316.html. Accessed March 1, 2012."-  Pharmacists as Vital Members of Accountable Care Organizations. Academy of Managed Care

Pharmacy. http://www.amcp.org/aco.pdf. Accessed February 16, 2012."-  ACO Success Depends on Optimal Medication Management. The Pink Sheet. July 23, 2012 -  "Health Policy Brief: Accountable Care Organizations," Health Affairs, July 27, 2010. -  Berwick DM. Making good on ACOs’ promise – the final rule for the Medicare Shared

Savings Program. N Engl J Med 2011; 365:1753-6

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