Financial Models for Pharmacist-Provided Care: Opportunities in Health Care Reform Wayne W. Oliver Center for Health Transformation Center for Innovative Pharmacy Solutions

Health Reform Goals Should Have Been … Lower CostsImprove Quality Expand Coverage

In Reality, Health Reform Was … Expanding Coverage Health Insurance Reform

21st Century Personalized Intelligent Health System Requires Transforming 4 Boxes Financing to Enable 300,000,000-Payor Insurance System Effective, Efficient and Productive Health Delivery System Individual Rights, Responsibilities and Expectation of Behavior Maximize Cultural and Societal Patterns for a Healthy Community

Health Reform (2012 and beyond)  Not a “Bill” …. It’s Statute (Law of the Land)  Creates Some Opportunities  Classic 1966 Epic Spaghetti Western Film The GOOD, The BAD and The UGLY –Advance and Enhance the Good –Mitigate the Bad and –Eliminate the Ugly The Impact on Pharmacy Profession

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The Impact of Health Reform  States must expand Medicaid programs  18 to 20 million expansion and expand government control over healthcare financing and delivery.  Availability of prescribers? Physician payments under Medicare and Medicaid are well below the prevailing rates in the private sector.  On average, physicians in Medicare are paid 81 percent of private payment.  On average, physicians in Medicaid are paid 56 percent of private payment.  Some sporadic access issues for patients in Medicare, and major access problems for patients in Medicaid.

Implications or Opportunities? Short Term Future for Pharmacists  Older Medicare Population MTM Services Medical Home ACO’s & Shared Savings  More Chronic Disease  Other Disease States Alzheimer's, Cancer …  How does pharmacy prepare?

Challenges for the Pharmacy Profession  Creating Value Personalized medicine  Issues with Interoperable IT  Limited Resources for ‘New’ Programs Medicare/Medicaid have funding issues Value-based benefit design  Keeping up with constant change Expanding role of pharmacists Internal Conflict in the Pharmacy Profession –From Purveyor of Drugs to Respected Clinician –Better Positioning as “Medication Expert”

 Health reform may create opportunities for pharmacists: Shortage of primary care physicians  ACOs will push collaboration and integrated “team” approach to care.  Care Coordination Improve Quality, Reduce Costs More appropriate utilization of care by patients Implications or Opportunities? The Impact of Health Reform

 Health reform will create opportunities for pharmacists in a “traditional” role: Health counselors »Face-to-Face vs. Telephonically Wellness and prevention awareness Immunizations Medication Therapy Management (MTM) »Mirixa: Private sector network of pharmacists  Payment reform could result in new non-traditional opportunities Pay-for-Performance Advancing Pharmacy Profession

 Value-based care will validate need for payment reform.  Pharmacists have a strong desire to utilize their clinical knowledge in providing direct patient care and interaction with the prescribers.  Pharmacists in a unique position to assist in the coordination of care.  New Medicare expanded MTM opens more patients and more diseases. Payment Reform Opportunities

 Private Sector, Medicaid Managed Care MTM programs and other pharmacy based clinical services such as adherence programs and disease specific initiatives.  Clinical data captured through these pharmacy-based services will be important in the new care delivery models including patient-centered care. Advances in Primary Care Patient Centered Medical Home Payment Reform Opportunities

 Clinical and administrative medication data will be on boarded to HIEs to support the new care delivery models. Nebraska, Utah and Florida  Providing real value through marrying clinical data with direct patient care.  Reducing hospital readmission rates. Pharmacists as care coordinator Communication and business process Payment Reform Opportunities

 HIT breakthroughs to create data rich information. Clinical data to drive best practices and evidence-based medical and pharmacy care creating an integrated “team” approach to care.  Health reform creates a “non-profit” Patient- Centered Outcomes Research Institute. Formerly called “Comparative Effectiveness Research” (CER) but term drew criticism of rationing. It will be financed through a Patient Centered Outcomes Research Trust Fund, with initial funding starting at $10 million this year, and reaching $150 million annually in Fiscal Year 2013, with additional revenues from insurance fees. Health Reform Opportunities

Building a Sustainable Pharmacy Care Model  Fundamental Payment Reform:  “Personalized medicine” and individually centered pharmacy care models.  Restoration of the traditional physician-pharmacist- patient relationship.  “Clinical” pharmacists are not just in clinical settings. They are in community, institutional practices.

Building a Sustainable Pharmacy Care Model  Embracing an individually centered model of care:  Coordinated care, advances in primary care, PCMH  Alignment of provider and patient incentives  Targeted Medication Therapy Management –The CVS study estimated that 35% of patients don't take their medications as directed –Consequences per every 100,000 : »16 unnecessary heart attacks »5 unnecessary strokes and »7 unnecessary deaths

Creating Innovative Models  State & Local Governments are the “Hotbed” of Reform: “Where the Rubber” hits the road Medicaid Funding Pressures –Expansion of coverage –Creative approaches Public – Private Partnerships: –Asheville Project –Ten City Challenge

Creating Innovative Models  State & Local Governments are the “Hotbed” of Reform: Exploring unique new opportunities –MTM “Clinics” at employer sites (plants) –Freestanding MTM Services in communities (Mirixa) –Adherence Clinics »Compliant patients with high cholesterol patients have fewer hospitalizations by 9% and reduce costs per patient by as much as $944 during an 18-month period.

Accelerating Ideas that Work  CHT 21 st Century Intelligent Pharmacy Project:  Accelerate adoption of best practice  Leading edge experts on patient safety, improving quality, medication adherence, pharmacy practice innovation, pharmacy education, care coordination, pharmacy technology 

Center for Health Transformation Health Reform Report Health Reform Resources

Wayne W. Oliver, J.D. Wayne W. Oliver, J.D. Vice President, Center for Health Transformation Thanks!