Financial Models for Pharmacist-Provided Care: Opportunities in Health Care Reform

1. Financial Models for Pharmacist-Provided Care:Opportunities in Health Care Reform Wayne W. Oliverwoliver@gingrichgroup.comCenter for Health Transformation Twitter: @wayne_oliver Center for Innovative Pharmacy Solutions

4. Health Reform Goals ShouldHave Been … Lower Costs Improve Quality Expand Coverage

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

6. 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 4. 3. 2. 1. Maximize Cultural and Societal Patternsfor a Healthy Community

7. Health Reform (2012 and beyond) Not a “Bill” …. It’s Statute (Law of the Land) Creates Some Opportunities • Classic 1966 Epic Spaghetti Western FilmTheGOOD, TheBADand TheUGLY • Advance and Enhance the Good • Mitigate the Bad and • Eliminate the Ugly The Impact on Pharmacy Profession

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9. 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.

10. 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?

11. 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”

12. Implications or Opportunities?The Impact of Health Reform • 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

13. Advancing Pharmacy Profession • 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

14. Payment Reform Opportunities • 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.

15. 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

16. 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

17. Health 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.

18. 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.

19. 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

20. 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

21. 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.

22. Accelerating Ideas that Work • CHT 21st 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 • http://www.healthtransformation.net

23. Center for Health Transformation www.healthtransformation.net Health Reform Report www.healthreformreport.com Health Reform Resources

24. Wayne W. Oliver, J.D.Vice President,Center for Health Transformationwoliver@gingrichgroup.comTwitter: @wayne_oliver Thanks!