Value-Based Care Lecture 10.23 PDF

Value-Based Care: A Pharmacist’s Perspective Amy Kelleh,PharmD,BCGP,CDCES PHAR5371 [email protected] October 10th, 2023 Objectives 1. 2. 3. 4. 5. Define Value-Based Care (VBC) Differentiate Value-Based Care & Fee-For-Service Review US Healthcare System Payment Models Discuss the characterist...

Value-Based Care: A Pharmacist’s Perspective Amy Kelleh,PharmD,BCGP,CDCES PHAR5371 [email protected] October 10th, 2023 Objectives 1. 2. 3. 4. 5. Define Value-Based Care (VBC) Differentiate Value-Based Care & Fee-For-Service Review US Healthcare System Payment Models Discuss the characteristics & differentiators of Value-Based-Care Discuss components of developing a clinical pharmacist program within a Value-Based Care system 6. Review the importance of electronic health records integration for successful implementation of clinical pharmacy program 7. Discuss methods to report outcomes & financially build the case for clinical pharmacy program in VBC What is Value-Based Care? Value-based care ties the amount health care providers earn for their services to the results they deliver for their patients, such as the quality, equity, and cost of care. Through financial incentives and other methods, value-based care programs aim to hold providers more accountable for improving patient outcomes while also giving them greater flexibility to deliver the right care at the right time. Value-Based Care vs. Fee-for-Service Value-Based Care Fee-for-service Focuses on quality, efficiency and patient outcomes Healthcare providers are reimbursed for each service delivered to a patient Reimbursement is based on the quantity of the services delivered Larger panel sizes, less frequent visits Incentivizes quality and cost-effective care Smaller panel sizes and more frequent visits Emphasis on prevention and lifestyle changes to improve health Hospital care when medically necessary and with consent of individual patient Payments usually higher in high-cost populations Emphasis on procedures and treatments No incentive to avoid hospitalization Payments do not vary based on the health of the population Types of Payment Models in US Healthcare System Fee-for-Service Providers are paid for each service performed Pay-for-Performance Providers are only compensated if they meet certain metrics for quality and efficiency Value-Based Purchasing/Bundled Payment Providers treating a patient for the same or related conditions are paid an overall sum for taking care of a condition vs. for each individual treatment Incentive to coordinate care Shared savings and risk Key in the Medicare delivery system reform under the Affordable Care Act A way to facilitate coordination and cooperation among providers to improve the quality of care for Medicare Fee-for-Service beneficiaries and reduce unnecessary costs Type of Payment Models in US Healthcare System (cont.) • Global Payment/Capitation • Networks of hospitals and physicians band together to receive fixed monthly payments for enrolled health plan members, payment made on a per member basis • Risk adjustment essential to adequately compensate providers for the risk they take-on • Payments differentiated based on the characteristics of the enrollees in each provider patient group • Some risk adjustment factors: age, sex, health status, prior health care utilization & socio-demographic factors Global Payment/Capitation: An Example of Risk Adjustment • Key to VBC payment model HCCs-hierarchical condition categories • Used to calculate patient risk • Higher the risk score, the higher the benchmark will be for expenditures • Risk Adjustment Factor (RAF) scores are part of the model used by CMS to estimate the associated cost of Medicare Advantage beneficiaries. The RAF score determines the amount paid by CMS to the health plan per beneficiary during the corresponding payment year. |7 Characteristics of Value-Based Care A closer look at the goals of VBC Improve patient experience Better management of diseases Lower Costs Streamlined payment and reimbursement Better access to care Minimized delays and denials Value-Based Care Ecosystem Medical Assistants Referral coordinators or patient care coordinators Value Based Care Model: Social Determinants of Health (SDOH) • VBC aims to reduce health inequity • The factors that prevent individuals from reaching their full health potential • Health equity- “the absence of systematic disparities in health between and within social groups that have different levels of underlying social advantages or disadvantages.” • Emerging research shows the need for policy interventions to address factors that influence health that extend beyond clinical interventions • SDOH: • • • • • Poverty Unequal access to health care Lack of education Stigma Racism What are some ways VBC models attempt to address SDOH? TRANSPORTATION SERVICES HOUSING PARTNERING WITH COMMUNITIES TO ADDRESS FOOD INSECURITIES EDUCATIONAL CLASSES – GENERAL & DISEASE-STATE FOCUSED ADDITIONAL PLAN-BASED BENEFITS VBC & Medicare Advantag e Plans • Public-private partnership which is an option for Medicare beneficiaries vs traditional Medicare • Known as “Part C” or “MA plan”, different from traditional in that the things it covers • Combines Part A (Hospital) Part B (Medical) and Part D (drug coverage) • More access to dental, vision, hearing, and wellness benefits • Include unique plan-based benefits such as transportation to doctor’s appointments, meal delivery, and home care post-hospitalization & OTC benefits on a value-based system in which Medicare Advantage health plans receive a permember, per-month payment for each beneficiary’s care, and are tasked with using those dollars most effectively Pharmacist Perspective on VBC in Primary Care Creating a Pharmacist-Led VBC Program in Ambulatory Care Establish the appropriate relationships especially with key players Education on VBC, Stars/Hedis, Clinic Operations, roles, finances Determine an effective way to document activity-productivity and outcomes Identify most impactful ways to engage with patients and providers geared to meat organizational value-based payment model goals Evaluate the needs that pharmacists can help address Establish appropriate workflow & documentation • i.e. patient & provider education, medication access, care coordination • eHR utilization is key Build analytics on the role activities Determine & implement approach for scaling Goals: reduce cost, improve quality of care, improve patient experience & reduce provider burden Factors to Consider for Clinical Pharmacy Program Development Top 8 Ambulatory Care Sensitive Conditions (ACSC) • • • • • • Priorities of the provider group/payer Analytics-led identification of areas of opportunity Using risk stratification if possible Demographics/needs of the population • High volume of CHF, COPD, DM? • High volume of psych? Literature review of previous clinical pharmacists program in similar settings Potential for high impact that will outweigh cost of pharmacist services i.e. potential save in cost of care for patient, provider burden reduction APT=Admits per Thousand. Total admits divided by total membership multiplied by 12,000 PMPM= Per member per month Measures the average cost of providing healthcare services to each member of a defined population within a specific time frame | 16 Let’s Take a Deeper Dive into the role of the Clinical Pharmacist in this setting… Impacting Stars Measures | 17 Ways that Pharmacists can Impact Total Cost of Care for Patients in VBC? • Targeted interactions/interventions for high utilizers • Implementation of collaborative drug therapy management activities for chronic disease state management • Telephonic outreach/follow-ups in between provider visits • Involvement in P&T activities • Transitions of care activities Clinical Model: Intervention Example-Integrated Pharmacist Program: Referral Criteria Post-Discharge Med Rec Transitions of Care • Recent acute/obs admission AND • ≥ 15 active medications OR • Admission diagnosis was related to diabetes, CHF, COPD Diabetes Chronic Care • Most recent HbA1c ≥ 10% OR • Most recent HbA1c ≤ 7% & treated with insulin OR • Care coach/coordinator documentation of > 2 hypoglycemic episodes in past 30 days CHF Chronic Care *Example of pharmacist programs criteria • TOC program enrollment for CHF exacerbation OR • Presence of maintenance loop diuretic prescription at moderate dose OR • Elevated BP >160/90 COPD Chronic Care • TOC program enrollment for COPD exacerbation OR • Moderate complexity inhaler regimen (>3 active inhaled maintenance medications on medication list*) Interdisciplinary Team Meetings • • • • As identified by Risk Stratification Report Polypharmacy High utilizers Chronic non-adherence Meets criteria for TOC or chronic care programs *Considering individual components of combination products | 19 Clinical Pharmacist – Intake Process & Workflow Information coming in… Clinical Pharmacist Actions taken… Medication Management PHARMACIST • Transitions of Care (medication reconciliation) - Hospitalizations • STARs quality initiatives (MTM, SUPD/SPC, etc.) • Medication Access (adherence, benefit optimization, preferred product use, patient assistance) • All new disease diagnosis education - COPD/Asthma, DM, CHF/CAD • Provider consultation • Daily/Monthly clinic rounds • Stable disease management (in states that allow) • Formulary Management • Medication list management • Face to face & virtual patient appointments • Drug therapy monitoring & modification recommendations • Training for insulin administration, COPD inhaler usage & self-management • Identify gaps in care and medication adherence opportunities with provider and pharmacies • Promote immunizations and public health Example of general pharmacist workflow & interventions 20 Clinical Pharmacists in Action-Patient Cases Formulary Management in Action: • Integrated clinical pharmacist notified of a PA required for a patient at a clinic that they cover. • Due to the high cost, pharmacist reviews the patient’s chart, last visit note and drug history to evaluate the necessity of the medication What are some factors that the pharmacist should consider to recommend or not recommend that the PA be completed? | 22 Chronic Care Management-DM Management | 23 Medication Reconciliation Example Pharmacist-Provider recommendation | 24 Medication Reconciliation Example Cont’d | 25 Leveraging Technology-Electronic Health Records Leveraging Technology: Use of Electronic Health Records (EHRs) for Pharmacists in VBC Pharmacist Patient Panel & Documentation Clear visibility of pharmacist assessments and interventions requires IT involvement Provider Communication Direct documentation of recommendations into provider eHR or alternative that allows easy access Analytics Extraction of valuable key performance indicators (KPIs) and leading indicators from pharmacist documentation and interventions Continuous Quality Improvement Ensuring streamlined process and automizing where possible | 27 Leveraging Technology Example: Provider EHR Utilization by Pharmacists in VBC • • • • • • EHR integration key to implementation of successful clinical pharmacy program Workflow should be geared toward simplicity of documentation & minimization of manual tracking of productivity Requires knowledge of functionality of eHR system and IT/Analytics assistance Leverage functionalities already existent for non-provider staff i.e. Nurses and other ancillary personnel Documentation should be based on the desired reportable content EHR example: • Template-based with items identified as important to evaluate productivity and value • Includes pharmacist-specific progress notes categorized by disease state i.e. CHF,COPD,DM | 28 Sample Progress Note Template Buildout for EHR | 29 Sample Progress Note Template Buildout for EHR cont’d | 30 Sample Progress Note Template Buildout for EHR cont’d | 31 Showing Value with Outcomes Steps to Measuring Outcomes • Report on basic productivity metrics: number of patients in clinical pharmacy programs, total numbers of visits, time spent, vs total population • Identification of patients that the clinical pharmacist has engaged with & measure engagement • Establish a control group that is matched by patient demographics but have no clinical pharmacist engagement • Measure patient utilization data for pre and post program • Identify KPIs & leading indicators to report by programshould include both clinical and stakeholder KPIs • Based on impact on cost i.e. utilization, cost to care for a member (PMPM) work the analytics & finance to calculate a cost avoidance by clinical pharmacist impact on patients that they engaged with Measuring Pharmacist Outcomes Measuring Pharmacist Outcomes Example of Admits per thousand graph trend in a valuebased care model | 36 A closer look at a pharmacist’s impact: Patient Story References • Arvin Garg, Charles J. Homer, Paul H. Dworkin; Addressing Social Determinants of Health: Challenges and Opportunities in a Value-Based Model. Pediatrics April 2019; 143 (4): e20182355. 10.1542/peds.20182355 • Coleman, Zachary “The value of pharmacists within and beyond value-based care” • Journal of the American Pharmacists Association, Volume 61, Issue 6, 661 – 663 • Leusder M, Porte P, Ahaus K, et alCost measurement in value-based healthcare: a systematic reviewBMJ Open 2022;12:e066568. doi: 10.1136/bmjopen-2022-066568 • Teisberg E, Wallace S, O'Hara S. Defining and Implementing Value-Based Health Care: A Strategic Framework. Acad Med. 2020 May;95(5):682-685. doi: 10.1097/ACM.0000000000003122. PMID: 31833857; PMCID: PMC7185050. • Werner, Rachel M. MD,PhD, et al. "The Future of Value-Based Payment: A Road Map to 2030." Health Care Access & Coverage, 2021. • Frequently Asked Questions | Social Determinants of Health | NCHHSTP | CDC • Diabetes coding in Hierarchical Condition Coding (HCC) – CodingIntel • Medicare Advantage Value-Based Insurance Design Model | CMS • Value Based Payment Models (ashp.org)