The Patient Protection and Affordable Care Act (PPACA) of 2010 brought many changes to the types of provider organizations available. Accountable care organizations (ACOs) and patient-centered medical homes (PCMHs) are two organizations formed under the PPACA. Both ACOs and PCMHs are models that are established to promote coordinated high-quality care at lower costs and improve patient outcomes. You must select either ACOs or PCMHs for this final paper.
For your Managed Health Care Delivery Models final paper, you must complete an eight- to 12-page paper.
In your paper,
Discuss the origin and structure of your selected managed health care delivery model.
Describe how your selected model has striven to contain the costs or improve the quality of care.
Summarize health care providers contracts and payment methods in your selected model.
Assess the impacts of your selected model on either Medicare or Medicaid.
Examine one specific public policy or regulation (e.g., PPACA) in relation to your selected model.
Evaluate the challenges or opportunities facing payers and providers in your selected model.
Create a plan of action to overcome identified challenges or take advantage of identified opportunities in the context of access, quality, and cost.
The Managed Health Care Delivery Models final paper,
must be eight to 12 double-spaced pages in length (not including title and references pages and formatted according to APA
must include an introduction and conclusion paragraph.
Your introduction paragraph needs to end with a clear thesis statement that indicates the purpose of your paper.
Research Article
Improving Medication Adherence in an ACO
Primary Care Office With a PharmacistLed
Clinic: A Report From the ACORN SEED
Journal of Pharmacy Practice
2021, Vol. 34(6) 888893
© The Author(s) 2020
Article reuse guidelines:
sagepub.com/journals-permissions
DOI: 10.1177/0897190020934271
journals.sagepub.com/home/jpp
Genevieve Hale, PharmD, BCPS, BCCP1 ,
Cynthia Moreau, PharmD, BCACP2 , Tina Joseph, PharmD, BCACP2,
Jessica Phyu, PharmD3, Nemesis Merly, PharmD4,
Nicole Tadros, PharmD, BS3, and Martha M. Rodriguez, MD, PA5
Abstract
Background: As health care moves into the era of value-based medicine, both ambulatory and acute settings are being held
accountable for the quality of care provided to patients. Previous studies have shown improved clinical outcomes through medication therapy management (MTM) due to improved medication adherence. Objective: The purpose of this study is to assess the
effects of a pharmacist-led MTM clinic in an accountable care organization (ACO) affiliated primary care office on adherence to
renin-angiotensin system (RAS) antagonists, diabetic medications, and/or statin medications reported through Healthcare
Effectiveness Data and Information Set (HEDIS) Medicare Star Ratings. Methods: In this retrospective cohort study, data were
collected via chart review of pharmacist-led MTM patient interviews and follow-ups between October 2015 and April 2017.
Eligible patients were Humana HMO Medicare beneficiaries, with at least one chronic disease state, for which they were treated
with a RAS antagonist, statin, or diabetic medication. The primary outcome of this investigation was a change in Star Rating scores
for medication adherence to RAS antagonists, diabetic medications, and statins from pre- and postpharmacist MTM intervention.
Results: A total of 102 patients were referred to the MTM clinic. Out of these, 32 had a follow-up visit, resulting in a total of 25
interventions. One year prior to MTM clinic implementation, most Star Ratings were consistently 3 (out of 5) for RAS antagonists,
diabetic medications, and statins. Postintervention, ratings increased to 4 or 5 across these categories. Conclusion: Implementing a
pharmacist-led MTM clinic in the ACO primary care setting improves Medicare Star Ratings in patients with chronic conditions.
Keywords
pharmacy, medication adherence, medication therapy management, accountable care, STAR measures
Background
As health care continues to move into the era of value-based
medicine, ambulatory and acute patient care settings are held
accountable for the quality of care provided. From a national
level, primary care practices within accountable care organizations (ACOs) and/or patient-centered medical homes (PCMHs),
among other entities, are measured based on a set of 8 performance benchmarks called Core Quality Measures outlined by
the Centers of Medicare and Medicaid.1 Additionally, according
to the National Committee for Quality Assurance, 90% of US
health plans rely on Healthcare Effectiveness Data and Information Set (HEDIS) measures to compare health care performance
with other health plans.2-5 In order to determine the quality of
Medicare-sponsored plans including Medicare Advantage (Medicare Part C) and prescription drug Medicare Advantage plans
(Medicare Part D) Star Ratings are employed to allow Medicare
beneficiaries and their families/caregivers to compare the quality
of health and drug plans being offered. Medicare health and drug
plans are given a rating on a 1 to 5 Star scale, with 1 Star
representing poor performance and 5 Stars representing excellent performance.6,7 This also translates into potential cost savings and financial reimbursements for primary care and other
1
Department of Pharmacy Practice, Nova Southeastern University College of
Pharmacy, Palm Beach Gardens, FL, USA
2
Department of Pharmacy Practice, Nova Southeastern University College of
Pharmacy, Davie, FL, USA
3
Nova Southeastern University College of Pharmacy, Davie, FL, USA
4
Nova Southeastern University College of Pharmacy, Palm Beach Gardens, FL,
USA
5
MMR Healthcare Internal Medicine Clinic, Boynton Beach, FL, USA
Corresponding Author:
Genevieve Hale, Department of Pharmacy Practice, Nova Southeastern University College of Pharmacy, 11501 North Military Trail, Palm Beach Gardens,
FL 33410, USA.
Email: gh341@nova.edu
Hale et al
health care practices as well as evaluating the quality of
Medicare-sponsored programs.
Most quality measures/ratings are directly or indirectly
affected by medication use, including optimizing pharmacotherapy and medication adherence. For instance, a tripleweighted measure (ie, a measure counted 3 times as much as
a measure given a weight of 1) is medication adherence to
renin-angiotensin system (RAS) antagonists (eg, angiotensin
converting enzyme inhibitors/angiotensin II receptor blockers),
diabetic medications, and HMG-CoA reductase inhibitors [statins]).4 However, the presence of a medication expert, namely a
pharmacist, within ACO primary care offices and/or PCMHs, is
lacking and medication management remains suboptimal in
this setting leading to poor scores and less financial reimbursement opportunities. Services pharmacists routinely perform,
such as medication therapy management (MTM), may assist
primary care providers (PCPs) in meeting these quality measures. Medication therapy management is defined as a service
or group of services that optimizes therapeutic outcomes for
individual patients through drug reviews, pharmacotherapy
consults, anticoagulation management, and other clinical services.8 These services are intended to target polypharmacy,
preventable adverse drug events, medication adherence, and
medication misuse through a medication therapy review, a personal medication record, a medication-related action plan,
intervention and/or referral, documentation, and follow-up.9
Objective
The purpose of this study is to assess the effects of a
pharmacist-led MTM clinic in an ACO primary care office
on adherence to RAS antagonists, diabetic medication, and/or
statin medications reported through HEDIS Star Ratings in
Medicare Humana health management organization (HMO)
beneficiaries.
Methods
In this retrospective cohort study, data were collected via an
electronic medical record chart review at an ACO primary care
clinic. Patients were referred to the pharmacist-led MTM clinic
by their PCP (physician or nurse practitioner) at the conclusion
of their appointment. Upon referral, initial MTM visits were
conducted the same day as the PCP appointment and led by one
pharmacist with a full-time faculty appointment at Nova Southeastern University College of Pharmacy who provided clinical
services at the primary care clinic 2 days/week during the study
period. Of note, 2 patients were seen by the pharmacist only on
the day of his/her initial appointment. Subsequent to the initial
visit, all follow-up visits were scheduled for the same patient
population at a future date and conducted by the pharmacist
only. Referrals were based on a history of medication nonadherence per previous Star Ratings scores provided by the health
plans (which the PCP was previously privy to) or per PCP
discretion based on suspicion of nonadherence during patient
interview. Medication nonadherence was defined as proportion
889
of days covered (PDC) of less than 80%. PDC is the percent of
days in the measurement period covered by prescription
claims for the same medication or another in its therapeutic
category.10,11 During MTM patient interviews, a clinical pharmacist within the primary care office conducted in-person
MTM services using OutcomesMTM platform.12 Clinical documentation of initial and follow-up visits between October 1,
2015 and April 30, 2017 were evaluated.
The primary outcome of this investigation was change in
Star Rating scores (based on quarterly and annual reports provided by health plans) for adherence to RAS antagonists, diabetic medications, and statins approximately 1 year before
(January to September 2015) intervention compared to postpharmacist MTM intervention (October 2015 to April 2017).
Secondary outcomes were number of interventions provided by
the pharmacist at each visit and changes in clinical markers
between initial (baseline) and follow-up MTM visit.
Eligible patients were Humana HMO Medicare beneficiaries
with at least one chronic disease state (ie, hypertension, diabetes,
hyperlipidemia, etc) and prescribed a RAS antagonist, statin,
and/or diabetic medication for the respective indication. Of note,
Humana Medicare beneficiaries were specifically evaluated (and
other insurance carriers were excluded) as the study site consisted mostly of patients with this insurance coverage. Demographic information (age, gender, race), medications prescribed
(RAS antagonist, statin, and/or diabetic medication), baseline
and follow-up clinical markers (blood pressure [BP], fasting
blood glucose, lipid panel) that were collected within 3 months
of the patient visit, history of ischemic stroke or myocardial
infarction, and pharmacist interventions were collected. Pharmacist interventions for the following reasons were assessed: generic substitution needed, drug too expensive (ie, patient reported
being unable to pay for medication), therapeutic interchange/
alternative therapy needed, adverse event identified, drug interaction identified, dose too high or low, dose interval too short or
long. All pharmacist interventions were approved or rejected by
the PCP as a collaborative practice agreement was not in place at
the time of this study. The number of patients given medication
reconciliation and educational counseling by the pharmacist
were also collected. Lastly, Star Ratings for medication adherence through HEDIS reports were obtained and assessed quarterly (ie, in the months of January, April, July, October) and
annually (ie, in the month of December) during the study time
period.
Statistical analysis of data were performed using Statistical
Package for Social Sciences (SPSS) version 25.13 Chi-squared
and Fishers exact tests were utilized for nominal data as appropriate. Paired student t test was used for continuous data.
Descriptive statistics were also reported. This study was
approved by the institutional review board of Nova Southeastern University.
Results
Patient demographic information and baseline clinical findings
can be found in Table 1. A total of 102 patients were referred
890
Journal of Pharmacy Practice 34(6)
Table 1. Demographic and Clinical Characteristics of Patients.
Characteristicsa
At initial MTM visit (n = 102)
At follow-up visit (n = 32)
77.8 ± 8.3
66 (64.7)
74 (72.5)
79 (77.5)
47 (46.1)
79 (77.5)
102 (140.4 ± 21.0)
102 (73.9 ± 10.4)
101 (71.5 ± 11.8)
98 (124.4 ± 61.3)
7.5 (7.5 ± 5.3)
97 (95.4 ± 34.9)
98 (53.0 ± 16.6)
98 (138.7 ± 72.3)
97 (177.4 ± 41.3)
2 (2)
13 (12.7)
76.8 ± 8.7
17 (53.1)
23 (71.9)
23 (71.9)
17 (53.1)
26 (81.3)
32 (138.9+22.6)
32 (73.6 ± 9.4)
31 (69.1 ± 11.6)
32 (143.7 ± 84.5)
23 (7.4 ± 2.2)
30 (99.9 ± 35.1)
31 (51.4 ± 14.7)
31 (147.8 ± 91.1)
31 (179.9 ± 38.2)
1 (3.2)
7 (21.9)
Age (years), mean ± SD
Female, n (%)
Caucasian, n (%)
Taking RAS antagonist, n (%)
Taking diabetic medication, n (%)
Taking statin, n (%)
Systolic blood pressure (mm Hg), mean ± SD
Diastolic blood pressure (mm Hg), mean ± SD
Heart rate (bpm), mean ± SD
Fasting blood glucose (mg/dL), mean ± SD
Hemoglobin A1C (%), mean ± SD
Low-density lipoprotein (mg/dL), mean ± SD
High-density lipoprotein (mg/dL), mean ± SD
Triglycerides (mg/dL), mean ± SD
Total cholesterol (mg/dL), mean ± SD
History of ischemic stroke, n (%)
History of myocardial infarction, n (%)
Abbreviations: MTM, medication therapy management; RAS, renin-angiotensin system; SD, standard deviation.
a
No significant differences were found between groups.
Table 2. Pharmacist Medication Adherence Interventions.
Interventions
Dose interval too long, n (%)
Adverse event identified, n (%)
Dose too low, n (%)
Therapeutic interchange/alternative
therapy needed, n (%)
Drug interaction identified, n (%)
Dose too high, n (%)
Dose interval too short, n (%)
Drug too expensive, n (%)
Generic substitution, n (%)
At initial MTM
visit (n = 81)
At follow-up
visit (n = 25)
21 (21)
15 (15)
14 (14)
12 (11.9)
8 (25)
4 (12.5)
2 (6.3)
5 (15.6)
8 (8)
6 (6)
2 (2)
2 (2)
1 (1)
4 (12.5)
2 (6.3)
0
0
0
Abbreviation: MTM, medication therapy management.
for an initial MTM visit, which resulted in a total of 81 interventions (0.8:1 ratio of interventions to patient); 64.7% of
patients were female aged 77.8 years on average; 72.5% of
patients were Caucasian; 77.5% of patients were prescribed a
RAS antagonist, 77.5% were prescribed a statin, and 46.1%
were prescribed a diabetic medication. Of note, any individual
patient could have been prescribed one, two, or three of these
drug classes. Dose interval too long (21%), adverse events
identified (15%), and dose too low (14%) were the most frequent interventions identified by the pharmacist (Table 2). All
patients received education by the pharmacist and 94.4%
received a medication reconciliation; 5.6% of patients refused
to receive a complete medication reconciliation due to time
constraints.
Out of the 102 patients, 31.4% had a subsequent follow-up
visit with the pharmacist resulting in 25 interventions (1.3:1
ratio of interventions to patient); 53.1% of patients were female
aged 76.8 years on average; 71.9% of patients were Caucasian;
71.9% patients were prescribed a RAS antagonist, 81.3% a
statin, and 53.1% a diabetic medication (Table 1). At followup, dose interval too long (25%), therapeutic interchange/
alternative therapy needed (15.6%), adverse event and drug
interactions identified (12.5%, respectively) were the most common interventions made by the pharmacist (Table 2). All patients
received education from the pharmacist and 84.4% had a medication reconciliation. Of the 32 patients who had a follow-up
visit with the pharmacist, self-reported adherence declined from
87.5% at the initial visit to 65.6% at the follow-up visit (P =
.077). Table 1 also summarizes mean changes in clinical markers
between initial and follow-up visits. No statistically significant
changes were observed.
Prior to the creation of the MTM clinic, Star Ratings were
consistently 3s out of 5 for the respective measures of medication adherence to RAS antagonists, diabetic medications, and
statins based on quarterly HEDIS reports provided in April,
June, and October 2015 for Medicare HMO beneficiaries.
Post-MTM clinic, Star Ratings increased to 4s or 5s based
on HEDIS reports from December 2015 through April 2017.
Reports were disclosed based an aggregate for all Humana
beneficiaries within the primary care clinic.
Discussion
A pharmacist-led MTM clinic within a primary care office did
increase Star Ratings for the triple-weighted measure of medication adherence to RAS antagonists, diabetic medications,
and statins. As a triple-weighted measure is counted 3 times
more than other measures scored in the Star Ratings, this translated into notable cost savings and reimbursements for the
ACO and affiliated primary care clinic. All patients received
educational counseling from the pharmacist (medications, lifestyle modifications, etc) and the majority of patients were able
Hale et al
to receive medication reconciliation. Of note, the pill burden of
each patient at baseline was not observed. Despite polypharmacy potentially negatively affecting medication adherence,
our findings were still favorable. Also, the current study population was limited to Humana HMO Medicare beneficiaries.
Therefore, generalizability of these findings to other commercial beneficiaries and patients without insurance is limited. It is
suggested that future studies take these variables into
consideration.
Medication reconciliations are of utmost importance when it
comes to patient safety and patient counseling ensures transparency within patient care and is associated with increased
medication adherence. Many interventions were identified by
the pharmacist at initial and follow-up visits with identification
of adverse events and dosing intervals too long among the most
common interventions. This aligns with the current literature,
which demonstrates that involving pharmacists on multidisciplinary teams, further improves economic outcomes due to
their expertise and capability to properly counsel patients on
their medications.14 In one randomized controlled trial, this
was demonstrated when the addition of pharmacist-led group
medical visits in 3 Veterans Affairs hospitals compared to
usual care in patients with diabetes achieved similar improvements in cardiovascular risk factors, but also showed a decrease
in the health care costs at 13 months compared to a rise in cost
for usual care.15 A prospective cohort similar to the current
study demonstrated significantly lower per patient total health
expenditures from US$11 965 to US$8197 when pharmacists
provided MTM services. Furthermore, the reduction in total
annual health expenditures exceeded the cost of providing
MTM services by more than 12 to 1.16 This same return on
investment has been confirmed in other subsequent studies
when comparing the overall health care costs of patients with
diabetes receiving MTM services to those who do not receive
these services.17 However, some patients still reported nonadherence at follow-up. The top reasons reported by patients were
fear of adverse events and misunderstanding of medication
regimen needing reinforcement in education. This was further
demonstrated by the interventions identified at follow-up as
they appeared to be the same as those found at baseline in the
majority of patients. As such the pharmacist provided more indepth educational counseling and review of the medication
regimen at the follow-up visit.
Although our small cohort did not find a significant difference in clinical markers related to BP, lipids and diabetes, the
present body of evidence has revealed that pharmacist-led
MTM can improve patient care, including quality of life, in
these populations.16-24 In one investigation, BlueCross BlueShield beneficiaries receiving face-to-face MTM services provided by pharmacists in collaboration with PCPs experienced
improved clinical outcomes in HEDIS measures for hypertension and hypercholesterolemia. This further elucidated that
clinical outcomes of MTM services have chronic care improvement and value-based purchasing implications.16 In another
report, 23 pharmacists affiliated with a Pioneer ACO conducted
a pharmacist-led MTM program that resolved over 2780
891
medication-related problems and found that a composite of
hemoglobin A1c, low-density lipoprotein, BP, aspirin use, and
abstinence from smoking was significantly improved for
patients receiving MTM services.17 Unlike these reports, it is
important to note that the small portion of patients receiving a
follow-up visit by the pharmacist and the short study duration
may have influenced the nonsignificant clinical results highlighted in this study. Fortunately, the low rate of follow-up was
mainly influenced by resolution of problem(s) identified by the
pharmacist at the initial encounter, and therefore, a follow-up
visit was not mandatory. Another cause was patients canceling
follow-up appointments for unknown reasons. Overall, there is
wide variation in populations and interventions in studies with
MTM services leading to inconsistencies in results from previous studies. However, widespread implementation of MTM
coexists with the urgent need for actionable information for
policy, program policies, and training.25
Also encouraged in the literature and current study is the
promotion of a multidisciplinary approach with pharmacists
involvement on the health care team to optimize chronic disease state management, direct patient care, and reduce physician workload. In patients with hypertension, tighter BP control
has been shown to improve when clinical pharmacists assist
with patient management. In a prospective, cluster randomized,
controlled study, a physician and pharmacist collaborative
intervention achieved significantly better mean BP and overall
BP control rates compared with a control group.26 Similarly in
a randomized, pragmatic clinical trial focusing on MTM in a
combined pharmacist-PCP team approach versus usual PCP
care in a university-based primary care clinic established
cost-effective management of hypertension. In the MTM
group, pharmacists managed drug-therapy initiation and monitoring, medication adjustments, biometric assessments,
laboratory tests, and patient education. The MTM team was
more effective in lowering BP than usual care at 6 months in
all patients and at 9 months in patients who continued to see the
pharmacist.27 In addition to MTM, the current literature has
demonstrated that the pharmacists ability to provide direct
patient care and assist in transitions of care makes this health
care professional ideal to reduce unnecessary physician visits,
adverse drug events, drug expenditures, emergency department
visits, hospital readmissions, reduce length of stay, and optimize patient outcomes. Furthermore, pharmacist interventions
can improve the appropriateness of prescriptions by providing
prescribers with education regarding evidence-based therapies
for various chronic conditions.19
The aggregate number of Humana HMO beneficiaries on
RAS antagonists, diabetic medications, and statins at the
study site slightly varied due reasons such as death, patients
joining/leaving the practice, and/or patients changing medications during the duration of the study period. Of note, none of
the patients involved in the study population died or left the
practice. Some did change medications if deemed necessary
by the aforementioned interventions identified by the health
care team. The most patients during the study period on RAS
antagonists were 379, on diabetic medications were 117, and
892
on statins were 347. Therefore, approximately 21% (79
patients) were taking RAS antagonists, 59% (47 patients)
were taking diabetic medications, and 23% (79 patients) were
taking statins at the initial pharmacist-led MTM visit. However, it is important to keep in mind that not all patients were
referred to the pharmacist as only patients deemed to be nonadherent during the study timeframe were eligible for inclusion in the study. With this said, although the sample size of
this report is low, the percentage of patients seen within the
total number of Humana beneficiaries is substantial, which is
further highlighted by the improvements seen in Star Ratings
post pharmacist intervention.
As a result of demonstrated improvement in Star Ratings
scores and other indirect and direct benefits found at the time of
this study, as well as a means to set itself apart from competitor
groups, a pharmacist-run MTM telephonic call center at Nova
Southeastern University was established in June 2016. This
was part of the Accountable Care Organization Research Network, Service, and Education (ACORN SEED) to accommodate other Humana beneficiaries from any primary care office
of the investigators partner ACO. Presently, as the ACO continues to be a leading Next Generation ACO, the center serves
not only as a call center but also as a practice site for student
pharmacists. Overseen by an on-site clinical pharmacist, students gain insight and confidence by performing comprehensive medication reviews and transitions of care consults via the
telephone, speaking to patients regarding adherence issues,
communicating recommendations and interventions to
physicians, and participating in scholarly activity.28 Most
importantly, this exemplary collaboration between pharmacists, PCPs, and ACOs is a strong model that demonstrates the
valuable potential and opportunities yet to flourish in the present emerging health care environment.
Conclusion
Implementing a pharmacist-led MTM clinic in the primary care
setting improves Star Ratings for medication adherence to RAS
antagonists, diabetic medications, and statins in Humana beneficiaries with chronic conditions. As the medication experts,
pharmacists are a vital component to improve direct patient
care by providing significant economic and clinical impacts
within the primary care setting.
Acknowledgments
The authors would like to acknowledge the reviewers for ensuring the
quality of this review.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Journal of Pharmacy Practice 34(6)
ORCID iDs
Genevieve Hale, PharmD, BCPS, BCCP
https://orcid.org/00000002-2161-1543
Cynthia Moreau, PharmD, BCACP
https://orcid.org/0000-00031182-6388
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