The shift to value-based care is well and truly underway. According to a recent report from Change Healthcare, the number of states and territories that have adopted value-based reimbursement schemes has multiplied seven times over in just the last five years, with 48 regions now supporting accountable care.
These numbers are striking but not, given the appeal of value-based care, unexpected. Outcomes-based reimbursement programs have long been touted as a means for American providers and payers to break free from the problems of our conventional, if problematic, fee-for-service system.
“The general consensus in healthcare is that fee-for-service is one of the primary reasons why the industry is sinking,” one writer for RevCycle Intelligence put the matter in a recent article on the issue. “The financing mechanism encourages providers to protect their bottom lines by delivering more services, which results in unnecessary costs and utilization, as well as a ‘sick care’ system.”
Value-based care, in contrast, benefits everyone — from providers to patients to payers alike. In 2018, researchers for United Healthcare found that employer-sponsored and individual accountable care organizations (e.g., organizations that apply value-based reimbursement) performed better on 87 percent of the top quality measures than non-ACOs. These organizations also saw a 10 percent increase in primary care visits, 17 percent fewer hospital admissions, and a 13 percent drop in patients’ tendency towards ER use. In other words, value-based care helped providers limit unnecessary treatment and provide better-quality treatment, thereby empowering patients to stay healthier and facilitating cost savings across the board.
Given its host of potential benefits, value-based care has been in the healthcare sector’s conversational spotlight for years — however, some specialties have been largely left out of the discussion. While those of us in the field often discuss what needs to be done to bring physicians and specialists into the value-based fold, we rarely talk about pharmacy’s role in the reimbursement revolution.
This lapse is a mistake we need to remedy, because pharmacists can and should play a crucial role — both in supporting patients and in facilitating the United States’ transition to a value-based system.
Unlike traditional fee-for-service care, which takes a piecemeal approach to patient care, value-based care centers on delivering high-quality outcomes. As such, providers are motivated to look beyond individual patients to assess trends on the population level. Today, providers can leverage patient data and machine learning tools to see which treatments are most effective and readily identify areas of waste or over-treatment. For pharmacists, the shift to value-based care could pose an opportunity to look at how current medication management strategies are — or are not — working on the population level.
This is already happening in specialties outside of pharmacy. Take cardiovascular care as an example. In 2019, Aurora Advocate — a health system that maintains a focus on value-based care — launched a study to assess whether the use of predictive analytics could facilitate more effective and timely care interventions for heart failure patients. Their investigation was an unquestionable success, as Aurora was able to cut unnecessary care utilization by a full 23 percent.
The idea that underpins Aurora’s investigation can and should be applied to pharmacy. Under the fee-for-service system, pharmacy faces an inefficiency problem that often contributes to adverse patient outcomes. According to a recent report from StatNews, 42 percent of American adults over the age of 65 took five or more medications in 2012 — a percentage nearly double that reported a decade before. The sharp increase in prescriptions has led to a parallel rise in adverse drug events and poor patient outcomes.
“If nothing is done,” StatNews researchers write, “adverse drug events over the next decade can be expected to cause 4.6 million hospitalizations of older Americans, 74 million outpatient visits, and nearly 150,000 premature deaths.”
There’s an opportunity here for value-based pharmacists to moderate — to use population data and care team insights to identify problematic trends and jettison inefficient or dangerous medication strategies. If pharmacists can do so, they may be able to help providers cut down on unnecessary care and facilitate better patient outcomes overall. At the very least, pharmacists should have a role in minimizing or eliminating the use of contra-indicated drugs and supplements. At the most, they can have a place in supporting prescribing physicians; they can optimize the medication patients receive from both an efficacy and cost perspective by applying AI and being more proactive in providing medication therapy management support.
To borrow a quote for IBM Watson Health’s Senior Deputy Chief Health Officer, Dr. Tina Moen, “Including pharmacists in the optimization of medication therapy guidelines for a population enriches the outcome by capitalizing on training and expertise from across the care team.”
In this light, not bringing pharmacists into the value-based conversation seems to be at best, an oversight — and at worst, a terrible error.