Financial Models for Pharmacist-Provided Care: Opportunities in Health Care Reform Wayne W. Oliver Center for Health Transformation.
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Presentation on theme: "Financial Models for Pharmacist-Provided Care: Opportunities in Health Care Reform Wayne W. Oliver Center for Health Transformation."— Presentation transcript:
Financial Models for Pharmacist-Provided Care: Opportunities in Health Care Reform Wayne W. Oliver firstname.lastname@example.org Center for Health Transformation email@example.com Twitter: @wayne_oliver 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 4.3. 2.1.
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
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 http://www.healthtransformation.net
Center for Health Transformation www.healthtransformation.net Health Reform Report www.healthreformreport.com Health Reform Resources
Wayne W. Oliver, J.D. Wayne W. Oliver, J.D. Vice President, Center for Health Transformation firstname.lastname@example.org Twitter: @wayne_oliver email@example.com Thanks!