Data prove the point: Pharmacists provide value at Tripler in Hawaii

Innovations

Pharmacists deliver value every day in the care that they provide. To make a business case for the value of pharmacists’ patient care services, it’s important to know what data drive decision making. 


An emerging trend in health care is that some patient-centered medical homes (PCMHs) are including pharmacists. At Tripler Army Medical Center in Hawaii, a 1-year pilot showed that the value of PCMH clinical pharmacists can be quantified in both cost and quality terms. Based on the study’s results, the U.S. Army is funding the program’s expansion to the remaining Army medical treatment facilities, with a goal of one clinical pharmacist per 6,500 enrolled beneficiaries.


The results included a return on investment (ROI) calculation based on estimated costs avoided that were linked to previous research from the U.S. Department of Veterans Affairs (VA) showing improvements in health outcomes and cost. “We quantified the number of interventions and the costs avoided to yield an estimate of what costs would have been had we not done these interventions,” said LTC Mark S. Maneval, BSPharm, PhD, Assistant Chief, Operations, of Tripler’s Department of Pharmacy. “When you do the math, you divide $5.1 million in costs avoided by $1.4 million in salary expenses [including benefits]. That yields a return on investment of approximately 3.6[:1].” 


The 3.6:1 ROI included only the medication therapy interventions by clinical pharmacists that could be categorized as allergy or adverse drug reaction, therapeutic duplication, drug–drug interaction and contraindication, drug–disease interaction and contraindication, drug not indicated (inappropriate therapy), modify medication dose and/or schedule, and initiate new medication. The analysis was restricted to those specific interventions to be conservative for stakeholders, Maneval said. 


But the 10 clinical pharmacist FTEs in the PCMH pilot did many other things, such as formulary conversion, he continued. When a few of those things were included in additional analysis, the ROI went up to approximately 5:1. 


“Quantifying the value of what clinical pharmacists do is directly dependent upon the quality of those clinical pharmacists,” said Maneval. “Our clinical pharmacists are stellar performers. They care about patients, they care about outcomes, and they care about what direction the pharmacy profession is going. They are a model for why pharmacists should be given provider status.”


Paradise for pharmacists



Donna Kido, PharmD, BCOP, and COL Cheryl Riby, BSPharm, MSA, review positive clinical outcomes generated by clinical pharmacists in patient-centered medical home clinics at Tripler Army Medical Center.

A strikingly pink local landmark nestled in the lush green hills of Honolulu, Tripler was built in 1948 on the island of Oahu in tropical Hawaii, which became the nation’s 50th state in 1959. The largest U.S. federal treatment facility in the Pacific Basin, Tripler is a 250-bed tertiary care academic medical center that serves 435,000 eligible beneficiaries.


Although the Army adopted the PCMH model many years ago, embedding clinical pharmacists into medical homes has been a newer goal, according to COL Cheryl L. Filby, BSPharm, MSA, Chief of the Department of Pharmacy at Tripler and Pharmacy Consultant for the Pacific Regional Medical Command. 


One of the principles of the medical home model is to tailor the resources available to the patient’s needs, Maneval explained. Tripler is treating a population that includes soldiers. For a soldier on flight status, a clinical pharmacist can make sure the soldier isn’t taking medications that could interfere with that flight status or with performance as a flight crew. A soldier in the warrior transition unit who has suffered injury from combat or training may be on multiple medications. A pharmacist can review the complex medication regimen, ensure no overlapping adverse effects or additive sedation, and work with other providers in the clinic to tailor that soldier’s regimen to avoid bad outcomes and optimize good outcomes.


Tripler’s clinical pharmacists participate fully in the PCMH model, including morning huddles and collaborative interdisciplinary team meetings, and are considered and included as clinic staff, according to Maneval. Patients are referred to pharmacists by other providers, and pharmacists may see patients several times between follow-up appointments with their primary care provider “to make sure they’re headed in the right direction and meeting their goals,” said Donna Kido, PharmD, BCOP, Chief, Clinical Pharmacy Services, at Tripler.


“The pharmacists who are performing the interventions are really stepping out in front and acting as autonomous providers. We have that luxury to do so in a federal setting,” said Brian White, PharmD, Assistant Chief of Tripler’s Department of Pharmacy. All pharmacists at Tripler hold clinical privileges, including being authorized to order laboratory tests and write for and modify prescriptions. “They’re blending some of the more historical roles of pharmacists with some of the newer, cutting-edge roles of pharmacists,” White said.


Understanding value



L to R: Susan Fujii, PharmD, and CPT Gregory Hare, PharmD, discuss changes necessary to optimize medication therapy for a patient in the Internal Medicine Clinic at Tripler.

From dispensing medications to working with patients and prescribers to improve medication access and use, “pharmacists are doing things every day that provide value,” said APhA Trustee Brad Tice, PharmD, MBA, FAPhA, Product Leader for Medication Therapy Management at Cardinal Health, a health care services company. “What we’re moving towards is a system where [pharmacists] don’t simply receive a ‘thank you’ from a patient and say, ‘You’re welcome,’ and move on to the next patient. We’re moving towards a system where pharmacists are able to quantify and be recognized for that value, and compensated for that value.”


Pharmacists should understand how performance and value are being measured to make sure they’re positioned to perform towards what health plans and payers understand as value today, Tice said. “A lot of the efforts of community pharmacists are centered on star ratings. In these instances, payers are looking for pharmacists to improve adherence.” CMS assigns Medicare Advantage and Part D prescription drug plans an overall star rating of one to five based on the plans’ performance on industry-standard quality measures. Five stars is the highest rating, and people tend to pick the higher-rated plan. Medicare Advantage plans that score well on star ratings get quality bonus payments, but Part D plans don’t. 


CMS’s star ratings program is a first step forward in outcomes measurement in a pharmacy—one that will likely evolve and become more sophisticated over time, Tice added. A criticism of the quality measures used for star ratings is that they’re not true outcomes measures but rather are process-based measures. “We’re not measuring prevention of a heart attack, or we’re not measuring prevention of a disease,” he explained. “We’re measuring if someone is being adherent to a medication or measuring that they’re on a medication that would prevent progression,” which are leading indicators, he said.


Pharmacists also should understand how the people they’re serving—whether that’s a health system, health plan, physician, or accountable care organization, and including the patient—find value in pharmacists’ services. “One of the interesting aspects of ROI,” Tice said, “is oftentimes it depends on whom you’re sitting across the table from and what they buy into.”


For some health systems, preventing 30-day readmissions is something that they can easily buy into. “You can measure that in 30-day increments. You can have a faster return on investment because you have a shorter timeframe to measure it,” he explained. “Versus when you are trying to prevent a heart attack, then what you run into are health plans who [may say], ‘Well, how do you know that person was going to have a heart attack?’”


So pharmacists may want to discuss with decision makers what is valuable and how it will be measured up front, according to Tice. Then pharmacists can measure that which is considered valuable and provide results in a meaningful way.


Health plan perspective



Members of the physician staff, including Sean Harap, MD, Staff INternist in the Internal Medicine Clinic, are outspoken advocates for the expanded role of clinical pharmacists.

One great example of a health plan that has agreed internally on how to measure ROI, Tice said, is Ohio-based CareSource, a large Medicaid managed care plan. As reported in May 2014’s Pharmacy Today starting on page 50, CareSource launched a medication therapy management (MTM) program with OutcomesMTM and the Ohio Pharmacists Association in July 2012 that 1 year later had demonstrated a 1.35:1 ROI in drug cost savings alone, and a 4.40:1 ROI in total savings, including avoided hospitalizations, emergency department visits, and other unnecessary health care consumption.


Jim Gartner, BSPharm, MBA, Care­Source Vice President of Pharmacy and Medical Management, designed and implemented the program—an MTM benefit for all of CareSource’s beneficiaries for which pharmacists are reimbursed. In an interview for this article, Gartner recalled, “When we first launched this program, I was challenged by my folks in our C-suite: ‘Well, pharmacists are doing this already.’ And my answer was they’re not doing it to the extent we want them to,” and that the current reimbursement is not enough to cover these types of services. “So we really need to pay the additional fees,” he continued, “to make sure that there is a touch point with our members.”


Someone needs to pay for these services, Gartner explained. A pharmacist trying to offer these services to a member having to pay for them would be hard pressed to get people to sign up and do that, he said. “I think a lot of this reimbursement is really going to be driven by health plans. I’ll always advocate for health plans to start doing this whether it be in the Medicaid space [or in the] commercial space. The great news is Medicare does require it. I think down the road, there will be some federal guidelines across all kinds of government-funded business. We’re not there yet, but I can see it happening.” Gartner added, “Quite honestly, our program, as big as it is, has people looking at it.”


Making a business case



LTC Mark S. Manerval, BSPharm, PhD, attributes the success of the pilot to Tripler's innovative clinical pharmacists.

Many well-written research articles talk about the pharmacist’s role and value, but the “shortcoming of those articles is they aren’t able to really convert that value into a sustainable business model. That’s been the bugaboo. Payment is what triggered provider status efforts and other changes down the road,” said former APhA President Bob Davis, PharmD, FAPhA, Professor and Chair at the Kennedy Pharmacy Innovation Center and Clinical Professor at the South Carolina College of Pharmacy of the University of South Carolina. The Kennedy Center is testing different types of payment models toward figuring out a sustainable business model for pharmacists in a PCMH.


Pharmacists should understand how to approach decision makers, including assessing their needs, developing a business proposal, and then delivering the right message to persuade them, according to Davis.


For physicians out in the community, the value of pharmacists’ services is measured by a combination of four or five things, he said. What are the revenue sources? What clinical outcomes occur—in the context of the pressure on primary care to produce outcomes and be paid based on those outcomes? Is physician productivity improved? What about measures of patient satisfaction for star ratings?


Pharmacists also should understand the vision of leadership of their key audiences, according to Davis. Does the leadership take a collaborative, team-based approach? Are they very heavily revenue driven? Are they being driven by quality or by satisfaction? What type of disease mix do they have? Where are their financial shortcomings? Are physicians productive? 


“You can’t go straight into the sales mode,” he added. “You really understand their needs and craft solutions based on what’s going on to speak well to them, what they’re after, and how they measure success.”


At APhA2015 in San Diego, Davis spoke in an education session on making the business case for integrating pharmacists into team-based care. In one case, pharmacists provided comprehensive medication management services within a PCMH at Palmetto Primary Care Physicians in Charleston, SC, from November 2013 to October 2014. Against new expenses of $140,000, the annualized value of pharmacists’ services—adding up revenue based on fee for service and pay for performance ($98,000), physician productivity ($220,000), cost avoidance and quality ($1,756,000), and customer satisfaction (“priceless”)—led to an ROI calculated at 15:1.


Tice said that the evolution of pharmacy practice is still in the early stages. But it’s “really happening,” he added. And the idea is to “get pharmacists recognized for the value they create that otherwise goes unnoticed.”


Value for the patient

At Tripler, the pharmacy department sought to develop a method, focused on patient-centered outcomes, of designing how clinical pharmacists would be utilized in a PCMH environment to improve outcomes. They collected data in a standardized format on the specific things pharmacists do when they see a patient and linked the program to previous research from the VA. And they designed a tool in the electronic medical record for pharmacists to document the care that they provide; while the tool was developed specifically for the pilot, the intent was for it to be standardized and used by pharmacists across the entire U.S. Department of Defense. 


This tool is one of what Maneval called “a triad of tools” for use and scaled-up implementation in the future. A second tool is for patient risk identification. The third tool is for simulation modeling that uses population-based methods to value, and provide value for, pharmacists’ services.


The value of clinical pharmacists in Army medical homes may be described best in terms of outcomes desired by the soldier and beneficiary, said COL John Spain, PharmD, MA, BCPS, the Army Pharmacy Consultant and Program Manager for the Army Surgeon General. “I don’t want to be admitted for a medication-related event. I don’t want to take unnecessary medications. I don’t want to have a repeat experience of a medication-related allergy, adverse reaction, or to take a previously ineffective medication,” he explained. “I want the best possible quality of life.”