Editor’s note: This was originally posted at Center for Health Journalism.
Several factors suggest that expanding the practice of clinical pharmacy can significantly improve health care outcomes. First, chronic medical conditions are the major cost driver within the U.S. health care system, and they can often be successfully managed using life-long drug therapy. Second, patients often find basic medical services difficult and costly to access, and the outpatient pharmacist is often the most convenient health care professional for them. Most importantly, pharmacists possess the clinical training to address treatments in collaboration with the patient’s physician.
The USC School of Pharmacy and researchers at the Schaeffer Center for Health Policy and Economics recently studied the extent to which expanding pharmacists’ services in the outpatient setting can improve quality and save money. The study was conducted in cooperation with the Kern Health Systems and Synergy Pharmacy Solutions, both located in Bakersfield, California. Synergy Pharmacy Solutions was paid to oversee the transition from the hospital to home for about 1,100 high-risk Medicaid patients discharged from the hospital April 2013 through March 2015. For the study, published on March 15 in the American Journal of Managed Care, researchers found that the pharmacists’ care-transition program reduced the 30-day readmission rates for the Kern Health Systems by as much as 28 percent. It also reduced patients’ 180-day readmission rates by nearly 32 percent.
The study reinforced how technology can help pharmacists provide those services required to manage life-long, outpatient drug therapies. Historically, outpatient pharmacists have had very limited access to the clinical data required to manage patients. These data access problems can now be solved through access to electronic health record systems. Health insurance companies and government programs have been extremely reluctant to pay the community pharmacy for professional services based on a simple fee-for-service system. Stated bluntly, payers want assurances that the patient required intervention and that the intervention was effective. Again, advances in technology may now make solutions feasible.
In designing any “pay for performance” system, the first thing to establish is what defines “success.” For outpatient drug therapy for chronic medical conditions, success can be defined as either adherence to drug therapy or achievement of treatment goals.
Adherence is easily measured using prescription claims. In a pay for performance system, a patient who successfully refills their prescriptions would result in a bonus for the pharmacist. The “refill” is easily verified though there is a small risk of fraudulent claims being submitted by the pharmacy. The disadvantage would be that there is no verification that the desired clinical impact is being achieved, as might happen during a doctor visit.
Gauging whether a patient is meeting treatment goals can be measured through laboratory tests or clinical assessments, both of which can be measured now in the pharmacy. For that to work, the pharmacy must have the capability to accurately assess and report a patient’s clinical outcomes. That is, the pharmacy needs to be capable of measuring A1c, fasting LDL/HDL, or measuring blood pressure using a system that reports outcomes electronically to the payer (and physician).
Other clinical assessments may be beyond the capabilities of the pharmacist, such knowing when an asthma patient ends up in the ER or urgent care. In that case, the health insurer will have this data and the pharmacist would be paid a stipend for every month the patient does not access costly ER or inpatient services. That gives pharmacists an incentive to keep patients they’re working with out of the hospital, thereby lowering costly admissions.