Pharmacy News

Rachel Kollmeyer, Pharm.D., clinical care coordinator, SpartanNash/Medical Advantage Group, Flint

As the United States healthcare system evolves to value-based reimbursement, pharmacists will be utilized in new and different ways to help improve patient outcomes. With new payment models comes a lot of new terminology and acronyms. For pharmacists unfamiliar with outpatient practice, it may seem like ambulatory care pharmacists speak a different language. Let’s try to break down some of the more common terms as they relate to outpatient, value-based reimbursement.

Fee-for-Services (FFS) refers to the method of healthcare billing where a provider is reimbursed for each service performed.¹ This is seen as the traditional method for reimbursement and payment is not tied to any quality or outcome measures. Current healthcare trends are moving away from FFS to value-based reimbursement.

Value-based reimbursement (VBR) refers to payment models that reward providers for providing high-quality care with improved patient outcomes and decreased healthcare costs.² This can also be referred to as pay-for-performance, provider incentive programs or alternative payment models. Currently value-based reimbursement is typically additional revenue for healthcare providers above their FFS billing.

When it comes to value-based reimbursement programs, there are many variations based on different payers and contracts. Some of the more common programs are accountable care organizations (ACOs) and patient-centered medical homes (PCMH).

Accountable care organizations were developed by the Centers for Medicare and Medicaid Services (CMS) to encourage coordinated, high-quality care for Medicare patients.³ ACOs may be comprised of physicians, hospitals and other healthcare providers.³ If an ACO is able to deliver high-quality care and decrease healthcare costs for its patients, providers will receive part of that savings from Medicare. This is called shared savings.

A patient-centered medical home is not a physical location, but a delivery model that focuses on coordinated patient care.² Care is typically coordinated through a primary care physician and is intended to decrease healthcare cost by preventing redundant services across multiple providers.

Value-based contracts have different methods to deliver payments to providers. As mentioned previously, ACOs function as a shared savings program that provides payment to providers if cost savings is achieved. These contracts may have one-or two-sided risk. One-sided risk means a contract only has upside or downside risk. Two-sided risk contracts contain both upside and downside risk for the provider. In upside risk contracts, providers receive payments when metrics are met, but are not penalized for not meeting metrics. Conversely, downside risk refers to contracts that require participants to pay if metrics are not met. Taking on additional risk typically means bigger rewards if shared savings is achieved.

Other value-based reimbursement may come as lump sum incentive payments or as uplift payments. Uplift refers to an increase in the amount of payment beyond what would have normally been paid and is typically a percentage.⁴

Even though some of the terminology may be different in ambulatory care, pharmacists across all areas of practice are actively working to improve quality of care and patient outcomes. By understanding value-based reimbursement, ambulatory care pharmacists can find ways to be indirectly reimbursed for the services they provide.

References:

1. Glossary [Internet]. Baltimore (MD): U.S Centers for Medicare and Medicaid Services; [cited 2019 Oct. 3]. Available from: https://www.healthcare.gov/glossary/.
2. What is value-based healthcare? [Internet]. NEJM Catalyst. 2017 Jan. 1 [cited 2019 Oct. 3]. Available from: https://catalyst.nejm.org/what-is-value-based-healthcare/.
3. Accountable care organizations (ACOs) [Internet]. Baltimore (MD): Centers for Medicare and Medicaid Services; 2019 Oct. 2 [cited 2019 Oct. 3]. Available from: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO/.
4. The payment reform glossary [Internet]. Pittsburgh (PA): Center for Healthcare Quality & Payment Reform; [cited 2019 Oct. 3]. Available from: http://www.chqpr.org/downloads/PaymentReformGlossary.pdf.

Kari Vavra Janes, Pharm.D., BCPS, Associate Professor Ferris State University College of Pharmacy, Big Rapids

As you’ve been reading the past several months, the theme for this year is “achieving patient care outcomes.” Dr. Clark in his January article said his stretch goal for all of us this year is to show how to measure and report our effect on patients’ outcomes. As he noted, pharmacy hasn’t historically been the best at this. Pharmacists are making a difference – we just need to step it up when it comes to measuring and reporting the difference we are making.

In trying to pick a topic for my article this month, I came across an article on the American Medical Association’s (AMA) website from 2018 titled “Add a pharmacist to the team to see better outcomes.”1 How fitting with the theme for this year! The article supports adding a pharmacist to improve patient outcomes and recognizes pharmacists as key partners in patient care.¹ The article goes on to describe the impact pharmacy has had at Providence Medical Group in Oregon. Pharmacists there assist with medication therapy management, including virtual consults, follow-up visits, medication starts/titrations/tapers, and much more.1 Although the article doesn’t discuss specific patient care outcomes or present metrics, it’s awesome to hear our healthcare colleagues support our contributions to the team!

Additionally, this article goes on further to link pharmacists to their AMA STEPS Forward module.2 The free online module assists with figuring out what pharmacy needs exist and identifying the best type of support.2 It’s a quick read and it’s great to see that there is a focus on measuring pharmacist impact. To provide a little more information about the module, the learning objectives from the module include the following: ²

1. Explain what it means to embed a pharmacist within a practice.
2. Describe the different roles a pharmacist can play within a practice.
3. Identify skills and qualities a pharmacist should have in order to provide benefit to the practice.
4. List ways to measure the impact of embedding a pharmacist within the practice.

As the year is winding down, continue to think about the theme “achieving patient care outcomes.” We all have a role to play and now is the time to show how we are making a positive impact. Making our impact known benefits everyone – the patients we care for, the healthcare providers we work side-by-side with and the greater pharmacy community.

References:

1. Berg S. American Medical Association. Add a pharmacist to the team to see better outcomes. https://www.ama-assn.org/practice-management/payment-delivery-models/add-pharmacist-team-see-better-outcomes. Accessed Aug. 29, 2019.
2. Choe HM, Standiford CJ, Brown MT. American Medical Association. Embedding Pharmacists Into the Practice; Collaborate with pharmacists to improve patient outcomes. https://edhub.ama-assn.org/steps-forward/module/2702554. Accessed Aug. 29, 2019.

Name: Jason Williamson, Pharm.D.
Employment: Clinical Pharmacy Manager / PGY1 Residency Program Director at Ascension Genesys Hospital, Grand Blanc, MI
Member since: June 2011

Describe Your Role/Day In the Life:
I lead an outstanding team of pharmacists and help advocate for the advancement of pharmacy practice to improve patient care. Much of my day-to-day work includes coordinating clinical initiatives (currently focusing most greatly on implementing emergency department pharmacist practice); oversight of student, resident and preceptor practice; and helping my team members navigate change and any difficulties in their practice. I also have roles on a number of different committees and workgroups at the hospital, including our drug shortage workgroup, P&T committee and COPD transitions of care workgroup.

Why You’re an MSHP/MPA Member:
I’m an MSHP / MPA member because of the value being involved with these organizations have provided to my career. There are many opportunities to contribute and to influence our profession, whether this looks like presenting a continuing education presentation, serving on a committee or engaging at a legislative advocacy event. Additionally, I am able to reconnect with many different professional contacts and create new connections with each MSHP / MPA event I attend.

Recent Accomplishments:
In 2018, the PGY1 residency program at Ascension Genesys Hospital received full accreditation for eight years from ASHP and I also accepted an offer to serve as a guest surveyor of PGY1 residency programs for ASHP. So far, I’ve surveyed two programs and have learned a lot from each experience. Also in 2018, I was selected as the institutional / health system IPPE preceptor of the year by Ferris State University (FSU).

How MSHP/MPA Has Helped You Achieve Any Accomplishments (if applicable):
MSHP has connected me with outstanding resources to be successful in my practice as a pharmacist and as a leader. One thing that has positively impacted my career was completing the Michigan Pharmacy Foundation’s Healthcare Professional Leadership Academy (MPF HPLA), and this provided me with the right foundation to engage with leadership roles and opportunities. In addition, MPA offers preceptor development programming and opportunities to help refine my skills as a preceptor, student experiential coordinator and residency program director.

Andrea Winkel, Pharm.D.; Tawnie McGraw, Pharm.D.; Anna Boik, Pharm.D.; Juan Reyes III, Pharm.D., PGY1 Residents at Mercy Health Muskegon

Due to emerging evidence since the 2014 guidelines, a focused update for the management of patients with atrial fibrillation (AF) was released by the American College of Cardiology (ACC), the American Heart Association (AHA), and the Heart Rhythm Society (HRS) in July 2019. This focused update removed the ambiguity associated with the 2014 guidelines and has provided a more objective approach to determining a patient’s need for anticoagulation. Key components of the update include the incorporation of recently approved medications such as edoxaban and andexanet alfa, precise treatment recommendations utilizing CHA₂DS₂-VASc scores based on sex, and non-pharmacological interventions. This revision maintains consistency with the use and definition of "anticoagulant" versus "antithrombotic" throughout the document.

The focused update now defines antithrombotic as the "combination of an anticoagulant and an antiplatelet." Many sections were revised to use the term "anticoagulant" when "antithrombotic" had previously been stated. This removes the possibility for multiple interpretations.

Some of the biggest changes in recommendations occurred in the Risk-based Anticoagulant Therapy section. The update removed the distinction between valvular and non-valvular atrial fibrillation and instead gives precise recommendations based on sex and CHA₂DS₂-VASc score for all patients with atrial fibrillation excluding two groups: those with moderate-to-severe mitral stenosis or mechanical heart valve. Previously, the 2014 guidelines recommended anticoagulants if the CHA₂DS₂-VASc score was > 2 for men and women. The 2019 update now recommends the use of anticoagulants as summarized in Table 1.


 

The list of recommended anticoagulants has also been updated to include edoxaban, which was approved after the 2014 guidelines were published. The list of anticoagulants now includes warfarin and novel oral anticoagulants (NOACs) including dabigatran, rivaroxaban, apixaban and edoxaban. A class I (strong) recommendation has also been made to use NOACs over warfarin in patients with atrial fibrillation (excluding patients with moderate-to-severe mitral stenosis and mechanical heart valve).

Along with this new recommendation came an additional class I (strong) recommendation for the assessment of both renal and hepatic function before initiating a NOAC and at least annually while on NOAC therapy. Edoxaban has been included throughout the updated guidelines to reflect its current data outcomes. Edoxaban was not recommended in patients with end-stage renal disease (ESRD) or who are on dialysis, but the update recommends that it may be used if the creatinine clearance is between 15 to 50 mL/min. However, it is not currently approved for use in patients with a creatinine clearance < 30 mL/min or > 95 mL/min. Before the update, warfarin was the only recommended anticoagulant for patients with ESRD or who are on dialysis. Now, apixaban has been added as a recommendation in this population when the CHA₂DS₂-VASc score is > 2 in men or > 3 in women.

Other new recommendations highlight the benefits of weight loss and modification of risk factors in patients with atrial fibrillation to decrease symptoms, severity and frequency of atrial fibrillation episodes. More subtle changes were made throughout the update as well, including the omission of a goal INR range for patients with mechanical heart valves on warfarin. While warfarin is still the recommended anticoagulant for patients with mechanical heart valves, there is some limited evidence for lower INR goals with certain mechanical valves. NOACs were added to previous recommendations that had only included warfarin, such as surrounding cardioversion and in patients with concomitant acute coronary syndrome, atrial fibrillation and a CHA₂DS₂-VASc score > 2. Idarucizumab is now included as a class I (strong) recommendation for the reversal of dabigatran for urgent procedures or life threatening bleeding and andexanet alfa was given a class IIa (moderate) recommendation for the reversal of rivaroxaban and apixaban in the case of life-threatening bleeding.

Overall, the biggest change is the use of CHA₂DS₂-VASc scores along with sex to recommend anticoagulation for patients with atrial fibrillation. Also, studies that proved NOACs to be non-inferior or superior to warfarin were included to support the growing use of NOACs for use in preventing stroke and systemic embolism in patients with atrial fibrillation. In conclusion, the focused 2019 update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation helps to clarify previous evidence found and incorporated new data for future practice.

References:

1. January C, Wann S, Calkins H et al. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation. J Am Coll Cardiol. 2019 July 9;74(1):104-132. Available from: http://www.onlinejacc.org/content/early/2019/01/21/j.jacc.2019.01.011?_ga=2.184713199.751774949.1563839778-458285286.1529684827
2. January C, Wann L, Alpert J, Calkins H, Cigarroa J, Cleveland J, et al. Circulation. 2014 Dec. 2;130(23):e199-267. Available from: https://www.ahajournals.org/doi/pdf/10.1161/CIR.0000000000000041

Christopher Bond, 2020 Pharm.D. candidate, University of Michigan College of Pharmacy, Ann Arbor

As I began my P4 year, with the end of pharmacy school finally in sight, I thought back to the previous years of sleepless nights, grueling exams and awkward patient encounters. These memories entered my mind as I gathered with my class for orientation. We gathered into a tight room where we had spent many days in intense discussion or sometimes interminable boredom. Many in my class reminisced with disbelief that what seemed like yesterday, enrolled as P1s, full of naivety and curiosity regarding what our future in pharmacy would be. Now, we were arriving at the end of that journey with maturity and eagerness to enter the world to finally fulfill a dream we worked so hard to create for ourselves. However, this journey seemed like a lifetime.

The shrill shriek of each early morning alarm still pulses through my head as I face each day of recurring tasks and looming project deadlines. I knew this final year of pharmacy school would be challenging and exhausting. I have never been one to ignore my mental health, I constantly strive to improve my well-being. Over the past few years, I had heard of the growing prevalence of burnout among health professionals and I worried that I could become another victim.

The World Health Organization defines burnout as “a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed.”¹ They characterize it by three dimensions: “feelings of energy depletion or exhaustion; increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job; and reduced professional efficacy.” These days, it is hard to find a piece about the pharmacy school experience that does not mention burnout. A quick internet search will lead you to dozens of lengthy scholarly articles, blog posts and news stories examining the harmful effects of constant stress on a person and workplace productivity in a plethora of jobs. The profession of pharmacy is no exception. It leaves its practitioners at risk for burnout with high-pressure environments, demanding expectations, inadequate staffing or abuse from patients. Raising awareness of burnout is difficult work in itself, but the real challenge lies in innovating new ideas for prevention and treatment.

In recent years, the University of Michigan (UM) College of Pharmacy has prioritized students’ mental health. A psychologist was hired to meet the needs of pharmacy students. Last year, I was honored to serve as the student body president, where I won with a platform of refocusing our efforts toward reducing student stress and anxiety. A student mental health committee was formed to match a similar existing committee composed of faculty and staff. The committees collaborated to institute stress relief events, promote mindfulness activities through student organizations and to begin a summer reading program in which students learned to develop resilience and maintain an open mindset.

I encourage readers to discover what resources are available to you to help with the burden of burnout. Explore a few of the numerous techniques that can help ameliorate or prevent burnout. Perhaps the technique that might work best for you is to find a quiet place to work, to focus on long-term goals or to add more artistic outlets to what free time you may have. You could exercise regularly, find ways to take more control over your life or try one of the many popular stress management techniques.

It takes a conscious effort to develop the resiliency required to make it unscathed through the gauntlet of pharmacy school, residency and beyond. The important thing is to know your limits and to know when to seek help. Lastly, we should use our passion for public service to help others in our field. We often focus on caring for patients more than each other. Everyone should consider what actions there are able to take or roles to fill that can improve the long journey of pharmacy school and the career beyond. Together, we can be a remedy for burnout to better patient care, the profession and ourselves.

References:

1. World Health Organization. (2019). Burn-out an "occupational phenomenon": International Classification of Diseases. [online] Available at: https://www.who.int/mental_health/evidence/burn-out/en/ [Accessed 7 Oct. 2019].