Integrating Pharmacists into Accountable Care Organizations (ACOs) and Coordinated Care

A recent study found that including community pharmacists on medical teams targeting chronic disease is a “viable solution to improve U.S. health care,” but presently there’s no clear path for pharmacists to participate in such teams, known as Accountable Care Organizations (ACOs), that are set forth in the health care reform law.

The journal Medical Care recently published a review finding that “including pharmacists on patient-care teams improves key health outcomes—including lower blood pressure, lower cholesterol, and better control of diabetes.”

According to a summary of the article, pharmacist involvement was “largely favorable” and “clinically meaningful.” In addition to improved vital signs for patients battling diabetes, high cholesterol or high blood pressure, pharmacists were also associated with a nearly 50 percent decrease in adverse drug reactions, fewer medication errors, improved patient compliance with drug regimens, and higher overall quality of life scores.

The study was led by Marie Chisholm-Burns, Pharm.D., M.P.H., of The University of Arizona College of Pharmacy, Tucson. She concluded that “incorporating pharmacists as health care team members in direct patient care is a viable solution to improve U.S. health care” and called for “the increased utilization of pharmacists as members of the health care team and as direct patient care providers.”

The work of Dr. Chisolm-Burns and her colleagues provides additional evidence of the critical, cost-saving role community pharmacists can play in the health care system. Efforts like the Asheville Project in North Carolina and Smith Drug Company in South Carolina have produced similar health benefits and reduced costs.

The health reform law establishes a new category of health care structure—the accountable care organization (ACO) within the Medicare program, with rules for provider participation and principles for sharing in the savings generated by this coordinated method of health care delivery.  It also specifically references the critical role that pharmacists can play in ACOs as well as in similar entities such as “medical homes”, “transition of care” teams, and “medication reconciliation activities.”

Dr. Don Berwick, administrator of the Centers for Medicare & Medicaid Services, participated in a national conference on transitions of care, attended by NCPA, on December 3rd. Dr. Berwick said pharmacists have an important role on the health care team in keeping patients safe, and he indicated support for including pharmacists in transition of care teams.

These are all welcome signs that involving pharmacists in coordinated care is gaining greater acceptance in health care policy and government circles. But more work remains.

In 1996, the Federal Trade Commission and the U.S. Department of Justice jointly issued the Statements of Antitrust Enforcement Policy in Healthcare to provide guidance to health care providers and related entities about the agencies’ enforcement policies in this area and to provide examples of types of collaboration among these providers or entities that the agencies would not challenge as violative of antitrust laws. However, that guidance was restricted to physicians and hospitals and does not mention pharmacists.

The U.S. House Judiciary Subcommittee on Courts and Competition Policy held a hearing recently to examine whether or not existing rules are adequate for today’s needs and in light of the health care law’s provisions. According to Bloomberg, a Justice Department official pledged to expedite its review of proposed ACOs and offer guidance.

As Congress, DOJ and FTC examine this issue, to empower community pharmacists to better serve patients and help lower health care costs, NCPA argues that:

  • First, the FTC guidelines should be updated to include a “safe harbor” provision that would allow pharmacies to collaborate in order to participate in ACOs and other collaborative care models.
  • Second, the FTC should provide additional guidance to those allied health care providers, such as pharmacists, that are likely to be included in these entities. This is particularly important in the case of independent pharmacies that do not have the already-existing infrastructure of regional and large chains to contract with an ACO or medical home to offer services and negotiate terms of participation.
  • Third, NCPA recommends that the FTC revise the Statements of Antitrust Enforcement Policy in Healthcare to expressly permit independent pharmacies to collaborate with one another in order to be able to participate in ACOs and other collaborative care models.

3 Responses to “Integrating Pharmacists into Accountable Care Organizations (ACOs) and Coordinated Care”

  1. 1 John Cronin December 7, 2010 at 11:21 pm

    There have been at least a few proposals for pharmacies to collaborate that have been approved under the 1996 Statements of Antitrust Enforcement Policy in Healthcare by the DOJ or FTC via the Advisory Opinion process. Although these occurred in the late 1990’s there has been only limited use of the opinions because of a reluctance on the part of pharmacy owners to aggressively pursue these options. NCPA needs, however, to make a clear distinction between what is appropriate for “pharmacies” as opposed to “pharmacists.” I don’t think there is any significant barrier in the 1996 Statements of Antitrust Enforcement Policy in Healthcare to pharmacists joining together in group practice or similar models to contract for professional services much like physicians have done for years. The antitrust treatment of pharmacies who compete with each other in drug product distribution is treated substantially different.

    • 2 Jim Fields RPh February 2, 2011 at 4:18 pm

      I suggest that Pharmacy needs to put forward business models to work with Physicians collaboratively; forming ACOs inside IPAs and VPOs now. Not waiting for 100% clarity on anti-trust regulations.
      There is in place inside the ACO legislation provisions to give federal agencies the authority to keep antitrust laws, anti-kickback laws, and similar laws from interfering with ACO operations.
      There is also available the development of a presumptive approval standard, a less rigorous review than what might be needed under a “rule of reason” test.
      Regardless of the above antitrust outcomes, for pharmacy to wait again on the sidelines for political guidance while other health care business models and health care professional move forward is suicidal for independent pharmacist.
      We independents do have the ability to form an infrastructure similar, but larger, than regional and national chains and we can do it quickly, we independents do have access to existing business models to meet CMS/Medicaid guidelines to service and be an ACO.
      We must take the leap and create and support these business models, NOW.
      Jim Fields RPh
      CFO ApproRx

  2. 3 John Cronin February 2, 2011 at 5:14 pm

    I agree with your comments, but note with some disappointment that although independents may have the “ability” to form an infrastructure similar to the national chains, they have consistently failed to show a “willingness” to do so. The first obstacle independents need to address is this reluctance to give up some “independence” in order to be relevant and competitive in the evolving health care marketplace.

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