Over the past several months, we’ve delved into two separate yet very important aspects of healthcare and pharmacy practice. We have followed the birthing pains of President Obama’s signature legislation some weeks while discussing the importance of medication adherence other weeks. We will now discuss how these two seemingly isolated realms of healthcare are indeed intertwined.
The goal of the Affordable Care Act (ACA) is to improve the well-being of American citizens, rein in costs associated with healthcare in our country, and provide health insurance to those that could otherwise not afford it. As a future pharmacist, I will focus on the goal I perceive to be most important to my chosen profession: improving the well-being of my fellow Americans.
As we’ve discussed in previous posts, medication adherence is paramount in the constant battle to improve patient care. In the past, topics such as technology and techniques to monitor patients were assessed in Mission Impossible: How to tell if your patients are taking their medications; as well as why patients don’t take their medications in Why Don’t You Take Your Medication? in Part I and Part II installments. While it is the responsibility and duty of us as pharmacists to make sure that patients are taking their medications as directed, Uncle Sam has taken matters into his own hands by passing legislation to encourage health care professionals to improve outcomes.
Why has Washington taken such an interest in medication adherence? The reality is that medication non-adherence is estimated to cost $290 billion per year in additional healthcare costs. With almost 13% of the total yearly expenditure in healthcare being spent on preventable diseases and procedures, law makers and healthcare professionals alike see an opportunity to make medicine more affordable to the American patient.
The ACA has multiple provisions aimed at improving patient outcomes. Under the ACA and Medicaid expansion, hospital re-admission for certain conditions will result in penalties to the institution. With the real threat of not being compensated for services provided to re-admitted patients, hospitals across the country are revising procedures and doing their best to increase medication adherence and lower re-admission rates. As pharmacists, we will have a pivotal role in this revision of policy.
Along the same lines as re-admission rates, hospitals will now be subjected to quality assurance measures to hold them accountable. The Pharmacy Quality Alliance (PQA) is a non-profit organization that has developed measures related to medication use; PQA has adopted ten such measures that will cover a range of services, including medication adherence. In addition to such assurance measures, there is something known as Medicare Advantage “Star” ratings that will provide financial incentives to plans in the Medication Advantage (MA) program. In the Star Ratings system, medication adherence is weighted HEAVILY because of its importance (medication adherence accounts for 11% of the total star score). This “Star” rating system has the opportunity to influence the care of over 12 million Medicare beneficiaries.
Three models being experimented with now are patient-centered medical homes, accountable care organizations (ACOs), and episode-based payments. These models are intended to lower health care costs and improve the overall quality of care being distributed to patients. And as is the case with hospitals, they will be evaluated on measures established by the ACA. ACOs for example will be assessed by the same kind of quality assurance measures as previously discussed. And as discussed before, medication adherence is a number one priority in those measures with 20 of the 33 measures relating directly to medication adherence.
When we discussed in previous posts why patients don’t take their medications, cost was a major factor. An important aspect of the ACA is to lower costs that would deter a patient from seeking care or filling a potentially life-saving prescription at a pharmacy counter. A portion of the ACA that doesn’t get much publicity is that it has a provision that impacts Medicare and Medicaid benefits. Under the new healthcare law, the threatening “doughnut hole” has been closed. This effort to close the gap in Medicare coverage is estimated to save beneficiaries $3.4 billion in prescription drug costs which comes out to $837 per person, per year. This is no small amount of money and could indeed encourage people to get that necessary prescription filled. When the decision for a retired individual on a fixed income to choose between their groceries or medicine is no longer necessary, everybody wins.
While this is an exciting time for healthcare, we as pharmacists are entering a brave new world. As I’ve discussed, the ACA calls for many changes in the way healthcare will be administered with an emphasis on medication adherence; and with pharmacists being the medication experts, we will be expected to lead the charge in making many of these changes a reality. This presents our profession of choice with an opportunity to not only create value as health care professionals, but also put our foot in the door and establish ourselves as vital cogs in the 21st century healthcare machine. At this time the ACA does not establish a system by which we as pharmacists will be compensated for our increased duties and responsibilities which is obviously not a desirable situation. But don’t be discouraged. We as pharmacists should take this opportunity to not only elevate the prestige of our profession, but also establish value that will positively impact the way we are compensated in the future. Pharmacists are no longer ‘pill counters.’ We are well respected experts in a vital facet of medicine and it is time we are recognized as such. As Horace so eloquently put it: Carpe diem!
Mackenzie F. Blair, PharmD '15