By: Shital Mars, Chief Executive Officer of Progressive CareToday, healthcare providers are increasingly entering into risk-based and full-risk contracts with insurance carriers. Spearheaded by Centers for Medicare and Medicaid Services (CMS), risk-based payment models aim to improve healthcare outcomes and lower costs by instituting an accountable cycle of care through the physician. Unlike fee-for-service, these contracts provide physicians with a flat monthly fee for each member and an incentive bonus structure based on healthcare savings.The motivating concept is this: the less money a physicians’ patients spends on healthcare, the “better” the physician has performed.While this structure presents a notable challenge for physicians who manage high risk patients (such as those with rare diagnoses, advanced stage ailments, and infectious diseases), the trend to establish risk-based and value-based programs is increasing. Commercial plans aim to double the amount of risk and value-based care arrangements this year, and many of these plans intend to extend the model to specialists and acute care providers.1 Hospitals are also rigorously mandated to adhere to risk-based performance metrics with many of them facing monetary penalties for readmissions occurring within 90 days of discharge.Most providers are ill-equipped to manage risk within their practices due to scant time and resources. Physicians are pressured to balance large patient loads, which decreases the amount of time a physician can spend with a patient to go over the healthcare process before a patient leaves the office. With less information and more prescriptions, patients are confused and at high risk of adverse health events due to non-adherence, medication complications, and non-compliance with a treatment or diagnostic plan.Pharmacies are in the best position to manage medication risk; CMS reports that nearly 40% of physician performance scores are based on pharmaceutical services. Pharmacies encounter individual patients more frequently than physicians and are responsible for managing the medication protocols that patients administer at home outside the supervision of a physician. To effectively manage risk, pharmacies must employ pharmacological expertise, proactive patient engagement, data analysis and reporting, and educational outreach to monitor patient healthcare usage.Physicians are required to monitor the following adherence measures: ACEI/ARB Utilization, Diabetes Medication Adherence, Statin Therapy for patients with Cardiovascular Disease, Statin Use in Persons with Diabetes, and Medication Reconciliation Post Discharge. Under risk management insurance models, pharmacies are judged primarily on many of the same categories as doctors. Therefore, when the pharmacy performs well, so does the doctor.Managing adherence risk requires more than just getting medications to the door of the patient. At PharmCo, we seek to navigate the dizzying maze of insurance, drug interactions, and healthcare providers to provide a clear plan for the patient to take their medications as prescribed. We also seek to understand a patient’s financial situation, diagnosis, preferred method of taking medication, and even how they feel about taking said medication. It is vital to respect a patient's humanity and free will when creating and administering a treatment plan.To further streamline the healthcare system and improve performance, PharmCo also works with primary care physicians to provide them with reports and analysis of drug utilizations, cost analysis, formulary compliance, brand-to-generic ratios, high risk medications, statin therapies, medication gaps, refill and prior authorizations, new drug therapies, and best practices. We provide a complete cycle of communication with the patient and their caregiver so that we take away every obstacle to adherence. PharmCo’s services of convenience packaging, language assistance, and at home pharmacy triage were all designed to effectively remove unnecessary medications and provide recommendations on medication support and adherence.Risk management is more than just knowing numbers and statistics. It’s about knowing the patient, and that’s what we do best.1. OPTUM Trend Watch, Risk-based contracting and the future of health care payment and delivery, 2014https://cdn-aem.optum.com/content/dam/optum3/optum/en/resources/trend-watch/optum-trend-report-1st-issue.pdf
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