A Tech-Enabled Value-Based Program to Reduce Total Cost of Care

Healthcare costs have been rising for the past several decades.¹

One of the primary drivers of rising costs is the increasing prevalence of chronic disease and associated morbidity. Management of modifiable risk factors such as blood pressure, HbA1c, lipids, and more has been shown to reduce chronic disease complications and total cost of care.

Value-based care models have grown in prevalence and popularity in the last twenty years. Medicare has adopted value-based care programs around medical practices, health systems, and ACOs. Largely, pharmacists have been excluded from these models, generally due to existing an environment separate from the physician and contracting through the pharmacy benefit instead of the medical benefit. Through the Medicare Modernization Act, the Part D benefit was created and ultimately produced the requirement for plans to offer Medication Therapy Management (MTM) programs to promote optimization of members' drug regimens. As a product of developments in the CMS STAR Measure Program, pharmacists were charged with performing comprehensive medication reviews (CMRs) and medication adherence interventions.

The profession and expertise of modern pharmacy has existed for over a century. For the better part of that history, pharmacies have been a tenant of many urban and rural communities as a destination for healthcare expertise and supplies. Similar to many other product-driven industries, reimbursement in pharmacy was created around the infrastructure of the drug product. Still today, the majority of pharmacy revenue is generated from insurance or patient reimbursement for medication supply. Although the burden of chronic diseases managed through optimal treatment oversight and monitoring continues to rise, reimbursement policies have prevented any significant change in pharmacy practice and have failed to incentivize value-based activity to curb rising healthcare costs. This needs to change if payers intend to leverage all types of accessible providers to address gaps in care for their beneficiaries.

In 2015, a Midwest Part D sponsor needed to find a technology and service partner in order to meet the goals of a CMS Innovation Center (CMMI) program model. CMMI had established program model specifications to assess whether providing Part D sponsors with additional payment incentives and MTM regulatory flexibilities better achieve desired outcomes of MTM.²

Effective implementation of a scaled pharmacy-based clinical program requires a robust technology infrastructure for member attribution, risk stratification, encounter reporting, performance measurement, and payment automation. The Midwest Part D sponsor was challenged to implement this complex model in a standardized manner across a highly variable pharmacy network.

The forward-thinking Midwest Part D sponsor chose DocStation as their partner to streamline the EMTM model requirements. DocStation met the technological needs while enrolling the pharmacies who would drive clinical interventions and patient care. DocStation was chosen to minimize the administrative burden of execution and implementation so that network participants were highly engaged and focused on achieving outcomes.

DocStation addressed this need by applying functionality to automatically assign patient panels, identify care opportunities, capture & report interventions, and disburse monthly service payments.

DocStation worked closely with the sponsor to specify member targeting criteria to close gaps in care in the following areas:

• immunization compliance
• medication reconciliation
• hemoglobin A1c control
• blood pressure control
• medication non-adherence
• transitions of care
• high-risk opioid use

DocStation configured member targeting algorithms that identified gaps in care specific to each target population. For example, members whose calculated morphine milligram equivalent (MME) exceeded 90 were flagged for opioid use and safe disposal intervention. DocStation then worked with the Part D sponsor to customize interventions which standardized outreach and streamlined encounter reporting. Effectively, when a gap was identified, pharmacists were prompted with a suggested encounter template which discretely captured SNOMED CT codes relating to patient findings and interventions.

The plan sponsor emphasized the priority of a flexible value-based payment model to incentivize desired pharmacist provider activity. The resulting model included baseline and bonus payments for achieving certain goals across the population. Additionally, DocStation specified and configured the Pharmacy Quality Alliance's (PQA's) performance measure for blood pressure control which freshly calculated the quality measure numerator and denominator each week. This enabled automatic calculation of monthly payments and bonuses for a network of 300 pharmacy locations.

In this Enhanced MTM model, DocStation facilitated interventions for nearly 30,000 Medicare patients receiving care at 300 pharmacies across 7 states. The preliminary results reported across all given program participants found $2.21 PMPM reduction in gross health care expenditures across 1.9M covered lives.³ Additionally, the program achieved a cumulative reduction in hospital readmissions and SNF admissions of 6.19% and 0.88%, respectively, over the course of the model.⁴

On average, pharmacists completed 70% of the care opportunities that were identified by DocStation. In terms of revenue cycle, the average time to payment each month was 7 days, significantly shortening the feedback loop between intervention and payment compared to traditional industry reimbursement mechanisms.

1. CMS National Health Expenditure Data

2. CMS Innovation Center MTM Announcement

3. Part D Enhanced Medication Therapy Management (EMTM) Model. Center for Medicare and Medicaid Innovation, Aug. 2021.

4. MTM Fifth Evaluation Report - Appendix B