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Retail Pharmacy As The Digital Medical Home

I’m excited to deliver my presentation on the topic about the retail pharmacy as the digital medical home tomorrow at the intersection of three CBI conferences – Point of Care Summit, Retail Strategy Summit, and Strategic Distribution Planning for Specialty Products.  As always, I’m sharing my slides below via SlideShare, and I’ll set up some tweets to give you the cliff note version.

The key here IMHO is that retailers are best positioned to take advantage of this, but the key points are:

  1. Why retail pharmacy?
    • Retail pharmacies have trust from consumers.
    • Easily accessible.
    • Pharmacy is the most used benefit.
  2. What’s the challenge?
    • Successfully engaging the consumer.
    • Integration with the provider so there are process oriented care gaps.
    • Data.
  3. What needs to happen?
    • Focus on the golden moments for engagement.
    • Systemic model for engagement – e.g., Prochaska.
    • Tools and skills to motivate the consumer – e.g., Motivational Interviewing, Incentives.

2013 PBMI Presentation On Pharmacy Need To Shift To Value Focus

Today, I’m giving my presentation at the PBMI conference in Las Vegas.  This year, I choose to focus on the idea of shifting from fee-for-service to value-based contracting.  People talk about this relative to ACOs (Accountable Care Organizations) and PCMHs (Patient Centered Medical Homes) from a provider perspective.  There have been several groups such as the Center For Health Value Innovation and others thinking about this for year, but in general, this is mostly a concept.  That being said, I think it’s time for the industry to grab the bull by the horns and force change.

If the PBM industry doesn’t disintermediate itself (to be extreme) then someone will come in and do it for them but per an older post, this ability to adapt is key for the industry.  While the industry may feel “too big to fail”, I’m not sure I agree.  If you listened the to the Walgreens / Boots investor call last week or saw some of things that captive PBMs and other data companies are trying to do, there are lots of bites at the apple.  That being said, I’m not selling my PBM stocks yet.

So, today I’m giving the attached presentation to facilitate this discussion.  I’ve also pre-scheduled some of my tweets to highlight key points (see summary below).


Planned PBMI Tweets

Diabetes Infographic

Our marketing team at inVentiv Medical Management created this infographic that I thought I would share.

Diabetes infographic inVentiv

Condition Specific ACOs – Perhaps Kidney and Oncology

One of the more interesting discussions out there about ACOs is that around carving out specific conditions. While the general ACO concept is built around the idea of a Medical Home where the PCP is your “guide” (not gatekeeper) and helps you to make decisions, complex patients with certain chronic conditions may be better served to have a specialist managing and coordinating their overall care.

While DaVita with their push for Kidney specific ACOs built around their focus on dialysis has been one key player here, BCBS of FL has actually come out with what they referred to as an Oncology ACO. What CMS will do here is still TBD, but the idea of taking some of these high-cost and complex conditions and putting them into a fixed fee or bundled payment structure tied to outcomes sounds right.

I personally could even see more drug companies and medical device companies playing in this area since they could directly control certain costs and often have incredible amounts of research in certain conditions.

[To see more about our physician directed Accountable Care Solutions at inVentiv Medical Management, click here. Or contact me if you’re interested in how we’re applying these to support ACO and “ACO-like” organizations in their efforts to engage consumers and drive health outcomes.]

P4P, PCMH, ACO…The Concept Is The Same

Healthcare is very good at creating TLAs (Three Letter Acroynms). The Accountable Care Organization (ACO) and the adjacent models are no different.

You have:

These are of course governed by:

And, they were significantly impacted by the SCOTUS (Supreme Court of the United States) decision regarding PPACA (Patient Protection and Affordability Care Act).

But, at the end of the day, the goal here is the same. We need a solution that addresses:

  • Cost, Quality, Care (the Triple Aim)
  • Our existing infrastructure
  • Our unique healthcare environment in the US
  • The challenges of changing patient behavior

We all know that the healthcare system is not sustainable without change. What will happen to health reform with the election is still TBD, but at the end of the day, change is needed. PPACA might not be perfect, but it was better than a lot of options (IMHO). As I said before, I would focus on phased change:

  • Improve access for all Americans
  • Build out connectivity and technology
  • Develop a new payment model
  • Integrate payment with outcomes

The Core Of The ACO – The Provider

While my other post talked about the IT priorities of the ACO, I believe that a large part of the ACO (Accountable Care Organization) effort driven by CMS is about creating a provider-centric approach to care management. While medicine certainly began as a provider to patient relationship, that has changed over the years to a managed care driven relationship. This peaked years ago with the HMO backlash that led to the revised system that most of us have grown accustomed to operating within.

Then, with the discussions around exchanges, Medicare, and the individual market, we’ve seen a shift to a more patient-centric approach to healthcare focused on the patient experience and understanding their behavior. Is anyone necessarily wrong – no. But, there needs to be a balance. I personally think that the ACO approach is trying to build some of that with a Kaiser type of framework. Physicians would be at the heart of the solution with technology, process, and financial support from managed care companies and medical management companies. And, they would have to partner with the patient to really affect behavior and ultimately health outcomes.

Will it work? Who knows. There have been a lot of smart people who have spent a lot of time and energy trying to figure out health outcomes and cost with limited effect in any scalable way.

There have been a few initial articles about ACO success:

There have also been a few people talking about ACO 3.0 and the future of how ACOs will evolve from what we know today.

Of course, most of this is focused on the CMS ACO model while others are using the “ACO” moniker as a framework for pay-for-performance (P4P) within the physician world.

[To see more about our physician directed Accountable Care Solutions at inVentiv Medical Management, click here. Or contact me if you’re interested in how we’re applying these to support ACO and “ACO-like” organizations in their efforts to engage consumers and drive health outcomes.]

Building Accountable Care Solutions

Right now, it’s a little bit of the Wild West in terms of building Accountable Care Solutions (ACS’s)…which is not necessarily bad.

You have physicians building ACOs. You have hospitals building ACOs. You have managed care companies buying physician groups to have ACOs. You have managed care companies providing technology to providers to have ACOs. You have consultants helping design ACOs. You have technology companies building components of ACOs. Eventually, my prediction is that you’ll end up with some type of franchise model on ACOs that providers can leverage. Perhaps it’ll be like the Medicine Shoppe model for pharmacies.

But, as I read through all the literature and try to have opinions on this space, there are a few core things I keep coming back to:

  • Leveraging Evidence-Based Medicine (EBM) guidelines
  • Consumer engagement and behavior change
  • Quality tracking and reporting
  • Technology enablement
    • Patient registries to collectively manage similar patients
    • Gaps-in-care identification
    • Risk modeling
  • Coordination of data and care across PCP, specialists, hospitals, pharmacy, clinics, and labs
  • “Care coordinator” role (probably a blend of human and automation)
  • Sharing value and risk

While traditional providers have been focused on actual diagnosis and care, they haven’t focused on most of this. This is a fundamentally different business (at least at the individual physician level). Even the one that most naturally fits with the practice of medicine – Evidence Based Medicine – is a challenge given the pace of change and information. Plenty of studies have documented this challenge.

So, while everyone is now using this term that our team started using last year, the reality is that ACS’s are complex solutions that take a holistic view of the patient and their care and manage using EBM with an integrated solution that blends technology and face-to-face care with a focus on specific health outcomes.

To borrow from Ernst & Young, here’s a framework they propose on their website about Accountable Care:

[To see more about our physician directed Accountable Care Solutions at inVentiv Medical Management, click here. Or contact me if you’re interested in how we’re applying these to support ACO and “ACO-like” organizations in their efforts to engage consumers and drive health outcomes.]

Five Critical Components Of An ACO

The Advisory Board out of Washington DC has jumped headfirst into the pool around ACOs. They have some great information on their website and like any other consultants, provide some great frameworks to leverage.

One that I found helpful lays out the 5 critical IT components for developing an ACO (see image below):

  1. Network Interconnectivity (Practice Management System and Electronic Medical Record integrations in my words)
  2. Clinical Knowledge Management (Evidence-Based Medicine in my words)
  3. Patient Activation (or Engagement)
  4. Financial Operations
  5. Population Risk Management (or Medical Management or Population Health Management)

I think this is a good starting point for understanding what technology you need to provide an ACO (and theoretically make money doing it).

[To see more about our physician directed Accountable Care Solutions at inVentiv Medical Management, click here. Or contact me if you’re interested in how we’re applying these to support ACO and “ACO-like” organizations in their efforts to engage consumers and drive health outcomes.]

What Is An ACO?

Here’s my paraphrased summary from the HHS (Health and Human Services) website about ACOs and the CMS site

  • Established on October 20, 2011, by CMS under PPACA
  • ACOs create incentives for health care providers to work together to treat an individual patient across care settings – including doctor’s offices, hospitals, and long-term care facilities.
  • The Medicare Shared Savings Program (Shared Savings Program) will reward ACOs that lower their growth in health care costs while meeting performance standards on quality of care and putting patients first.
  • An ACO refers to a group of providers and suppliers of services (e.g., hospitals, physicians, and others involved in patient care) that will work together to coordinate care for the Medicare Fee-For-Service patients they serve.
  • The ACO will be responsible for maintaining a patient-centered focus and developing processes to promote evidence-based medicine, promote patient engagement, internally report on quality and cost, and buy phen375,  and coordinate care.

[To see more about our physician directed Accountable Care Solutions at inVentiv Medical Management, click here. Or contact me if you’re interested in how we’re applying these to support ACO and “ACO-like” organizations in their efforts to engage consumers and drive health outcomes.]

inVentiv Medical Management and Vital Decisions

I’m excited about a new relationship at work with Vital Decisions.  Some of you have heard me talk about Palliative Care before.  The whole area of working with patients that have an advanced illness is a hot discussion topic especially within the CMS community (see yesterday’s WSJ).  But, while many consumers focus and worry about the idea of cost containment at this emotional time, Vital Decisions does a great job of using their behavioral counselors to work with patients to help them articulate their desires to their family and their physicians.  They’re not counseling them on medical decisions or trying to limit care.  They are simply trying to help patients to find a way to talk about this topic with their caregivers.

In some ways, it reminds me of the Engage With Grace movement to try to get families to talk about this with each other.  In this case, the conversation is coordinated with our care manager and part of an overall patient-centric approach to care.

Here’s some of the press release:

inVentiv Medical Management (iMM), an inVentiv Health company and provider of best-in-class medical management services to the healthcare industry, today announced that it has formed a partnership with Vital Decisions to better serve the needs of payers, providers, and seriously ill patients nationwide. The joint offering will support patients by empowering them to be more proactive decision makers when it comes to their health, and, thereby, reduce the use of costly care that is medically inappropriate or unwanted by individuals with advanced illnesses.

Together, iMM and Vital Decisions – an Edison, New Jersey-based company that provides patient-centered behavioral counseling programs for those with advanced illnesses – will offer a unique care management and counseling program to individuals battling metastatic cancer, end-stage heart or lung disease, and progressive neurologic conditions, such as Alzheimer’s or Lou Gehrig’s disease (Amyotrophic Lateral Sclerosis-ALS). The program is designed to encourage patients to work with their physicians and family members to make well-informed care decisions as their illnesses progress. inVentiv Medical Management case managers will provide patients with clinical advice, while Vital Decisions specialists will offer counseling support using the company’s proprietary “Living Well” program, which helps individuals with advanced illnesses communicate their quality-of-life preferences to those involved in their care.

Pediatric Cancer Article in EBN

“In the 1950s and 1960s, 4% of children survived with that diagnosis [leukemia].  In 2010, 80% to 85% of children in all risk categories survived and are cured.”  Dr. Beverly Bell, Medical Director of the oncology program at inVentiv Medical Management

This is a quote from the June 1, 2012 article titled Trial and Error in Employee Benefit News.  It’s an important fact as we watch cancer go from a terminal diagnosis and medical event to a chronic disease.  Working with the survivors is something that Dr. Bell and I have discussed several times.

Here are some other facts from the article:

  • 1/3 of childhood cancers are leukemias.
  • 10,400 kids under 15 in the US were diagnosed with leukemia in 2007.
  • About 1,545 of them will die fro the disease.
  • Approximately 75-80% of pediatric cancer patients are put on a clinical trial.

The article goes on to talk about several things to consider:

  • Plan language modifications.
  • Access to pediatric oncology nurses.
  • Access to a oncology network of centers of excellence.
  • General support for the entire family perhaps through an EAP program.
  • Hospice care.
  • Medical travel / tourism.

Creating a holistic strategy to address oncology is a big effort and one that is critical to helping these patients.

Took A New Job With inVentiv Medical Management

As some of you know, I’ve taken a new job.  I just joined inVentiv Medical Management which is a company focused on reducing care costs and improving health outcomes quality for self-insuring employers, their employees and family members.  One of the exciting new products that they launched before I came is called Accountable Care Solutions.  Here’s a description from the press release:

Powered by a combination of clinical and financial algorithms and evidence-based decision-making rules, inVentiv Medical Management’s Accountable Care Solutions ensure that physician-ordered procedures are the best option from a treatment effectiveness and patient risk perspective. The new suite of solutions includes Comprehensive Oncology Care Management(TM), Comprehensive Cardiovascular Care Management(TM) and Comprehensive Kidney Care Management(TM). These Accountable Care Solutions offer customers – such as third-party administrators, employer groups and reinsurance carriers – best-in-class resources to effectively and efficiently enhance healthcare quality, while reducing overall costs of medical claims and improving patient outcomes.

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