Driving Value-based Success Among Pharmacists in Health Systems and Health Plans

In 1977, health care spending as a share of gross domestic product (GDP) was a mere 8.4%, but absolute costs and share of GDP have increased with each passing decade. By 2017, health care spending as a share of GDP more than doubled, reaching 17.9%. Projected estimates for 2027 are 19.4%. During a session at AMCP 2021, presenters Joseph A. Albright, PharmD, Manager, Clinical Pharmacy Programs; and Brenden O’Hara, RPh, BCACP, Clinical Pharmacist, Provider Engagement Initiatives, both of Blue Cross Blue Shield of North Carolina, explained that this trend signals a critical need for change.

Value-based health care models have been introduced by the Centers for Medicare & Medicaid Services over the years, but the presenters contend that a new value-based model has emerged that could potentially “transform health care across the state of North Carolina.” Their Advanced Payment Model (APM), called Blue Premier, offers value-based care, puts primary care first, and ensures integration of mental and behavioral health.

They described their model as a collaborative relationship where both the health plan pharmacist and the health system pharmacist focus together on information to support the work (helping avoid duplication of work in support of each other’s work), and to track progress and report accordingly.

According to the presenters, the APM has three different pharmacist roles: in the health system, the community, and the health plan. In the Blue Premier health system, the pharmacist has direct patient interaction; provides education to providers; and has access to electronic health records for data on adherence, disease state management, and transitions of care. In the community, the pharmacist has interaction with patients on a regular basis, and can identify and reduce barriers to medication access while permitting immunizations so as to improve adherence and disease management. In the health plan, the pharmacist is involved with formulary management, assists in visibility to gaps in quality across health care settings, interprets quality data, does population identification, and identifies medication fills across systems.

During their virtual presentation at AMCP 2021, Dr. Albright and Mr. O’Hara identified data-sharing opportunities to drive success among pharmacists in health systems and health plans in a value-based model, discussed various factors that may drive success for value-based contracts, and detailed a reproduceable model with bidirectional communication that yields improved outcomes in members and decreased cost.

According to the presentation, they believe movement toward the APM is progressing and that the pharmacist’s role in this model is increasing. The pharmacist has an impact on formulary management, collaborative drug therapy management, transitions of care programs, population health efforts, immunizations, comprehensive medication management, and quality support-adherence.

Albright JA, O’Hara B. Expanding Collaboration Between Health-System Pharmacists and Health Plan Pharmacists in a Value-Based Contract. Presentation B4. Presented at AMCP 2021; April 12-16, 2021.