Download this article from Academic Pharmacy Now: Fall 2012: A Lite-r Approach
This edition of Academic Pharmacy Now includes reminders that the intent of the managed care insurance approach of the 1990s is reflected in the health system reform initiatives of today: improve quality and reduce cost. Today’s initiatives can be referred to as “managed care lite.” The difference this time is that our approach to reform is focused on enhancing the delivery of care, while also improving health and keeping people healthy. Provisions in the Affordable Care Act (PL 111-148) authorize the creation of shared savings programs. This allows the Centers for Medicare and Medicaid Services, acting through the Center for Medicare and Medicaid Innovation, to establish programs for the development and implementation of accountable care organizations (ACO) and their partners, patient-centered medical homes (PCMH).
In the traditional context of paying for services rendered, insurance companies are no longer the primary driver for managing care—or denying care as some asserted—by controlling payment for service delivery. The new managed care lite approach places greater responsibility on the patient and their team of providers to improve care coordination, utilize evidence-based care approaches, and share health information through technology. Controlling costs is important, but the benefits of a team approach to care are impactful. They include reductions in preventable hospital readmissions, unnecessary and duplicate tests and treatments, and increased patient adherence to care plans. These benefits are realized through a delivery system that supports patient adherence to—and provider delivery of—evidence-based guidelines, recommendations and performance measures and standards. Payment frameworks are established in turn.
Reorganized payment and delivery structures include the new managed care lite groups: ACOs and PCMHs. Payment to these entities is dependent on their performance against quality measures. Listen to a podcast with Dr. Charles Saunders, president for strategic diversification at Aetna, to gain a better understanding of the difference between managed care 1.0, 2.0 or even 3.0, and what he refers to as “enlightened managed care.”
So where do these quality measures come from and what is the evidence-base for their creation? The Healthcare Effectiveness Data and Information Set (HEDIS), developed through the National Committee for Quality Assurance (NCQA), provide much of the quality framework that ACOs, medical homes and many payers, including Medicare and Medicaid, use to establish payment structures. These structures are important because they must facilitate payment for the entire team as well as determine additional or decreased payments based on quality measure performance. Included in the HEDIS measures are concepts developed by the Pharmacy Quality Alliance, of which many pharmacy faculty are active members. Through their participation in the alliance, faculty have opportunities to influence HEDIS and other performance measures, once again demonstrating that academic pharmacy serves as an important resource in shaping healthcare policy.
William G. Lang is Vice President of Policy and Advocacy at AACP; firstname.lastname@example.org.
Initiatives of the Centers for Medicare and Medicaid Services http://innovation.cms.gov/initiatives/index.html
Accountable Care Organization (ACO) Watch BlogTalkRadio http://www.blogtalkradio.com/acowatch/2012/09/18/this-week-in-accountable-care-with-charles-saunders-md
National Committee for Quality Assurance http://www.ncqa.org/HomePage.aspx
Healthcare Effectiveness Data and Information Set (HEDIS) http://www.ncqa.org/HEDISQualityMeasurement.aspx
National Committee for Quality Assurance 2013 ACO HEDIS Measures http://www.ncqa.org/Portals/0/HEDISQM/HEDIS2013/ACO_Core_Measure_List_9.6.12.pdf
Pharmacy Quality Alliance http://www.pqaalliance.org