We all know healthcare is changing, and the driver for much of this change is the government. MACRA (Medicare Access and CHIP Reauthorization Act of 2015), the latest sweeping healthcare reform law from Congress, is being massaged by CMS, and while most believe it is the physician at the tip of the MACRA spear, it will have a profound impact on pharmacists, too.
MACRA will fundamentally change how providers are paid. It’s about time. Fee-for-service, the “do more, get more” reward system that has sent us into an economic tailspin in healthcare may finally become a thing of the past. Under value-based payment, the foundation of the reward system will be quality. This change in philosophy, from volume to value, and the change in economics, requires a shift in the existing relationships among stakeholders.
Payers, both government and private, will demand more value from clinicians. While MACRA may not directly impact pharmacies today, the future of value-based payment envisioned by Congress and crafted by CMS certainly will. Pharmacists and pharmacies that begin to adopt fundamental elements of the new value economy, those who position themselves as an essential part of the care team, will succeed. Those who don’t are likely to lose out.
MACRA received bi-partisan support. There’s no turning back. This time, it is play or pay. Adapt or face extinction.
It’s show time. Medication adherence and medication management are essential for driving health outcomes. Now they will be driving payment. The trend in payers and drug manufacturers adopting value-based payment has begun in earnest.
In May, The Wall Street Journal reported that Cigna announced that it was the first insurer to reach value-based contracts for a new class of cholesterol-lowering drugs. If Cigna’s members who are taking the new and more costly drugs don’t achieve results (lowering LDL cholesterol) consistent with outcomes reached in clinical trials, the manufacturers must further discount the price of the drugs. If outcomes meet or exceed expectations, the original negotiated price remains. Other such arrangements have been struck for cancer and hepatitis C drugs. In arrangements such as these, the pharmacists’ contribution to patient management is vital to the patient outcome and the financial outcome.
Complex therapies and medications focusing on chronic conditions require intense patient management strategies. Physicians are care team leaders under MACRA. If physicians benefit financially by partnering with top-performing pharmacists who help them improve quality, they will seek them out. Pharmacists and pharmacies who can demonstrate their ability to manage medication and thus demonstrate their value will be recruited by accountable care organizations, clinically integrated networks and patient-centered medical homes. These pharmacists will no longer play supporting roles. They will be vital leads.
It’s scary. New value-based payment models and supporting arrangements will create uncertainty. Stakeholders will form new relationships. Each could be different. In any payer and provider scenario, though, URAC strongly believes in these basic tenets:
- All healthcare is local, it will be solutions that work locally that are most effective
- The team approach is vital to delivering high quality
- The patient is at the center of the team, their voice must be heard
- Physicians will lead teams
- Each provider, including pharmacists, will be responsible for coordinating patient care
- Demonstrating improvement through performance measurement is critical
This new environment should motivate pharmacists. Demonstrate value. Be a pivotal part of the care team.
We believe the best way to transition to value-based payment is to encourage physician practices, pharmacists and others to improve their processes and create sustainable transformation, and collect and share data that measures performance. That will include medication management and medication reconciliation and demonstrating medication adherence. To demonstrate, one must measure and report performance.
URAC believes that a standard for performance measurement is based on select, agreed-upon goals (outcomes) and that performance must be measured over time. With MACRA, it is not simply about belief. Proof is required, and money will be riding on the proof.
This approach to collaboration and measurement not only prepares providers and pharmacists for success in the future healthcare economy, it improves the care patients receive. In this new world, providers and pharmacists must be able to demonstrate an ability to collaborate, and measure, analyze, and report performance data in order to improve patient outcomes.
Collaboration will result in development of patient centered medical homes, clinically integrated networks and accountable care organizations where none exist today. URAC believes these entities must demonstrate their value through data reporting, validation of the quality of their process and continuous improvement through accreditation. It’s clear MACRA agrees.
MACRA will move the nation’s healthcare industry forward. Value over volume. It not only makes economic sense, it’s also the right thing to do.