Medication Management & Patient-Centered Care Coordination Across the Continuum: A Thought Leadership Roundtable

Introduction

Medication management plays a vital role in value-based care, affecting both quality and cost. Patients who receive and take evidence-based medications as prescribed by their physicians are more likely to have good outcomes and are less likely to experience avoidable hospital readmissions and other costly interventions. By improving health outcomes and lowering costs, providers demonstrate value to payers who under some payment systems will then financially reward them. Conversely, providers with poor outcomes and high costs may face penalties such as reductions in reimbursement.

With payment models continuing to shift from volume to value, many hospitals and healthcare systems are exploring ways to use digital tools to inform strategies and practices that optimize medication management. DrFirst recently hosted a thought leadership roundtable featuring six members of the College of Healthcare Information Management Executives (CHIME) to discuss best practices and challenges implementing medication management in healthcare organizations and across the care community. CHIME President and CEO Russell Branzell moderated the roundtable and DrFirst President Cam Deemer contributed to the discussion.

The CHIME members were:

• George Hickman, Executive Vice President & Systems Chief Information and Chief Analytics Officer at Albany Medical Health System
• Joan Hicks, CIO at the University of Alabama at Birmingham Health System
• Sheree McFarland, CIO for the West Florida Division of HCA Healthcare
• Jeremy Meller, CIO at Children’s Healthcare of Atlanta
• Daniel Nigrin, MD, CIO at MaineHealth
• Rick Schooler, CIO at Lee Health

Transitions in Payment Models

In the not-so-distant past, hospitals and healthcare systems were largely reimbursed based on the amount of healthcare services provided with little accounting for the quality of care, clinical outcomes or cost. This fee-for-service or volume-based care model helped drive up costs, with healthcare expenditures accounting for almost 18% of the Gross Domestic Product in the U.S. in 2019. Medicare, the nation’s largest payer, through the Centers for Medicare and Medicaid Services (CMS) has been trying to tamp down costs with alternative, value-based care models. Distilled to their core metrics, these models define value as quality (or outcomes that matter to a patient) divided by costs. Value increases when the numerator rises and the denominator drops, or one or the other occurs.

Fee-for-service is still dominant in the U.S., with respondents in CHIME’s 2020 Digital Health Most Wired survey reporting that 71% of their organizations’ reimbursement was volume-based. Nonetheless, most hospitals and healthcare systems are preparing for a transition that links reimbursement to value. CMS has already built the framework using incentives and penalties under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). More recently, the agency began revising its meaningful use program to include measures for clinical outcomes and patient satisfaction, while its innovation arm is developing and testing new payment models that promote high-quality, cost-effective care.

Integral to that shift is medication management, a tool that has been shown to meet or exceed measures for quality and patient satisfaction, improve outcomes and lower costs. Payers and providers alike recognize that effective medication management enhances value, but implementing and maintaining it is challenging.

“At a very high level, it (medication management) is an extremely important aspect of the care that we provide,” said Daniel Nigrin, MD, a physician who specializes in pediatric endocrinology and CIO at MaineHealth. “And it’s complex. On the surface you could argue, ‘oh, well doctor prescribes medication, patient takes medication, end of story.’ But I think we all know that it’s not quite that simple and therein lies the problem.”

“I totally agree with that,” concurred Sheree McFarland, CIO for HCA’s West Florida Division. “It’s multidisciplinary; it’s very complex; and despite the advances we’ve made in technology, there’s still a lot of failure points.”

Medication management typically requires many steps that involve many people over the lifetime of a patient. The system is only as good as the data being entered, which makes accuracy of the medication list a critical component. The responsibility crosses disciplines, with primary care physicians, specialists, pharmacists, nurses and other clinicians contributing with varying degrees of thoroughness. Medication reconciliation, medication adherence, affordability, patient engagement, workflow issues and ownership – especially as the patient transitions from one care setting to another – are tipping points that can affect quality, cost, outcomes and patient satisfaction.

Defining Ownership

Certain roles and disciplines may be best positioned to take on the responsibility of medication management and reconciliation. As a physician, Nigrin said he would be comfortable ordering and adjusting a patient’s medications within the boundaries of pediatric endocrinology but not for other co-morbidities. “That’s when you need a pharmacy-level person who’s really going to have that confidence to cross the whole domain,” he said. Pharmacists have the knowledge and expertise – but they may not have the bandwidth. “It becomes a person-power issue; we just don’t have enough people to do that.”

The CIOs cited transplantation, which often requires patients to take immunosuppressive drugs throughout their lifetime to prevent organ rejection, as a good discipline-based model for medication management. These programs may assign nurse coordinators to closely monitor their patients’ use of medications. Missing even one day of treatment with anti-rejection drugs can imperil a kidney transplant patient’s health, for instance.

“Those nurse coordinators are responsible for their patient’s medication list,” noted Joan Hicks, CIO at the University of Alabama at Birmingham Health System, referring to the health system’s transplant program. The nurse coordinators play an active role in educating patients and following up to ensure they follow their medication regimen. “If only we could spread that model and take everybody’s medication management as seriously as is done in certain populations.”

Identifying the Challenges

The cost of drugs can be a significant deterrent to medication adherence, McFarland pointed out. “How many of us have been in CVS or Walgreens and a person goes up to get their script and the first question they ask is, ‘How much is it going to cost?’ And then they say, ‘I can’t afford it,’ and they leave,” she said.

And when patients skip or reduce their prescribed medications, both the patient and the healthcare system pay a price. The U.S. Department of Health and Human Services estimated that annually 375 kidney transplant patients experience organ failure when they stop immunosuppressive treatment, which historically has been covered by Medicare for 36 months. When that happens, the patient must depend on dialysis, with Medicare covering most services and supplies. After a cost analysis showed that Medicare could save more than $400 million over 10 years by offering lifetime medication coverage after a kidney transplant, Congress passed the Comprehensive Immunosuppressive Drug Coverage for Kidney Transplant Act, which will go into effect in 2023.

Lack of ease and access can present barriers as well. Electronic prescribing solutions can be frustrating for patients, clinicians and clinician office staff since they often don’t conform with simple workflows and what should be a simple patient experience, noted George Hickman, executive vice president and systems chief information and chief analytics officer at Albany Medical Health System. Transferring a script for patients who show up at the right retailer but wrong store, or who decide they prefer a different store from what they initially requested but that pharmacy can’t pull down their medications, can be an onerous process for everyone involved.

“Workflow has been a real big challenge affecting the patient’s and physician office experience and could be improved by the respective vendors and pharmacy integrators agreeing to make some changes,” Hickman said. 

DrFirst President Cam Deemer said that the earliest iterations of these systems addressed the needs and preferences of pharmacy benefit managers, which has shaped the e-prescribing workflows that followed. “The e-prescribing was driven by the payer community, not the physician community, and everything that’s come since then is a result of that,” he offered.

Medication management across care settings creates another set of challenges. Patients may live part of the year in one place and part in another, or they may travel from home to see a specialist and then return to their community setting. “They are going back to their home community halfway across the state or another state,” said Jeremy Meller, CIO at Children’s Healthcare of Atlanta. “How do you help with that transition of care? You have to make sure the parents really understand because it can be kind of complex.”

Looking Ahead  

Forward-looking health systems are evaluating how they can engage patients in lifelong care through education and support systems, crossing what “has been traditionally just in a service line and following the patients for the whole journey, the whole life of the patient,” McFarland said. Medication management is part of the formula, with numerous models showing the clinical and financial advantage when medications are optimized.

Although medication management’s complexity poses challenges, those challenges can be overcome if healthcare organizations are motivated, the thought leaders agreed. The shift toward value-based care is providing that motivation, especially as reimbursement is increasingly tied to outcomes and cost. Possible approaches include assigning a clinician who “owns” the patient, as transplantation does, in other care settings; addressing concerns such as the cost that dissuades patients from getting medications or taking them as prescribed; and helping patients who move from one setting to another remain adherent through education and support systems. When their medication is properly managed, quality goes up, cost goes down and value increases – which translates to a higher reimbursement for the health system and greater safety for patients.

Conclusion

The march to value-based care is slowly gaining speed, and most healthcare organizations are preparing for a future that closely ties reimbursement to quality and costs. Properly managing a patient’s medication will be key for achieving high-quality, affordable care but the process is complex. Over a patient’s lifetime, medication management likely will involve numerous physicians, nurses and other clinicians across many disciplines working in multiple clinical settings and physical locations. Patients and their caregivers also will be partners in this journey. Despite its complexity and challenges, the clinical benefits combined with financial stakes will motivate healthcare organizations to find solutions that help monitor, assess and proactively intervene.    

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