Why are people saying that we don’t know how to contain health care costs? I’d argue that we do know how. What we don’t know is how to get better practices accepted and spread. Behavior change is difficult, even when we can advance quality of care and contain costs.
Let me give you one potent example: Get the pills right. A small experiment that the Jewish Healthcare Foundation, in Pittsburgh, funded over ten years was an eye-opener and started us down a promising path.
The foundation, which I direct, is made up of four different parts. We are a grant-making foundation with our own endowment, but we are also a “think, do, and teach” tank. We have our own regional quality improvement coalition called the Pittsburgh Regional Health Initiative (PRHI) Our mission: spreading high-quality care to contain costs . So, I will describe here how the foundation’s four parts came together to explore the value of clinical pharmacy.
We funded a team of health services researchers more than a decade ago. They proposed to have a pharmacist review the medication mix of every patient on a hospital unit who had been prescribed four or more medications. To our surprise, no patients left the hospital with the original prescription list; in fact, they invariably left with fewer meds, more generics, and a more potent and compatible mix of drugs. We also educated patients about their drugs, aiming for better compliance. The demo suggested that we could save money and make patients happier and healthier, if we included pharmacists as part of the treatment team.
We remembered this experiment when we turned our attention to the management of chronic illness, which currently accounts for more than 75 percent of our nation’s health care costs. We reasoned that a good medication protocol, more patient education about their meds, and better compliance would result in fewer costly hospitalizations, emergency room (ER) visits, and illness exacerbations. In 2009 we took our improvement methodology (Perfecting Patient Care), taught Lean quality improvement (QI) techniques to nine willing “Pharmacy Agents for Change,” and set each of them off on a project of their own to demonstrate the financial and clinical value of good medication management.
We weren’t disappointed—to say the least! We were dazzled at how much room for improvement exists in the management of chronic disease with the intervention of a clinical pharmacist and the accompanying attention and respect of the overall medical team. Each pharmacist had the support of his or her institution. Each attended our four-day Perfecting Patient Care University and received on-site coaching as their research projects progressed. For this initiative, we had the full support of every dean of pharmacy in our region . In fact, we were unaccustomed to how little opposition these behavior changes generated; there was enthusiasm all around.
We focused on improving communications between doctor and pharmacist and between the hospital and the primary care practice; we instituted more patient education and enlisted pharmacists to review and reconcile medications for the best possible result.
Each project yielded excellent results. However, in health care, good practices don’t often spread. One difficulty is getting physicians to enlist and value independent pharmacy assessments, and this is related to another hurdle—getting reimbursement for this service. These challenges exist in spite of the fact that almost everyone involved in our work acknowledged the problems with medication management and integration. For instance, 90 percent of the patients in a comprehensive lung center were discovered to have a suboptimum daily medication regimen, and more than 30 percent of the patients hospitalized with mental illness in many settings are readmitted within sixty days. (This last problem is greatly remedied when patients receive education and when they leave the hospital with their medications instead of just a written script of their meds.)
So, how do we institutionalize best practices like these? One opportunity is the Patient Protection and Affordable Care Act (PPACA), which was signed into law in March 2010. Provisions of the legislation provide some hope that we could move the needle. The key is to make sure that provisions of the law that extend the role of, and achieve reimbursement for, clinical pharmacy are activated.
There are carrots and sticks in the law. New Medicare financial penalties apply to frequent hospital readmissions and recurring medication errors. A new federal grant program supports medication management services, and there are telehealth provisions that incorporate annual medication reviews for Medicare patients with chronic illnesses. The value of clinical pharmacy is acknowledged.
Also encouraging is the Patient Protection Act’s approval of Accountable Care Organization (ACO) demonstrations, in which practices and providers will eventually go “at risk” for managing their high-risk populations and preventing hospitalizations, ER visits, and exacerbations of illness. Bundled payments could support the prevention activities of clinical pharmacy while measuring more broadly the return on investment when comparing the cost of pharmaceutical interventions against hospitalizations averted.
The PPACA also establishes a Medicare-based Community Care Transition Program that emphasizes medication review, including counseling and self-management support. Reimbursement for clinical pharmacy by Medicaid agencies and commercial insurers has been growing over the past few years as well.
So, let’s not accept that we don’t know how to contain costs in health care. Take the case of clinical pharmacy. What we don’t know how to do is to get acceptance for new and better ways to care for patients, to change behavior, to effect spread, and to achieve payment reforms.
“Why Pharmacists Belong in the Medical Home,” Marie Smith, David W. Bates, Thomas Bodenheimer, and Paul D. Cleary, Health Affairs, May 2010 issue.
Read something else by Karen Feinstein:
Feinstein couthored an article in the June 2010 issue of Health Affairs.