Integrating Pharmacy Programs

Jim Carlson, PharmDMay 12, 2010

What is Group Health?

•A nonprofit health care system

• Provides medical coverage and care in Washington and North Idaho.

Group Health owned and operated clinics

• 25 Primary care medical centers• 6 Specialty centers

Contracted network care sites

Affordable ExcellenceGreat outcomes and service at a price that lets us grow

Making sure MORE membersget MORE sensibleevidence-based things doneto them:• immunizations• cancer screening• ACE-I, statins, aspirin• optimal BP treatment

Making sure FEWER membersget things done to them thatare dangerous and/or unnecessaryand/or expensive• treatment errors• drugs of marginal value• excessive care at the end of life• unnecessary CT/MRIs• unnecessary procedures

HEDISNCQAPSHA

Patient safetyMedication Use ManagementShared Decision Making

Group Health Pharmacy- Affordable Excellence

26 owned and operated pharmacies

1 Central fill automated pharmacy - Mail order and refills for clinic pickup

>250 contracted pharmacies

Contact center for GHC/GHP/member support

Help Desk, Call Center, New Member Program

Centralized clinical support, drug information, network support and medication safety staff

500 Staff: Staff and Clinical Pharmacists, technicians

Group Health Pharmacy- Affordable Excellence

Pharmaceutical Care via Delivery of drugs and Information6 M Rx’s/year (500K per month)150,000/month via mail order80,000 calls/month from members15,000 Help Desk CallsSupport clinical and quality initiativesProvide drug information—newsletters, alerts, educationCompliance and medication safety programs$280M/year spent on drug expenses (12%GHC budget)Local Clinical RPh for every 20,000 enrollees (Primary Care) and Specialty Clinical RPh for service line and local support (TSC, CSC, ESSC)

Group Health Pharmacy- Affordable Excellence

Pharmaceutical Care via the Health Plan

Pharmacy and Therapeutics Committee and Formulary

New Member Program, Help Desk, Clinical Review (PA, RX Appeals)

PBM Relationship

Drug Benefit Design

Contracted RX Network

Group Health Pharmacy- Affordable Excellence

Support for Health and Public PolicyLegislative Policies: Organizational Content Expertise for Pharmacy Practice

Compliance: FWA activities

Quality and Information System SupportPopulation Management/ HEDIS

Medication and Patient Safety

IS Systems: COOPRx, EPIC, WEB

Drug Use Guidelines, medication order sets, clinical decision support and maintenance.

Group Health Pharmacy- Affordable Excellence

Mission: Provide superior care that makes a difference in our patients lives.

•Safety

•Affordability

•Quality

•Integration

Safety

1) Safety in drug selection/P&T process (“first do no harm”)

2) Safety in dispensing, automation, patient monitoring tools, error tracking systems

LEAF

Listen

Empathize

Apologize

Follow Up

Empathize

Apologize

ListenFollow up

High Risk Medications in the Elderly

Affordability

1) Purchasing/contracting strategy

2) MUM strategy and moving market share – saved $10 million in 2009

Medication Use Management Critical Components

• Clear sponsorship and active support from medical leadership

• Partnership between pharmacy and medical teams at the local level

• Clear, concise goals

• Actionable, timely data at multiple levels- cooperative, clinic, prescriber, and patient-level

• Epic alternative messages facilitating preferred prescribing

• Feedback via multiple venues and using multiple tools

• Standard processes deployed locally

• Standard education and academic detailing of all prescribers

• Concise clinical messaging

Use of Preferred Medications

Medication Use Management in action

Calcium Channel Blocker Marketshare by 30-day Fills(% amlodipine of long-acting dihydropyridines)

Filled 10/1/2007 - 12/31/2008

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

200710 200711 200712 200801 200802 200803 200804 200805 200806 200807 200808 200809 200810 200811 200812

Month

%

Marketshare

Quality

1) Clinical quality through pharmacist focus on medication use and education.

• HOPE trial- initiate ACE inhibitors in high risk patients

•Heart Protection Study- initiate statins in high risk patients

• eBP study- pharmacists improve control of BP better than usual care• Green BB, Cook AJ, Ralston JD, Fishman PA, Catz SL, Carlson JA, Carrell D, Tyll L, Larson EB, Thompson RS. Effectiveness of Home Blood Pressure Monitoring, Web Communication, and Pharmacist Care on Hypertension Control JAMA. 2008;299(24):2857-2867.

2) Service quality through superior service delivery.

Integration

Develop common goals across delivery systems with local implementation

Pharmacy committees in network areas

Partnership with Health Plan at Group Health

•Benefit Design- VBID, Cost shares, tiering

•Benefit adjudication

•Care Management

•Claims

•Member contracts

Medical Home: a Concept in Evolution

“The medical home is a point of access to health care that is organized around the patient’s needs built on a relationship between a patient and a physician. It is a primary health care base capable of providing 90% of health needs capable of providing 90% of health care needs but also coordinating specialty referrals and ancillary services. The Medical Home is a source of first contact care and comprehensive care across a continuum of preventive, acute, and chronic health care needs. It is a place where they get to know you.

(Grumbach & Bodenheimer JAMA 2002;288:889-893.)

Medical Home Design Principles

The relationship between the personal care physician and the patient is the core of all that we do. The entire delivery system and the organization will align to promote& sustain this relationship

The personal care physician will be a leader of the clinical team and be responsible for coordination & integration of services, and together with patients will create collaborative care plans

Continuous healing relationships will be proactive and encompass all aspects of health and illness. Patients will be actively informed and encouraged to participate in all aspects of their care

Access will be centered on patients needs, be available by various modes 24/7 and maximize the use of technology

Our clinical and business systems are aligned to achieve the most efficient, satisfying and effective patient experiences

Medical Home - 24 month Results

Significant improvements in all measures of patient experience.

Significant improvements in variety of composite and patient-centered quality of caremeasures.

Significantly less burnout among care team members, particularly less emotional exhaustion. Significantly greater work satisfaction.

Fewer hospitalizations, consulting nurse calls and emergency/urgent care visits.

Significant shift in primary care delivery to fewer inperson visits and higher e-mail messaging, and more telephone encounters.

Despite significantly higher primary care costs, the Medical Home saved $10.30 PMPM, a 1.5:1 return on investment.Reid, RJ, Coleman, K, Johnson, E et al. The Group Health Medical Home at Year Two: Cost savings, higher patient satisfaction, and less burnout for providers. Health Affairs. 2010: 29;844-851.

Questions?

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