By Gregory A. Hood, MD, MACP; and Lori Dickerson, PharmD, FCCP
Medication management learning-based training helped Quality Independent Physicians (QIP), an accountable care organization (ACO) composed of primary care practices throughout Kentucky and Indiana, decrease hospitalizations across all disease states by 26%. QIP saw a similar drop in admissions for high-risk disease states and a significant reduction in hospital readmissions. The organization’s medication management learning program proved effective in boosting these and other important Centers for Medicare and Medicaid Services (CMS) quality scores, while helping successfully manage key, at-risk patient populations.
With today’s emphasis on healthcare quality, efficiency, and cost-effectiveness, we’re always looking for ways to improve. We needed a focused effort to leverage medications to their maximal benefits, while avoiding difficult and potentially devastating mistakes. Well-researched and timely medication recommendations, a commitment to creating and communicating standardized clinical practice guidelines, and an inclusive atmosphere that encouraged organization-wide clinician buy-in were essential to the program’s results.
QIP comprises 50 physicians, as well as 20 nurse practitioners and physician assistants, who treat more than 12,000 Medicare patients annually, in addition to private insurance patients. In 2013, QIP devoted significant time and resources to a carefully structured enterprise-wide medication management training program. The ACO conducted an in-depth seven-month intervention to assess the effort’s effectiveness based on key medication-related CMS quality measures, the same criteria the government uses to judge QIP’s performance.
The study compared quality metrics from 2009 through 2013, prior to implementation, to metrics from January 2014 to March 2015, while the ACO was involved in the program.
Medication management is critical to quality of care
According to the Institute of Medicine (2006), medication errors kill or injure an estimated 1.5 million people in the U.S. annually. Medication mistakes rank among the most common type of medical error (Academy of Managed Care Pharmacy, 2010). Data from the National Quality Forum suggests that medication errors directly or indirectly cost the U.S. healthcare system more than $21 billion each year (National Priorities Partnership, 2010). Suboptimal medication use and lack of care coordination also takes a significant toll.
QIP leadership believed that collaborative guidelines and an integrated learning program would significantly boost patient care and quality metrics. The learning program needed to incorporate current medication management recommendations and deliver them at the point of care.
Clinical and financial goals
The program’s goals included keeping clinicians up to date on best practices for prescribing medications, utilizing medication resources more effectively and efficiently, standardizing medication management across all offices, educating patients about appropriate medication regimens, and changing prescriber behavior to elevate CMS quality measures.
Keeping an eye on quality measures was important because QIP is an ACO participating in the CMS Medicare Shared Savings Program (MSSP). As such, its Medicare reimbursements are determined by CMS quality scores and related ratings. Optimal medication management in office-based encounters is key because it promotes safer, more effective management of health conditions. Supporting transitions of care and best practices throughout the care continuum and at home is also crucial. Accordingly, we placed strong emphasis on information sharing across prescribers as well as on patient education.
Initially we targeted high-risk, high-cost conditions and those influencing specific CMS quality measures required for ACO reporting, particularly 30-day hospital readmissions. This enabled us to maximize the benefits for difficult-to-manage patient populations as well as ACO reimbursements. The conditions we studied included COPD, heart failure, bacterial pneumonia, hypertension, anticoagulation, diabetes, and acute coronary syndrome. Many are CMS cost-reduction priorities, with improved metrics driving higher reimbursements.
Structure, standards, and superior educational tools
Central to the program’s success were carefully vetted and standardized guidelines for medication management, which were implemented across all QIP offices and throughout the continuum of care.
To that end, QIP established an Evidence Based Medicine Committee to review and revise existing clinical guidelines as needed on an ongoing basis. It partnered with the Prescriber’s Letter medication learning service to provide an objective and timely knowledge-based framework for developing these processes and procedures.
Complementing this, Prescriber’s Letter provided robust clinician and patient educational content, which was delivered in print and online across the entire organization. Prescriber’s Letter also provided a customized educational resource package for each disease state, including newsletter articles on optimal medication use, coverage of disease-specific quality measures, drug comparison charts, online searchable medication management recommendations, and patient education handouts. Detailed documents on particular topics were also available to those who wanted to drill down for more information.
All new and existing content was also accessible through a customized website with links to additional material on the Prescriber’s Letter site. Consistent, actionable information helped align behavior across prescribers. That, in turn, streamlined transitions of care, enhanced patient satisfaction, and supported cost savings and efficiency.
Inclusion encourages clinician buy-in
QIP adopted a team approach to encourage clinician buy-in organization-wide and developed many opportunities for stakeholder involvement, including group meetings that promoted debate and discussion. Throughout the program, staff gathered monthly for organization-wide meetings to review educational material and modify medication guidelines as needed. Any agreed-upon changes were then distributed to all prescribers.
In addition, the education component fit within existing workflow, which helped drive adoption. A concise, unbiased, evidence-based presentation of information made the most of prescribers’ time and built credibility. It also encouraged acceptance of any necessary changes in standards of care. Feedback on the material was extremely positive, with prescribers generally looking forward to receiving new material.
Patient education in multiple settings
Serving as patient liaisons, practice care coordinators were included in the training process and regarded as valuable team members. They met with patients in the office for educational sessions and followed up with them at home on a regular basis to field questions and help ensure medication adherence. Distribution of patient-specific handouts helped high-risk populations understand their illnesses, recognize significant changes in their condition, and know when to seek medical help, avoiding unnecessary office and emergency room visits. In short, targeted patient populations were closely and cost-effectively managed in a full range of settings. QIP pharmacists were also very helpful in stewarding patient medication programs to work within the limitations of Medicare insurance coverage.
Enhanced outcomes and income
By the study’s conclusion, care quality was up and expenditures were down. Most physicians were open to changing medication-related procedures when necessary. The program achieved significant improvements on all ACO MSSP utilization reports required by CMS as the basis for Medicare payments. In addition to decreasing hospitalizations across all disease states, the program also realized a drop in discharges for high-risk conditions and 30-day hospital readmissions. As a result, hospitalizations across all disease states decreased by 13% per 1,000 person-years. Thirty-day readmission rates dropped from almost 170 per 1,000 person-years to just under 160. These improvements have already resulted in overall cost savings and higher reimbursements. Based on the average patient readmission cost of approximately $13,000, savings could reach as high as $130,000 per 1,000 patients.
Because ACOs are ranked and reimbursed relative to one another, we believe the program gives QIP a clear advantage over its peers. As a result of the study, QIP will expand its focus across all high-risk disease states and continue with the educational program to stay on top of developments in both drug therapy and CMS regulations.
Gregory Hood is medical director of Quality Independent Physicians.
Lori Dickerson is associate editor of Prescriber’s Letter.
Academy of Managed Care Pharmacy. (2010, June). Concepts in Managed Care Pharmacy: Medication Errors. Alexandria, VA: Author. Retrieved from http://www.amcp.org/WorkArea/DownloadAsset.aspx?id=9300
Institute of Medicine. (2006, July). Preventing Medication Errors. Quality Chasm Series [Program Brief]. Washington, DC: Author. Retrieved from http://iom.nationalacademies.org/~/media/Files/Report%20Files/2006/Preventing-Medication-Errors-Quality-Chasm-Series/medicationerrorsnew.pdf
National Priorities Partnership. (2010, December). Preventing Medication Errors: A $21 Billion Opportunity. A Roadmap for Increasing Value in Health Care [Compact Action Brief]. Washington, DC: Author. Retrieved from https://psnet.ahrq.gov/resources/resource/20529/preventing-medication-errors-a-$21-billion-opportunity