Evaluating Adherence in Accountable Care Organizations

COMMENTARY
July 12, 2017
Executive Vice President, Chief Medical Officer, CVS Health

As health care evolves toward a more value-based care model, Accountable Care Organizations (ACOs) have been growing rapidly. ACOs are groups of health care providers that together, agree to be responsible for the cost and quality of the care they deliver to a specific patient population. The growth in ACOs has been especially pronounced since the passage of the Affordable Care Act (ACA) in 2010. In 2016, more than 28 million people were estimated to be covered by ACOs.

But does simply putting patients in an ACO help improve outcomes or demonstrate gains in key areas such as medication adherence? A study by the CVS Health Research Institute published in the Journal of the American Medical Association (JAMA) Cardiology found that there were no meaningful increases in use of, or adherence to, medications that improve outcomes for patients with diabetes or cardiovascular disease. There is no question that ACOs provide a valuable service in improving patient care. However, the findings of this study indicate that adding programs specifically targeted at improving adherence may provide greater value by helping ensure that patients are taking their medications as prescribed.

ACOs and Medicare Shared Savings Program

The ACA included ACOs in Medicare given their triple goal of improving health, providing better patient care experience, and reducing cost. Since then, ACOs have become a leading payment and delivery reform model at the Center for Medicare & Medicaid Services (CMS). In 2012, Medicare also launched the Medicare Shared Savings Program (MSSP), which incentivizes ACOs to improve quality while spending less on providing care. Any savings are shared with the ACOs. In 2017, there are 480 MSSP ACOs with nine million beneficiaries.

Of those, 31 percent of the MSSP ACOs received shared savings bonuses, had somewhat higher quality scores and were able to spend less than their per-beneficiary benchmark in 2015, the most recent year for which data is available. Many of the quality measures used to assess ACOs focus on disease control and medication use among patients with diabetes and cardiovascular disease.

The Study and its Findings

The study evaluated whether and how use of medication among beneficiaries changed after entering an ACO that was part of the MSSP. Researchers looked at Medicare claims from 2009-2014, for a cohort of beneficiaries continuously enrolled in Medicare Parts A, B and D. On average, 24.8 percent of beneficiaries were enrolled in an MSSP ACO after 2012.

Researchers assessed the use of six drug classes commonly prescribed for diabetes or cardiovascular conditions including statins, angiotensin converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), beta blockers (β-blockers), thiazide diuretics, calcium channel blockers, and metformin. Beneficiaries in the study sample were screened to include only those who had the relevant condition.

The study compared changes in medication use and adherence for beneficiaries in ACOs from before to after the start of ACO contracts with a control group of beneficiaries not in ACOs. Researchers found no meaningful changes in medication use during the study period for any cohort in an MSSP ACO despite some slight increases in specific drug classes or cohorts. For instance, there was a slight increase in the use of thiazides among beneficiaries with hypertension who entered an ACO in 2013.

Why it Matters

The findings of our study suggest that savings and reported improvements in management of these conditions in MSSP ACOs may be due to factors other than improved adherence to prescription therapy, such as preventing unnecessary readmissions to hospitals through medication reconciliation at hospital discharge.

While those measures are important, the positive benefit of medication adherence on outcomes has been well established. Given the potential for improved quality and savings in MSSP ACOs, a targeted effort to improve adherence to prescribed medication may help achieve better outcomes and savings. Research by the CVS Health Research Institute and our experience have shown that use of proven pharmacy benefit management (PBM) programs can deliver meaningful improvements in adherence.

Programs and tools that can help improve medication adherence among members with chronic conditions such as diabetes or cardiovascular disease include:

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One-on-one counseling and care management through programs such as Pharmacy Advisor and Specialty Connect*

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High-touch engagement and personalized support for diabetes patients with Transform Diabetes Care

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ScriptSync, which offers 90-day prescriptions and prescription consolidation and synchronization

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The ability to get 90-day prescriptions through mail or at a local CVS Pharmacy through Maintenance Choice

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Prescription management tools such as ReadyFill, which includes digital reminders

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Multi-dose packaging which helps simplify complex drug regimens through medication reconciliation, synchronizes medications and packages them in single-use packs delivered in a clearly labeled box**

Partnering with a PBM that offers targeted adherence programs could help improve health outcomes for patients in ACOs and lower cost for payors.

There is ample evidence to show that pharmacists can play a significant role in helping improve adherence. In addition, retail clinics located inside pharmacies can lower total cost of care by helping close gaps in care and provide high-quality patient care.

The role of pharmacists and medication management is even more important in Medicare Part D plans. SilverScript, the CVS Caremark Medicare Part D plan, collaborates with several ACOs to help improve pharmacy care for Part D beneficiaries. The collaboration allows clinicians at participating ACOs to trace prescription activity and usage for the SilverScript beneficiaries they treat and work together to develop and implement appropriate interventions. SilverScript offers actionable, real-time pharmacy data about opportunities to manage unnecessary medication costs through a provider portal. It also uses a shared savings model to return half of any savings that ACOs deliver back to the providers. Our Health System Alliances team helps support population health management goals for ACOs through physician engagement strategies and implementation of targeted adherence solutions.

ACOs are a valuable part of our health care system and have the potential to continue to improve care coordination and outcomes. Including pharmacists and targeted adherence programs like those offered by PBMs within an ACO can help deliver even greater patient care benefits and achieve their intended goal of providing accountable care at lower net cost.

Want to learn more about indication-based management? Ask Us
COMMENTARY
July 12, 2017
Executive Vice President, Chief Medical Officer, CVS Health

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*Where allowed by law. In-store pick up is currently not available in Oklahoma. Some states require first-fill prescriptions to be transmitted directly to the dispensing specialty pharmacy. Products are dispensed by CVS Specialty and certain services are only accessed by calling CVS Specialty directly. Certain specialty medication may not qualify. Services are also available at Long’s Drugs locations.

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