Improving care through shared knowledge

How Does CCNC’s Model Align with

Value Based Payments?

Lead Community Pharmacy Coordinator

CCNC

V.P. Moose Pharmacy

Joe Moose, PharmD

$100 Total Healthcare

Spend

$10

$90

Pharmacy Spend

Non-pharmacy

Health Care

Spend

“How we got to where we are…”

(… our community pharmacy

experience)

>32,000 Individuals received CCNC Transitional Care Support in 2015

Dilemma: How to Scale Team-Based

Medication Optimization Efforts?

Breaking Out of the Bubble…”

(… our Policy Experience trying to Sell Community Pharmacy“)

Care Team

focus less

important

Care Team-Based

extremely

important

The Opportunity: In Health Reform

Terms

Opportunity Knocks…

CCNC

Enrollees

CCNC

Enrollees

with total

medical cost

> $10,000

Enrollees on

CCNC

Priority list

Enrollees on

TC Priority

list

Enrollees on

Medication

Management

Priority list

Total number of members 1,348,229 112,529 17,753 153,241 6,377

Total medical cost 4,078$ 27,527$ 23,813$ 18,215$ 25,345$

# of Inpatient visits 0.11 0.52 1.41 0.45 1.04

Inpatient costs 369$ 3,464$ 5,337$ 2,924$ 6,456$

# of mental health inpatient visits 0.01 0.04 0.04 0.04 0.04

ED visits 0.67 1.65 2.94 1.74 3.05

ED cost 178$ 745$ 1,262$ 816$ 1,657$

Outpatient visits 4.30 9.43 12.04 8.70 12.28

Mental health outpatient visits 0.62 1.88 1.04 1.53 1.14

PCP visits 2.09 2.91 2.53 2.65 3.52

Pharmacy visits 4.97 19.63 16.95 23.05 35.03

Pharmacy costs (Pre Rebate) 721$ 5,177$ 3,342$ 4,298$ 6,183$

It’s Not Just About Star Ratings

Single =

Home Run =

Grand Slam =

ACE-I Prescribed and Taken

Patient Hospitalization

Avoided

BP < 140/90

The reality of what is coming...

…or what may already be

here…

Refocusing on what matters…

Documenting what you

did to get paid.

Sharing what you did to

help others care for your

patient.

Sharing what you found to

aid in care delivery.

Sharing what you plan to

do next with the patients

so others are aware.

Sharing Patient

Aspirations

What Does CPESN℠ NC look

Like?

Community Pharmacy Enhanced

Services Network

Enhanced Pharmacy Services - Services that

transcend conventional requirements of an outpatient

pharmacy program contract that are focused on

improving clinical and global patient outcomes

Examples include, but are not limited to:

• In-home delivery with patient status review

• medication synchronization with clinical review,

• Adherence packaging with patient coaching; and

• Care management services.

CPESN℠ Distribution

Types of Enhanced Services

24 Hour

Emergency

Services

Adherence

Packaging

Collection of Vital

Signs

Compounding

Comprehensive

Medication

Review

Home Delivery Home Visits Long-Acting

Injections

Med

Synchronization

Program

Multi-Lingual

Capability

Naloxone

Dispensing

Nutritional

counseling

Point of Care

Testing

Smoking

Cessation

Standardized

Assessments

(PHQ-9)

Disease State

Management

Programs

The Collaboration Card

24 Hour Emergency Service/On Call (Dispensing) X X X X X X X X

24 Hour Emergency Service/On Call (Non-Dispensing) X X X X X X X X X X X X X X

Adherence Packaging X X X X X X X X X X X X X X X X X X

Clozapine Dispensing and Monitoring X X X X X X X X X X X X X X X X

Collection of Vital Signs X X X X X X X X X X X X X X X

Compounding (Non-Sterile) X X X X X X X X X X X X X X X X X X

Compounding (Sterile)

Comprehensive Medication Review X X X X X X X X X X X X X X X X X X X

DME Billing (Medicare and Medicaid) X X X X X X X X X X X X X X X

Home Delivery– (Free) X X X X X X X X X X X X X X X X X X X

Home Delivery (Fee Applies) X

Home Visits X X X X X X X X X X X X X X

In Depth Counseling/Couching X X X X X X X X X X X X X X X X X

Long-Acting Injections X X X X X

Med Synchronization Program X X X X X X X X X X X X X X X X X X X

Multi-Lingual Capability X X X X X X X X X X

Naloxone Dispensing X X X X X X X X X X X X

Nutritional Counseling X X X X X X X X X X

Personal Medication Record X X X X X X X X X X X X X X X X X X

Plan of Care Development/Reinforcement X X X X X X X X X X X X X X X X

Point of Care Testing X X X X X X X X X

Pre-filling Syringes for Oral Administration X X X X X X X X X X X X X

Presumptive Eligible (Medicaid) Medication Dispensing X X X X X X X X X X X X

Smoking Cessation Program X X X X X X X X X X

Specialty Pharmacy Dispensing X X X X X X X X

Standardized Assessments (pain assessment, PHQ-9) X X X X X X X X X X X X X X X

Immunizations (Non Medicaid) X X X X X X X X X X X X X X X X X X

Disease State Management Programs X X X X X X X X X X X X X X X

We don’t offer any of these advanced patient care services

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0 The Pharmacy

Locator Application

We Must Determine

Impactable RiskTo prove a ROI to the payer

Determine which patients are impacting the metrics of the payer

Determine pharmacy activities that optimize medical benefits

Determine how to enhance referral patterns to those that can do something about the problems

ONC National Meeting, January 24, 2014

Targeting Strategy

Attributed Patients

with Continuous

Eligibility* 

Attributed Patients

with DTP

Declaration** 

Attributed Patients

with CMR Received at

CPESN Pharmacy***

(n = 27,252) (n = 2,973) (n = 409)

Total Health Care Cost $6,717 (SD: $18,529) $20,678 (SD: $31,556) $25,649 (SD: $36,655)

Preventable Health Care Cost $5,802 (SD: $15,341) $16,284 (SD: $21,570) $19,908 (SD: $24,383)

Impactable Cost $258 (SD: $783) $804 (SD: $1,578) $1,172 (SD: $1,952)

Number of ED visits 1.3 (SD: 2.7) 3.1 (SD: 5.4) 4.7 (SD: 6.6)

Number of IP visits 0.2 (SD: 0.7) 0.9 (SD: 1.7) 1.0 (SD: 1.8)

Global Risk Score 59.4 (SD: 13.8) 73.4 (SD: 10.8) 79.3 (SD: 8.0)

* Patients are required to have continuous eligibility to Medicaid from 7/1/2014 to 6/30/2015

** Patients had at least one DTP declaration in the 12 months period from 7/1/2014 to 6/30/2015

*** Patients had received Comprehensive Medication Review (CMR) in the past 120 days from 3/1/2015 to 6/30/3015

CCNC Goals:

1) $30M in Savings

2) Increased Quality

3) Integration with Medical Home

Care Management Structures

Targeting Strategy

The Opportunity: In Economic Terms to

Medical Benefit

The Opportunity: In Economic Terms

to Pharmacy

Typical Referred Patient 10 Rx/Pt/Month

Profit per Rx ~$10

How it Breaks Down

~ 100-300 pts/day/referred to NC CPESN

$1200/pt/yr X 200 pts = $240,000 in annual

net profit per day

The Big Picture

Increase, Develop and Sustain High Performing Networks of

Pharmacies that provide enhanced services offerings

Create Marketplace Presence of CPESN℠ Networks

Create Marketplace Dependency on CPESN℠ Networks

Facilitate local value propositions to other care team members to

establish margin positive referral patterns

Create care team dependency on clinical activities performed by

community pharmacies to mitigate against risk narrow networking or

reimbursement reductions on product distribution

Establish Relationships and Reimbursement models with

Medical Benefit side of payer infrastructure

What are patients, employers, taxpayers paying for?

Some expenditures are investments, others are the result of lack of investment

The Value Proposition at the End of the Day

What’s driving this?• It’s all about pivoting toward payers &

alternative primary care providers

• Desire to not be dependent on PBM’s

• $1,000,000,000,000 CMS

• Quadruple AIM

“How we got to where we are…”

(… our community pharmacy

experience)

“I worry that [these pharmacies] we

rely on for specialized services for

our challenging patients are going to

go out of business as their

reimbursement continues to fall…”

-Practicing Physician(and Medical Director)

Wake Up Call #1

Contact InformationJoe Moose, PharmD

VP, Moose Pharmacy

Lead Community Pharmacy Coordinator,

Community Care of North Carolina

joe@moosepharmacy.com

Moose_Pharmacy