how does ccnc’s model align with value based...
TRANSCRIPT
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
Moose_Pharmacy