The document discusses implementing pharmacy services within an ACO/MSO business proposal. It provides background on ACOs, MSOs, and the evolving healthcare landscape. The proposal should include 1) pharmacy services to implement like medication therapy management, annual wellness visits, or chronic disease management and 2) how these services will improve patient care by impacting benchmarks for quality, care coordination, preventive health, and management of at-risk populations. The literature demonstrates benefits of these pharmacy services including reduced costs and improved outcomes.

1. Pharmacy Services Development within ACO MSO Business Proposal
Pharmacy Services Development within ACO MSO Business Proposal ON Pharmacy
Services Development within ACO MSO Business ProposalPlease write a 1-page business
proposal for developing pharmacy services within an ACO/MSO by the end of class today.
Review the self-study lecture handout to get an idea of the pharmacy services you may want
to implement. You can focus on all, some or one service that has been presented to
you.Attached you can find a powerpoint that will help with this informationYou will get full
credit upon submission of a completed proposal if it includes: 1) the pharmacy service(s)
you want to implement within an ACO/MSO; 2) an explanation of how this/these service(s)
will improve patient care within the ACO/MSO.Pharmacy Services Development within ACO
MSO Business Proposalattachment_1Unformatted Attachment Preview2/15/2021 The
Current State of Affairs Percentage of Adults Ages 45-64 and 65 and over with 2+ Chronic
Conditions http://www.cdc.gov/nchs/data/databriefs/db100.htm 3 3 2/15/2021 The
Current State of Affairs https://www.apha.org/topics-and-issues/generation-public-
health/health-rankings 4 4 2/15/2021 The Current State of Affairs Total Health
Expenditure per Capita, Select Countries, 2008 http://facts.kff.org/chart.aspx?ch=1952 5 5
2/15/2021 The Current State of Affairs 2009 National Health Expenditures by Category (%)
Centers for Medicare and Medicaid Services (CMS), Office of the Actuary. (CMS, nd., PD-US,
CC BY-NC-SA 3.0) 6 6 2/15/2021 Healthcare Costs • ~$25 to $45 billion per year wasteful
spending in 2011 • 50% had no follow-up visit to their primary care provider between
hospitalizations Health Affairs. 2012; 31: 939-947 N Engl J Med. 2009; 360:1418-1428 7 7
2/15/2021 Fee-for-Service (FFS) Healthcare Model • A method in which doctors and other
health care providers are paid for each service performed • Tests (e.g., laboratory tests) •
Office visits https://www.healthcare.gov/glossary/fee-for-service/ 8 8 2/15/2021
Everyone is demanding better quality at lower cost 9 9 2/15/2021 The Affordable Care Act
Better Individual Care ACA – Accountable Care Act ACO – Accountable Care Organization
Triple AimACA & ACOs Lower Growth in Expenditures Better Population Health Patient
Protection and Affordable Care Act; Public Law 111-148, Section 3022, 124 STAT 395 10 10
2/15/2021 Performance-based Healthcare Model • An umbrella term for initiatives aimed
at improving the quality, efficiency, and overall value of health care • These arrangements
provide financial incentives to hospitals, physicians, and other health care providers to
carry out such improvements and achieve optimal outcomes for patients
http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=78 11 11 2/15/2021
Performance-based Healthcare Model • The typical pay-for-performance (P4P) program

2. provides a bonus to health care providers if they meet or exceed agreed-upon quality or
performance measures (e.g., reductions in hemoglobin A1c in diabetic patients) • Programs
may also reward improvement in performance over time (i.e., year-to-year decreases in rate
of avoidable hospital readmissions)
http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=78 12 12 2/15/2021
Management Services Organization (MSO) In healthcare, a MSO is an organization owned by
a group of physicians, a hospital and physician group, or business investors with a physician
group Managed Care Contracting Wendy Knight Aspen Publications; 1997 13 13 2/15/2021
Managed Care • An organized health care delivery system designed to improve both the
quality and the accessibility of health care, while containing costs • Has evolved due to
different factors: • • • • • Historical Economic Technological Social Government Navarro RP.
Managed Care Pharmacy Practice. 2nd ed. Sudbury, MA. Jones and Bartlett Publishers. 2009.
14 14 2/15/2021 History Behind Managed Care: HMO Act of 1973 • Pharmacy Services
Development within ACO MSO Business ProposalFederal government gave $375 million
over 5 years for the development of HMOs using a Fee-For-Service payment • Also required
employers to offer a federally qualified HMO option in their health benefits plan • HMOs
now must satisfy a series of requirements: • • • • • Meeting minimum benefit package
standards Adequate provider networks Quality assurance system Employee grievance
system Complying with standards of financial stability Navarro RP. Managed Care Pharmacy
Practice. 2nd ed. Sudbury, MA. Jones and Bartlett Publishers. 2009. 15 15 2/15/2021
History Behind Managed Care: Medicare Modernization Act of 2003 • An act to provide for a
voluntary prescription drug benefit under the Medicare program and to
strengthen/improve the Medicare program • Was designed to address this problem that
patients, particularly senior citizens at whom Medicare was targeted, have found
prescriptions harder to afford • Created Medicare Advantage plans Navarro RP. Managed
Care Pharmacy Practice. 2nd ed. Sudbury, MA. Jones and Bartlett Publishers. 2009. 16 16
2/15/2021 Basic Functions of MSO • Provides administrative and business services to
individual physicians and group practices • Cost savings provide negotiating power with
health plans and healthcare purchasers • Relieves physicians of non-medical business
functions so that they can concentrate on the clinical aspects of their practice Managed Care
Contracting Wendy Knight Aspen Publications. 1997 Advanced IPA Contracting, Direct
Contracting William J De Marco. 1999 Physician Driven Health Plans William De Marco MA
CMC. 1998 17 17 2/15/2021 Accountable Care Organization (ACO) Network of healthcare
providers consisting of many stakeholders- payers, physician groups, hospitalsthat receives
reimbursement based on metrics of Quality Care, Patient Satisfaction, and Reductions in
Cost of Care https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/ACO/index.html?redirect=/ACO/ 18 18 2/15/2021 History Behind Accountable
Care 2007 • Elliott Fisher (Dartmouth Medical School) publishes “Creating Accountable
Care Organizations: The Extended Hospital Medical Staff” 2010 • Patient Protection and
Affordable Care Act (PPACA) signed into law • Outlines a “Shared Savings Program” 2011
2014 • CMS releases its proposed rules for the “Shared Savings Program: inviting
commentary before rules are finalized” • All first year ACOs will have reached the shared
risk stage, if they have continued with the Shared Savings program Fisher ES, et al. Health

3. Aff (Millwood) 2007;26:w44-w57 19 19 2/15/2021 Components of ACOs • A legal entity •
Composed of a group of providers • That assume responsibility (are accountable) to manage
and coordinate care • For a defined group of patients • In an effective (high quality) and
efficient (low cost) manner
https://www.acponline.org/system/files/documents/about_acp/chapters/md/kirschner.p
df 20 20 2/15/2021 Basic Functions of ACOs • Coordinate clinical efforts among all
participating providers (e.g., primary care physicians, specialists, hospitals) • Facilitate the
delivery of more effective and efficient care through increased care access, population
management, care management and care selfmanagement education • Facilitate the ability
to translate patient clinical and service use data to promote more effective care • Establish
clinical guidelines to more effectively care for these patients
https://www.acponline.org/system/files/documents/about_acp/chapters/md/kirschner.p
df 21 21 2/15/2021 ACO Quality Measures ACO Quality Measures Domains
Patient/Caregiver Experience Care coordination/Patient Safety Preventive Health At-Risk
Population https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/sharedsavingsprogram/Downloads/2018-reporting-yearnarrative-
specifications.pdf 22 22 2/15/2021 ACO Benchmark Measures • Benchmark measures the
rate of performance achieved to earn the quality points for each measure (example below)
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/sharedsavingsprogram/Downloads/2018-reporting-yearnarrative-
specifications.pdf 23 23 2/15/2021 Advantages of the Current Models • Performance
measurements • Pharmacy Services Development within ACO MSO Business
ProposalFostering local organizational accountability for capacity • Intervening to improve
quality and lower costs Fisher ES, et al. Health Affairs. 2007;26(1):w44-w57 24 24
2/15/2021 Challenges of the Current Models • Reversing the current market • Changing the
physician practice culture • Legal obstacles • Variability in the degree of alignment •
Practical challenges Fisher ES, et al. Health Affairs. 2007;26(1):w44-w57 25 25 2/15/2021
Evolving Healthcare Workforce Roles Care coordination Manage chronic conditions Patient
Education /Self-care Wellness 26 26 2/15/2021 Evolving Healthcare Workforce Roles •
Physician Nutritionists • Team leader • Mid-level practitioners Health coaches Pharmacists
• Establish patient goals Physician • Initiate referrals to specialists Mental health workers
Social workers Nurses 27 27 2/15/2021 Evolving Healthcare Workforce Roles • Social
workers/Care Nutritionists coordinators • Address socioeconomic and psychosocial issues
Health coaches Pharmacists Physician • Patient access • Promote communication among
care team Mental health workers Social workers Nurses 28 28 2/15/2021 Evolving
Healthcare Workforce Roles • Nurses • May serve as care coordinators Nutritionists Health
coaches • Communicate with patients/families • Quality Improvement Pharmacists
Physician Mental health workers Social workers Nurses 29 29 2/15/2021 Evolving
Healthcare Workforce Roles • Mental health workers • Aid in identifying patients with
social, neurocognitive disorders or mental health concerns • Tools to address depression,
anxiety, substance abuse, etc. Nutritionists Health coaches Pharmacists Physician Mental
health workers Social workers Nurses 30 30 2/15/2021 Evolving Healthcare Workforce
Roles • Health coaches • Frequent patient follow-up • Aid patients one-onone to attain

4. treatment goals Nutritionists Health coaches Pharmacists Physician Mental health workers
Social workers Nurses 31 31 2/15/2021 Evolving Healthcare Workforce Roles •
Nutritionists/Dieticians • Nutrition/lifestyle often at the core of many chronic conditions
(i.e., diabetes, hypertension, heart failure) Health coaches • Individualized counseling
Mental health workers • Encourage behavior change Nutritionists Pharmacists Physician
Social workers Nurses 32 32 2/15/2021 Evolving Healthcare Workforce Roles Nutritionists
Health coaches Pharmacists Physician Mental health workers Social workers Nurses 33 33
2/15/2021 Role of the Pharmacist • Medication expert • Experiences coordinating with
physicians, nursing staff and other staff members • Prevent hospitalizations, comorbidities,
adverse events, and decrease health costs • Determining appropriate and cost-effective
therapies to include in formularies www.ashp.org/DocLibrary/Advocacy/PolicyAlert/ACO-
Policy-Analysis.aspx 34 34 2/15/2021 What Does the Literature Show? Study Methods
Result Conclusion Brummell et al. Retrospective chart review 2,780 medicationrelated
problems Developing an MTM program to manage and optimize pharmaceuticals will be a
cornerstone to managing the health of a population Best practices: improving patient
outcomes and costs in an ACO through comprehensive medication therapy management 23
MTM pharmacists (~18 FTE) working in 30 locations n= 670 ACO patients 12:1 ROI ?
$11,965 to $8,197 per person in total health cost MTM – Medication therapy management;
ROI – Return on investment J Manag Care Pharm. 2014;20:1152-1158 35 35 2/15/2021
Pharmacy Services Development within ACO MSO Business ProposalBenefits of Medication
Therapy Management • Reduces prescription costs • Identifies eligible patients • Direct
interaction with patients • Role of protocols for pharmacists to change prescriptions •
Communication from pharmacist to physician 36 36 2/15/2021 What Does the Literature
Show? Study Alhossan A, et al. Methods Results Conclusion Retrospective 1608
interventions single-center (~5.4 per pt) chart review Outcomes of 272 referrals made
AWV n = 300 provided by patient 183 DM/Lipid pharmacists records in an ACO 370
vaccinations associated offered with a federally 24 dosage changes qualified health Total
revenue > center $22,000 Pharmacists recommendations during AWV for ACO had a high
acceptance rate and generated substantial revenue AWV – Annual wellness visit; ACO –
Accountable care organization Am J Health Syst Pharm. 2016;73:225-228 37 37 2/15/2021
Benefits of Annual Wellness Visits • New opportunity for pharmacists • • Recommendations
had a high acceptance rate by patients and healthcare providers • • Financially viable
patient care services Pharmacists preferred to schedule follow up appointments
Pharmacists provide medications related services • Gives healthcare providers more time
for specialty care 38 38 2/15/2021 Alternative Pharmacy Services • Chronic disease state
management • • Chronic care management • • Asthma, diabetes, heart failure, hypertension,
etc. Medicare patients with >2 chronic conditions 20 minutes/month of non-face-to-face
care Transitions of care • • • • Medication reconciliation Advise over the counter selection
Immunizations Perform transition of care within 5 days of discharge • Prevent
readmissions 39 39 2/15/2021 Benchmarks Impacted by Pharmacist: Patient/Caregiver
Experience Domain Measure Number Description ACO-1 Getting Timely Care,
Appointments, and Information ACO-2 How Well Your Providers Communicate ACO-3
Patients’ Rating of Provider ACO-4 Access to Specialists ACO-5 Health Promotion and

5. Education ACO-6 Shared Decision Making ACO-7 Health Status/Functional Status ACO-34
Stewardship of Patient Resources https://www.cms.gov/Medicare/Medicare-Fee-for-
Service-Payment/sharedsavingsprogram/Downloads/2018-and-2019-qualitybenchmarks-
guidance.pdf 40 40 2/15/2021 Benchmarks Impacted by Pharmacist: Care
Coordination/Patient Safety Domain Measure Number Description ACO-8 Risk-
Standardized, All Condition Readmission ACO-35 Skilled Nursing Facility 30- Day All-Cause
Readmission Measure ACO-36 All-Cause Unplanned Admissions for Patients with Diabetes
Pharmacy Services Development within ACO MSO Business ProposalACO-43 All-Cause
Unplanned Admissions for Patients with Heart Failure All-Cause Unplanned Admissions for
Patients with Multiple Chronic Conditions Ambulatory Sensitive Condition Acute Composite
ACO-11 Use of Certified Electrical Health Record Technology ACO-12 Medication
Reconciliation Post-Discharge ACO-13 Falls: Screening for Future Fall Risk ACO-44 Use of
Imaging Studies for Low Back Pain ACO-37 ACO-38
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/sharedsavingsprogram/Downloads/2018-and-2019-qualitybenchmarks-
guidance.pdf 41 41 2/15/2021 Benchmarks Impacted by Pharmacist: Preventive Health
Domain Measure Number Description ACO-14 Preventive Care and Screening: Influenza
Immunization ACO-15 Pneumonia Vaccination Status for Older Adults ACO-16 Preventive
Care and Screening: Body Mass Index (BMI) Screening and Follow Up ACO-17 ACO-18 ACO-
19 ACO-20 ACO-42 Preventive Care and Screening: Tobacco Use: Screening and Cessation
Intervention Preventive Care and Screening: Screening for Clinical Depression and Follow-
up Plan Colorectal Cancer Screening Breast Cancer Screening Statin Therapy for the
Prevention and Treatment of Cardiovascular Disease
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/sharedsavingsprogram/Downloads/2018-and-2019-qualitybenchmarks-
guidance.pdf 42 42 2/15/2021 Benchmarks Impacted by Pharmacist: AtRisk Population
Domain Measure Number Description ACO-40 Depression Remission at Twelve Months
ACO-27 & -41 (Diabetes Composite) ACO-27: Diabetes Mellitus: Hemoglobin A1c Poor
Control ACO-41: Diabetes: Eye Exam ACO-28 Hypertension: Controlling High Blood
Pressure ACO-30 Ischemic Vascular Disease: Use of Aspirin or Another Antithrombotic
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/sharedsavingsprogram/Downloads/2018-and-2019-qualitybenchmarks-
guidance.pdf 43 43 2/15/2021 Summary • In the FFS model providers are paid for each
service performed whereas P4P model aims to improve the quality, efficiency, and overall
value of health care • An MSO is an organization owned by a group of physicians, a hospital
and physician group, or business investors with a physician group to provide management
and administrative for practicing providers • An ACO is a group of providers that are held
accountable a defined group of patients (i.e., Medicare patients) through high quality care at
a low cost • The pharmacist can play a vital role in the current health care models,
especially regarding enhancing quality for the patient and the healthcare team 44 44
…Pharmacy Services Development within ACO MSO Business Proposal