Managed and Accountable Care Organizations who are not using their medication programs as the core or (at a minimum) to synergize their population health programs may be missing a large opportunity.
At its roots, a medication management effort is a population health effort focused on aspects of a population’s health in which drug therapy is utilized. Medication management identifies a population of patients with potential therapy gaps, collects a minimum data set to verify those therapy gaps, and intervenes to close verified therapy gaps. Consequently, it is no stretch to think that a properly designed medication management program can and should be the core of your organization’s population health program.
Until recently, many people viewed population health as an academic pursuit - the new "trendy" name for public health. However, it has been firmly incorporated into the Affordable Care Act (ACA).
The ACA incorporates population health in five (5) key ways:
- Provisions to expand health insurance
As the number of individuals entering the insured pool continues to increase, the potential to understand the health of the population (at least at a claims level) becomes more and more of a reality.
- Provisions to improve the quality of care
National Strategy for Quality Improvement, CMS Center for Medicare and Medicaid Innovation, etc.
- Provisions to enhance prevention and health promotion
These provisions can be best seen in the implementation and requirements for Accountable Care Organizations (ACOs) that incentivize providers to take responsibility for population health outcomes. The CMS final rule suggests both population health and medication management as strategies for fulfilling the care management requirement.
- Provisions to promote community and population based activities
Establishment of the National Prevention, Health Promotion and Public Health Council which has already mandated the National Prevention Strategy.
- Addition of Internal Revenue Service (IRS) requirements
The first requires hospitals to conduct a Community Health Needs Assessment once every three years, and the second requires public health departments seeking accreditation to conduct a Community Health Assessment.
Most immediately, population health has become a key transformative tool being used to shift health care providers from a fee-for-service to a value-based payment system which bases payment on how well a population of patients achieves health outcomes.
What are the benefits of integrating your population health and Medication Management efforts?
- Killing Two Birds with One Stone
For many organizations, a medication management program of some type is a requirement. Whether it’s Medicare Part D medication therapy management, improving drug-related quality metrics, or improving the cost profile of the drug benefit, a medication management program is a necessity for most health care delivery organizations. Integrating a population health program allows the organization to achieve two objectives with one effort.
- Centralized Data
Integrating your population health and medication management efforts allows the organization to begin to develop a centralized repository of clinical data that synergize both efforts. Data collected through medication management initiatives inform the future direction of population health efforts and vice versa.
How do you design a Medication Management program to be a population health program?
One of the reasons that medication management programs are not typically viewed as population health efforts is that they suffer from a "loose" design syndrome. Many medication management programs have not progressed past their early academic origins to allow pharmacists to lay their hands on the medication regimen and like Midas gold will be produced.
If fact, high-performing medication management efforts are highly engineered and incorporate population health concepts. These include:
Should medication management programs be focused on a set of goals? I like to think of goals in care gap terms. The value of a medication management program is to close care gaps - the difference between clinical evidence and clinical practice. Your goals can be articulated in terms of the compendium of care gaps that will be closed - polypharmacy (decrease the average number of drugs in a population’s drug regimen), quality (decrease the members of a population with a high risk medication in their profile), etc. The overlap of goals between your medication management and population management programs is the natural point of integration.
- Data Set
The extent of value produced by a medication management program is the measure of how aggressively the program closed care gaps. Consequently, the minimum data set that describes both the process (how aggressively was the program operated) and outcomes (information required to determine if care gaps are in an open or closed state). This is very similar to a population health effort which collects a minimum data set of information to assess the current state and changes in some aspect of a population's health status.
- Data Collection and Organization
The medication management process must be designed to document gap evaluation, intervention efforts, and results. Medication management programs without an overtly articulated and operationalized workflow will suffer from deployment variability, and thus not achieve their goals. Similarly, population health programs incorporate a method as part of their design.
Medication management efforts which are designed using population health concepts allow for the collection of population health data and the assessment of population health status, but are likely to produce more poignant improvements in medication utilization.
Population Health Myths
Incorporating medication management and population health can help crack a number of population health myths. Two of my favorites are listed below:
- It’s a Long Way From Cup To Mouth
In a recent article in Health Care Informatics, Donald W. Fisher, Ph.D., president and CEO of the Alexandria, Virginia-based American Medical Group Association (AMGA) indicated that a population health effort requires a large transition. “We’re not quite there yet, and as we change to a new reimbursement system, even the large, sophisticated medical groups are going to need a few years to make the transition,” Fisher says. “You’ve got to put the infrastructure in place, and the large integrated health systems have been putting those elements in place—EHRs [electronic health records], alert systems, analytics systems, data warehouses—and some have teams of people mining the data to assess patient status.” Fisher's comments represent one perspective of how to initiate a population health effort where you put everything in place before you begin. However, another viable approach is to incrementalize toward a full-blown population health effort by "bootstrapping" other efforts such as medication management.
- Predictive Modeling
In today’s environment, trying to incorporate predictive modeling into a population health effort may be a bit "much ado about nothing". Leaving the problem of small data sets aside, job one of a population health effort should be to provide the organization with an understanding of the current health status of a population. Organizations that understand their population’s current health status will almost certainly identify two or three key care gaps in the population which, if closed, would reduce population risk immediately. Don't burden your organization's population health effort with trying to incorporate predictive analytics that sound appealing or "sexy" but will produce little value.
To illustrate an example of a population health initiative, CSS conducted an assessment for one of its clients concerning the prevalence of antipsychotic adverse drug events (ADEs). As part of the Medicare Part D MTM program, CSS included a question set focused on antipsychotic ADEs. Each patient who participated in a Comprehensive Medication Review (CMR) and had an antipsychotic agent in their medication profile was presented with the question set. The data collected was stored in the patient’s chart in a review of systems registry. After one (1) month of CMRs a frequency analysis of ADEs was compiled (see below).
The analysis highlighted that over 90% of the patients interviewed exhibited at least one (1) ADE, and over 30% exhibited at least eight (8) ADEs.
This case study illustrates that properly designed medication management initiatives provide a viable mechanism for conducting population health initiatives without adding significant overhead to the organization.
I would be happy to discuss any of these thoughts in greater detail. Feel free to reach out by phone or e-mail.
Founder & President, Clinical Support Services, Inc.