In the US, healthcare spending as a proportion of the gross domestic product rose to 19.7% in 2020; an increase of nearly 50% compared to 20 years prior. At the same time, a 2018 study attributed a staggering estimated cost of $528.4 billion dollars annually to non-optimized medications. From high-tech diagnostics to specialty therapies, recent decades have given us countless medical innovations promising to lower costs and improve the quality of care. With all of this technology at our disposal, how is it possible that we still spend so much on something as simple as not getting the medications right?
As a pharmacist, I’ve always been concerned with ensuring the best outcomes for my patients. Pharmacists are experts on how drugs affect the body, and as one of the most trusted healthcare professions, we know how to care for our patients.
A frequent frustration of pharmacists is contending with prescriptions for suboptimal medications. Being on the frontline, pharmacists are often made aware of issues patients are experiencing that are directly caused by drug interactions, dosing, timing, or lack of adherence. Connected care pharmacists use technology to identify and resolve medication problems, but for pharmacists in a traditional pharmacy, calling a provider to get a drug changed is sometimes easy, sometimes not, and sometimes feels like your recommendations are falling on deaf ears. With prescriptions to dispense, vaccinations to administer, and patients waiting in the lobby, community pharmacists are often put in the unfortunate position of having to choose their battles when it comes to pursuing non-critical medication changes.
Realigning incentives in healthcare
The problem with the US healthcare system is one of misaligned incentives. Prescribers are paid to evaluate patients and to administer care. All prescribers want the best outcomes for their patients, but the system does not incentivize choosing the best medications to promote those outcomes. Community pharmacies are paid to dispense the correct medication and ensure it will not cause harm. All pharmacists want their patients to be prescribed the best treatments, but the system only incentivizes dispensing the prescribed medication. The separation between financial incentives and patient outcomes is not unique for medicine or pharmacy; it is an endemic problem which exists throughout most healthcare sectors. Healthcare professionals want the best outcomes for patients, but traditionally, the system has not incentivized outcomes.
So how do we go about improving outcomes by tackling the issue of misaligned incentives in a way that will not lead us on the current path of ever-increasing healthcare costs?
Putting value-based care to work
Value-based care (VBC) is a relatively recent healthcare model concept which prioritizes the quality of healthcare delivered over the quantity. It’s much easier to measure services rendered or products dispensed than it is to measure the quality of those services or products, which is why the movement towards healthcare quality is the primary catalyst of the VBC trend. The Agency for Healthcare Research and Quality defines healthcare quality as the degree to which healthcare services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. Essentially, it is about finding evidence for whether a given product or service leads to positive or negative outcomes for a given patient, then building a concrete consensus around how to measure it. Quality metrics that receive national approval are then posted for payer organizations to implement in various programs, including public payer organizations such as Medicare and Medicaid.
Healthcare quality is a very large topic, but in short, by linking outcomes-based quality metrics to reimbursable aspects of healthcare, we systematically incentivize healthcare professionals to work together as a team with a unified goal of ensuring the best care for patients. Currently, Medicare and Medicaid have by far the largest array of VBC programs, but other types of private VBC programs are becoming increasingly common. All VBC programs work similarly, with some form of financial reward for achieving good patient outcomes, and oftentimes, financial penalties for those who do not.
Here are a few examples of quality metrics that could be used by VBC programs:
With the cost of non-optimized medication therapies amounting to 16% of the total amount spent on US healthcare annually, it’s fair to say that better, more cost-effective pharmacy care is needed. The rise of prioritizing value and quality to improve outcomes while lowering costs represents a massive opportunity for pharmacists, and especially for clinical pharmacists who have broken outside the bounds of traditional dispensing roles.
Connected solutions such as adherence monitoring, comprehensive medication management, chronic care management, and targeted medication review can help organizations adapt to the shift towards value-based payment models while simultaneously lowering costs and helping patients to live more productive, healthy, and fulfilling lives.
Photo: Natali_Mis, Getty Images
