In the US, health care spending as a share of gross domestic product rose to 19.7% in 2020; an increase of approx 50% compared to 20 years ago. At the same time a 2018 survey attributed a staggering estimated cost of $528.4 billion annually to suboptimized drugs. 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 this technology at our disposal, how is it possible that we are still spending so much on something as simple as taking the wrong medication?
As a pharmacist, I have always been concerned with providing the best outcomes for my patients. Pharmacists are experts in how drugs affect the body, and as one of the most trusted healthcare professions, we know how to care for our patients.
A common frustration for pharmacists is dealing with suboptimal drug prescriptions. As they are on the front line, pharmacists are often informed of problems experienced by patients that are directly caused by drug interactions, dosing, timing or lack of adherence. Allied care pharmacists use technology to identify and resolve medication issues, but for pharmacists in a brick-and-mortar pharmacy, calling a provider to change a medication is sometimes easy, sometimes not, and sometimes it feels like your recommendations aren’t being heard. With prescriptions to dispense, vaccinations to administer and patients waiting in the lobby, community pharmacists are often put in the disadvantageous position of having to pick their battles when it comes to pursuing non-critical medication changes.
Realigning Incentives in Health Care
The problem with the US health care system is one of misaligned incentives. Prescribers are paid to evaluate patients and administer care. All prescribers want the best outcomes for their patients, but the system does not incentivize choosing the best drugs to promote those outcomes. Community pharmacies are paid to dispense the correct medicine and ensure that it will not cause harm. All pharmacists want their patients to be prescribed the best treatments, but the system only incentivizes the dispensing of prescribed drugs. The divide between financial incentives and patient outcomes is not unique to medicine or pharmacy; this is an endemic problem that exists in most healthcare sectors. Healthcare professionals want the best outcomes for patients, but traditionally the system has not incentivized outcomes.
So how do we improve outcomes by addressing the problem of misaligned incentives in a way that doesn’t lead us down the current path of ever-increasing health care costs?
Using value-based care
Value-based care (VBC) is a relatively new healthcare model concept that prioritizes the quality of healthcare delivered over quantity. It is much easier to measure the services or products provided than to measure the quality of those services or products, which is why the movement toward quality in healthcare is the main catalyst of the VBC trend. The Agency for Healthcare Research and Quality determines quality of health care like the extent to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. Essentially, it’s about finding evidence about whether a product or service leads to positive or negative outcomes for a given patient, then building a concrete consensus on how to measure that. Quality indicators that receive national approval are then published for payer organizations to implement in various programs, including community payer organizations such as Medicare and Medicaid.
Healthcare quality is a very big topic, but in short, by linking outcome-based quality measures to reparable aspects of healthcare, we systematically encourage healthcare professionals to work together as a team with a common goal of providing the best patient care. Currently, Medicare and Medicaid have the largest array of VBC programs, but other types of private VBC programs are becoming more common. All VBC programs work in a similar way, with some form of financial reward for achieving good patient outcomes and often financial penalties for those who do not.
Here are some examples of quality metrics that can be used by VBC programs:
With the cost of non-optimized medical therapies in the amount of 16% of the total amount spent on health care in the US annually, it’s fair to say that better, more cost-effective pharmacy care is needed. Increasing the prioritization of value and quality to improve outcomes while reducing costs presents a huge opportunity for pharmacists, and especially for clinical pharmacists who have moved beyond traditional dispensing roles.
Related solutions such as adherence monitoring, comprehensive medication management, chronic care management and targeted medication review can help organizations adapt to the shift to value-based payment models while reducing costs and helping patients live a more productive, healthy and fulfilling life.
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