PHARMACY
The Primary Care Team Pharmacist A Vital Tool to Prevent Hospital Readmissions BY SANDRA LEO, PharmD
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he 21st century has brought many new challenges and opportunities to the world of health care, and they are not just due to the ongoing COVID-19 pandemic. As value-based and other alternative payment models have become more prevalent following passage of the Affordable Care Act in 2010, health systems are transitioning their focus to providing quality rather than quantity of care. Value-based programs have developed to incentivize health systems to improve quality measures and increase efficiency. As the face of reimbursement continues to evolve, so should practice in all areas of health care. Evolution of primary care practice models is no exception. One area in which health systems continue to struggle is with hospital readmissions. Hospital readmission rates are a key player in determining reimbursement rates for large health systems and are associated with significant costs both to the patient and the health system. The Hospital Readmissions Reduction Program, a key part of the Medicare value-based purchasing program, penalizes hospitals up to 3% of their Medicare reimbursements based upon readmission rates for chronic conditions such
as COPD, pneumonia and heart failure. Some of the most important and preventable contributors to hospital readmission are poor medication adherence and medication-related errors. Patients with multiple chronic conditions often have complex medication regimens, which can leave even the most medically literate patients daunted. Around 45% of Americans have more than one chronic condition, and about 20% take at least five medications on a daily basis. However, according to the World Health Organization (WHO), adherence to chronic therapy in developed countries is only around 50%. This difficulty is often compounded by the older age of this patient population and lack of health literacy. For example, say hello to Bob. Bob, who to this point had enjoyed good health, was recently discharged from the hospital following an extended ICU stay. He was diagnosed for the first time with Type II diabetes. When he was discharged, Bob was given prescriptions for both long-acting and short-acting insulin pens (as well as new prescriptions for a beta blocker and an ACE inhibitor); he was not given any oral antihyperglycemic medications. He had never used any injectable medications, had no idea how to use them and was given no education regarding them. He faces a difficult time adjusting to a new phase of his life, including a level of self-care that he’s never had to face before. Following his hospital discharge, rather than starting to use these new insulin pens, he goes without any medication treatment for his diabetes because he does not want to risk using his insulin pens incorrectly.
System disconnections
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AUGUST 2018
PHYSICIAN
THE INDEPENDENT MEDICAL BUSINESS JOURNAL
Volume XXXII, No. 05
CAR T-cell therapy Modifying cells to fight cancer BY VERONIKA BACHANOVA, MD, PHD
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niversity of Minnesota Health is now among the few selected centers in the nation to offer two new immunotherapy drugs for the treatment of diffuse large B-cell lymphoma. Both drugs—Yescarta and Kymriah—are part of an emerging class of treatments, called CAR T-cell therapies, that harness the power of a patient’s own immune system to eliminate cancer cells.
Physician/employer direct contracting
CAR T-cell therapy involves drawing blood from patients and separating out the T cells. Using a disarmed virus, the patient’s own T cells are genetically engineered to produce chimeric antigen receptors, or CARs, that allow them to recognize and attach to a specific protein, or antigen, on tumor cells. This process takes place in a laboratory and takes about 14 days. After receiving the modification, the engineered CAR-T cells are infused into the patient, where they recognize and attack cancer cells. Kymriah received initial FDA approval in 2017 for the treatment of pediatric acute lymphoblastic leukemia. CAR T-cell therapy to page 144
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Exploring new potential BY MICK HANNAFIN
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ith the continuing escalation of health care costs, large and midsized selfinsured employers are once again looking for an edge to manage their medical plan costs and their bottom line. They understand that they are ultimately funding health care as they pay for their population’s claims.
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Many of these employers have employed the same overarching set of strategies: shop for a new carrier that is willing to lower the administrative costs or underprice the risk, Physician/employer direct contracting to page 124
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During hospital stays, medications for chronic and other conditions are often changed, discontinued or added, leading to medication discrepancies (differences between what medications the patient takes after they are discharged and what their care team intends them to take), further intensifying the risk for readmission. Following hospital discharge, patients with medication discrepancies are twice as likely to be readmitted to the hospital within 30 days. A systemic review of nine studies published in 2018 found that rates of medication-related readmissions ranged from 3-64%, with a median value of 21%. This study further found that approximately 69% of these readmissions were avoidable if these medication discrepancies had been resolved. Transitions of care present a difficult and challenging time for the patient and the health system, but also a substantial opportunity to improve patient care and reduce readmission rates through changes in the primary care treatment model. In 2017, WHO targeted transitions of care (along with polypharmacy and high risk medications) as one of the three key action areas where interventions are needed to reduce medicationrelated harm. When moving from the acute setting to the community setting, communication and medication management can play a vital role in keeping our patients from readmission and may have a vast impact on reimbursement rates within our health systems.
Enter the pharmacist The role of the pharmacist has vastly changed in recent years. No longer limited to the dispensing of medication, the incorporation of pharmacists
