Pharmaceuticals, the prime treatment for many common conditions that lead to poor outcomes later on, play an important role in comprehensive approaches to providing quality healthcare.
Their proper prescribing and use prevent unnecessary hospital admissions or emergency room visits, so they need to be a consideration for accountable care organizations, Aetna's National Medical Director for Pharmacy Policy and Strategy Edmund Pezalla (pictured), M.D., told FierceHealthPayer in an exclusive interview.
ACOs recognize the importance of pharmaceuticals, but with so many other factors to operationalize they're not a main focus. As ACOs become more established, Pezalla said he expects they will become more savvy and innovative in their approach to pharmaceuticals.
For example, instead of having a utilization management program or prior authorization, ACOs would put practitioners in certain specialties in charge of specific medications. Specialists can make sure patients have the right diagnosis, are in the right stage of the disease and have received the other appropriate treatments, Pezalla noted.
To use pharmaceuticals to foster high-quality care, ACOs can't just look at them as a cost center but instead acknowledge their place in the treatment of patients, Pezalla added. They also have to focus on medication adherence to improve quality and outcomes. "Medications paid for and not adhered to are not going to do anything," he said.
Good news is ACOs are well-positioned to help patients take their medications appropriately: The physician is in the ACO arrangement and patients look to their physicians for treatment advice. A doctor who knows how to talk to a patient about adherence is a powerful tool, noted Pezalla.
The ACO focus on pharmaceuticals also needs to include the proper use and promotion of generic drugs. "If a generic will do the job for that patient then why not?" asked Pezalla.
Medicare Part D has found success with the increased use of generics--it's what keeps the program affordable and allows many Medicare patients to treat common ailments like high blood pressure and congestive heart failure.
Health insurers can help ACOs use pharmaceuticals to achieve cost and quality goals, Pezalla noted, because they have years of experience in evaluating medical interventions and developing formularies and clinical policies. Insurers can transfer that information to the ACOs and help them determine the ROI of choosing a more expensive medicine--taking into account whether the medicine is more effective, has fewer side effects or requires less testing.
"We can help them to work through some of these more complex analyses and give them tools so they can make it work in their own particular environment," he said.