September 20, 2018 by Navigant

Reducing Total Cost of Care in Targeted Areas

It was against this backdrop that population health executives representing hospitals, clinically integrated networks (CINs), and accountable care organizations (ACOs) nationwide convened in the summer of 2018 in Chicago for Navigant Consulting, Inc.’s 2018 Clinical Integration (CI) Summit. While all markets are different, this paper documents the key issues impacting organizations and proven strategies around how to overcome them.

Reduce Total Cost of Care in Targeted Areas

Though providers should not deconstruct their business models while still being paid on an FFS basis, it is possible to reduce total
cost of care to: 1) deliver on community missions, 2) ward off competitive threats, 3) capture benefit from value-based contracts, and 4) create a mutually beneficial relationship with payers. Focusing efforts on such areas as pharmacy care is essential to clinical and financial outcomes. The impact of medication nonadherence on providers and patients in the United States hasreached epidemic proportions. Experts suggest 4 20% to 30% of medication prescriptions are never filled, with about 50% of chronic disease medications not taken as prescribed. This lack of adherence leads to nearly 125,000 deaths, 10% of hospitalizations, and between $100 billion and $289 billion in added costs a year, studies show. Progress is being made, with approximately half of CI Summit attendees believing their organizations have successfully reduced pharmacy total cost of care (Figure 4).

Through a combination of research, strategic thinking, and early adoption of national best practices, Summit Health Management
(SHM) has developed a highly effective model that can be scaled and customized for other independent groups looking to adapt to the changing healthcare landscape. Founded in 2014, SHM was developed by multispecialty group physicians who wanted to share their best practices transitioning to value-based care. A key aspect of SHM’s model is driving meaningful collaboration between physicians and clinical pharmacists by integrating pharmacists into primary care, according to SHM Chief of Population Health Jamie Reedy, MD, MPH.



Through SHM’s program, pharmacists work alongside PCPs, care management, and social workers to improve medication adherence, increase generic drug use, and reduce use of high-risk drugs through medication reconciliation and patient education. Pharmacists perform comprehensive medication management consultations with patients, both via in-office visits and by phone, and have the authority to make clinical decisions based on reports from EHR systems. The model also places pharmacists in offices where physicians are struggling with certain conditions, such as hypertension. Among the results: an 84% reduction in high-risk medication use among the elderly, and diabetes, statin, and ACE-inhibitor medication adherence, well above top-tier performance among MA patients.

Finally, SHM implemented a strict vendor relationship policy, requiring all pharmaceutical reps to be vetted by the pharmacy services department. A list of approved reps is posted on the organization’s intranet for clinical staff to view. The program also prohibits pharma company-provided lunches and use of reps for medication education, which is now conducted by pharmacists to ensure unbiased academic detailing. Moreover, SHM’s sample medication policy restricts contents to evidence-based, cost-effective, and single-sourced products.