Role of Pharmaceuticals in Value-Based Healthcare: A Framework for Success


Accountable Care Organizations (ACOs) have received a great deal of attention and press through peer-reviewed articles and news stories, and new efforts are underway to develop tools needed to be a successful ACO. Success in an ACO world is different from success in a capitated environment, where the focus is only on managing costs. In an ACO, providers have at least some financial responsibility and they are also accountable for the quality of care they provide.  How does an ACO succeed in this environment of dual responsibility for costs and quality? How do pharmaceuticals fit in?

This research addresses these questions through the development of a conceptual framework for considering the role of pharmaceuticals in ACOs, including a condition-specific grid that lays out the cost and quality impact pharmaceuticals may have on each condition. If done correctly, value-based health care can enable patients to gain access to, and support in using, needed medications, and can do so while simultaneously lowering cost growth and achieving the quality benchmarks that the marketplace will soon demand.

The research also finds that:

  • Success in a value-based environment will depend on understanding the unique contribution of medications and utilizing them optimally across conditions and populations.
  • Medications cannot be viewed as a siloed expense item in a value-based environment. They need to be integrated so that the cost offsets and quality benefits resulting from optimized pharmaceutical use can be recognized and calculated. 
  • Medication therapy management (MTM) cannot be undertaken as a one-size-fits-all approach. The role, impact and characteristics of MTM will vary by condition.
  • Composite risk can be used to identify patients who are candidates for MTM strategies to watch for drug-drug, drug-disease, or polypharmacy concerns.
  • In each circumstance where there are condition-specific incentives to achieve economic savings, there should also be a quality metric to detect under-use of pharmaceuticals.