Evolution of ACO readiness to optimize medication use: are we there yet?

DISCLOSURES: No funding contributed to the writing of this commentary. The authors have nothing to disclose.

its potential to promote care coordination among providers and health systems, improve care delivery, and reduce costs.
However, as with all new care delivery designs, early ACOs faced several challenges that affected the model's potential. One such challenge was the ability of ACOs to optimize their use of medications. Despite medications being a critical component of patient care and an essential tool for meeting the cost and quality targets faced by ACOs, it was unclear if ACOs possessed the capabilities to support, monitor, and ensure appropriate medication use for their enrollees.
integrate a clinical pharmacist into care teams, and engage patients in treatment decisions and outcomes, was limited. Accordingly, we issued recommendations to improve optimal patient access and ACO success.
Over the years, accountable care models have advanced not only in number but also in sophistication, and ACOs have made incremental progress toward achieving medication optimization in select areas. Here, we review the growth of the ACO model, In 2014, the JMCP article "Are ACOs Ready to be Accountable for Medication Use?" shared results from a survey to evaluate the readiness of 46 ACOs to maximize the value of medications to achieve quality benchmarks and costs offsets. 1 The results were mixed. The survey found high readiness in ACOs' ability to transmit prescriptions electronically, with moderate readiness to (a) view prescription and medical data in a single system and (b) encourage generics when appropriate. Readiness in all other assessed areas related to medication optimization, such as the ability of health systems to communicate and manage potential adverse medication interactions, This year marked the tenth anniversary of the passage of the Patient Protection and Affordable Care Act, which among other policies, authorized the use of accountable care organizations (ACOs) to help transition the U.S. health system from volume-based to value-based care. Initially, there was excitement about the ACO model and

Editor's note
The year 2020 marks the 25th anniversary of the Journal of Managed Care + Specialty Pharmacy. To commemorate this milestone, we are publishing a series of articles that document the changes to the journal and profession over the past 2 and a half decades. Each month we reprint an original article from a previous year, dating back to 1995. The reprinted articles feature topics of significance in our industry. Each reprinted article is accompanied by a contemporary reflection that will consider the historical significance of the topic, as well as the current and future state.

Laura E. Happe, PharmD, MPH Editor-in-Chief C O N T E M P O R A R Y R E F L E C T I O N
Vol. 26, No. 11 | November 2020 | JMCP.org evaluate the progress made in 3 of the areas with limited readiness in 2014, and identify future opportunities for medication optimization in ACOs.

Growth of the Accountable Care Model
Since the publication of the 2014 article, the ACO policy landscape has changed substantially. Adoption of the ACO model has continued to increase among public and private payers. According to the National Association of ACOs, the number of Medicare ACOs has grown to 558 as of January 2020, serving more than 12.3 million beneficiaries, or about 1 in every 5 Medicare beneficiaries (compared with the 254 Medicare ACOs serving 4 million beneficiaries in 2014). 2 This is in addition to the hundreds more commercial and Medicaid ACOs that serve millions of additional patients. As of October 2019, most ACO enrollees were covered by commercial ACOs (60%), whereas Medicare and Medicaid represented 30% and 10% of covered lives, respectively. 3 New federal and state policy initiatives, including the Medicare Access and CHIP Reauthorization Act of 2015, which shifted Medicare physician payment away from traditional feefor-service and toward value-based payment, have also fueled additional interest in the adoption of accountable care models.

Progress in Communicating and Managing Potential Adverse Medication Interactions
The 2014 JMCP article found critically low ACO readiness to communicate and manage potential adverse medication interactions. Given that adverse medication reactions are a leading cause of preventable death in the United States, the article strongly recommended that ACOs adopt and implement protocols to manage them. Since then, there have been some promising improvements in this area. In 2017, we published a follow-up survey in JMCP that examined progress toward optimal medication use in ACOs and found a statistically significant increase in the number of ACOs that reported the capability to identify potential adverse interactions across all patient care efforts (percentage reporting high readiness increased from 43% in 2014 to 65% in 2017) and notify all patient care providers of potential adverse interactions (increase from 13% in 2014 to 45% in 2017). 4

Improvement in Patient Engagement in Treatment Decisions and Outcomes
The 2014 JMCP article also identified the need for ACOs to develop a robust health information technology infrastructure to foster patient engagement opportunities and promote shared decision making between patients and their providers. The 2017 follow-up survey found some progress in this area, with ACOs reporting a statistically significant increased ability to educate patients on diagnostic and therapeutic alternatives and implications when creating a medication care plan (increase from 11% in 2014 to 31% in 2017). The survey also reported a modest increase in the ability of ACOs to identify when a medication is prescribed and filled (9% in 2014; 16% in 2017) and to capture patient-reported outcomes (PROs) electronically (15% in 2014; 27% in 2017), although improvements in these areas were not statistically significant, and additional progress is still needed. Since the initial JMCP article's publication, multistakeholder interest in developing and implementing patient-reported outcome measures (PROMs) has continued to gain traction. The Centers for Medicare & Medicaid Services has now implemented value-based payment programs that use patient-reported measures to inform provider reimbursement and assess care quality. In 2019, the Department of Health and Human Services contracted with the National Quality Forum to convene a panel of experts and develop a list of best practices for selecting and implementing PROs and PROMs. Also, the Agency for Healthcare Research and Quality funded a toolkit to guide health care systems as they incorporate electronic PROs into care delivery. 5 While these efforts reflect meaningful progress in capturing care delivery quality from the patient perspective, there is still room for improvement.

Gaps in Accountable Care Quality Measures
The 2014 JMCP article identified the need for more sophisticated quality measures to evaluate the effect of appropriate medication use. This need still exists today and is compounded by the growing number of patients enrolled in public and private ACOs. Analyses of accountable care measure sets found that existing gaps in quality measures used by accountable care programs may unintentionally conceal issues or inefficiencies in care delivery that could undermine opportunities to improve patient outcomes. 6,7 health systems that have successfully navigated barriers to implementing accountable care models. Insights from these leaders who have successfully optimized medication use to lower costs and improve care were distilled into competency orientation guides and case study briefs that can help health systems achieve the essential goal of optimizing medication use. 8,9 As we navigate a changing health care environment, it is crucial to maximize the value of each health care dollar spent. In doing so, it will be essential to leverage the lessons learned within existing care delivery and payment structures, including ACOs, to optimize patient care while improving efficiency and reducing costs. Given the vital role and value of medications in treating chronic conditions and other diseases, optimizing medication use inside and outside of accountable care environments can help improve patient outcomes and contain costs.

DISCLOSURES
No funding contributed to the writing of this commentary. The authors have nothing to disclose.
These gaps in accountable care measurement can be addressed by refining core measure sets to use cross-cutting outcomes measures, which address quality issues across conditions, and PROMs to emphasize outcomes of significance to the patient. To advance the integration of PROMs in value-based payment and accountable care models, public and private sector collaborations, such as the Core Quality Measure Collaborative, can promote greater alignment in the measures used for quality improvement and payment purposes. Accountable care systems can use layered and modular approaches to strike a balance between the need for informative measures and the resulting administrative burden.

Future Opportunities for ACO Medication Optimization
As we look to the future, there are several opportunities to improve medication optimization in ACOs. As the ACO model has matured over time, a growing body of evidence-based research and resources has identified key factors associated with successful ACOs, including strategies for optimizing the use and value of medications.
Earlier this year, the Accountable Care Learning Collaborative, a nonprofit focused on accelerating the readiness of health care organizations to assume value-based payment models, convened the Committee on Medication Optimization. This committee included leaders from