Influence of a financial incentive on cognitive services: CARE project design/implementation

A conceptual framework for evaluation of community pharmacy pay-for-performance programs

BACKGROUND

Recent interest in initiating pay-for-performance (P4P) programs indicates an underlying belief that economic incentives will have a direct impact on health care quality and efficiency. Evaluations of the impact of P4P programs on health care organizations and providers have been presented in the literature; however, none have focused on the impact of an incentive targeting community pharmacies.

OBJECTIVE

To propose a theory-derived conceptual framework of how a financial incentive might work in a community pharmacy.

METHODS

Studies from the fields of economics (agency theory), psychology (intrinsic and extrinsic motivators; expectancy theory), and organizational theory (ownership, institutional layers, organizational culture, and change management; quality improvement) were reviewed to inform the framework's components. This proposed conceptual framework also integrated and expanded on previous health care-related P4P models.

RESULTS

P4P programs inherently use financial incentives to catalyze change; however, elements from psychology and organizational theories along with economic theory were identified as important considerations in how a financial incentive may operate when targeting a community pharmacy. Through the incorporation of these theories along with other P4P frameworks in health care, a conceptual framework was derived comprising 4 domains: incentive, pharmacy, other influencing factors, and P4P program measures. Hypothesized relationships among these domains were depicted.

CONCLUSION

As focus on improving the quality of health care provision develops, opportunities for pharmacists to provide patient care services beyond dispensing will continue to advance, along with expanded reimbursement mechanisms extending beyond traditional product dispensing. The proposed theory-derived conceptual framework serves to depict how the integration of P4P and other factors may affect the pharmacy environment and subsequently affect a pharmacy's capability to perform well on medication-related quality measures. This framework may be used as a foundation on which to design studies to investigate the association between community pharmacy factors and performance in a P4P program.

A behavioral model of clinician responses to incentives to improve quality

The use of pay for performance (P4P) and public reporting of performance (PR) in health care is increasing rapidly worldwide. The rationale for P4P and PR comes from experience in other industries and from theories about incentive use from psychology, economics, and organizational behavior. This paper reviews the major themes from this prior research and considers how they might be applied to health care. The resulting conceptual model addresses the dual nature (combining direct financial and reputational incentives) of the initiatives many policymakers are pursuing. It also includes explicit recognition of the key contextual factors (at the levels of the markets and the provider organization) and provider and patient characteristics that can enhance or mitigate response to incentives. Evaluation of the existing literature (through June 2005) about incentive use in health care in light of the conceptual model highlights important weaknesses in the way that trials have been reported to date and suggests future research topics.

Retrospective Financial Analysis of Wellness Center from an Independent Community Pharmacy Perspective

OBJECTIVE

To determine the net financial gain or loss from health screening services provided to patients at an independent community pharmacy-based wellness center.

DESIGN

Retrospective review of pharmacy wellness center records over a 24-month period.

SETTING

A wellness center at one independent community pharmacy.

PARTICIPANTS

Patients receiving one or more of nine different services (blood pressure [BP], blood glucose, body fat [BF], glycosylated hemoglobin [A1C], bone density [BD], total cholesterol/blood glucose, total lipid panel [TLP], total cholesterol/high-density lipoprotein, alanine aminotransferase) during a 2-year period.

INTERVENTIONS

The services were performed and results recorded by a resident or staff pharmacist.

MAIN OUTCOME MEASURES

Using a pharmacy perspective, net financial gains or losses were calculated for each of the individual services, for all of the services performed using the Cholestech LDX Analyzer, and for the wellness center as a whole. Sensitivity analyses were based upon a pharmacist, a pharmacy resident, or both a pharmacist and pharmacy resident each providing half of the total number of services over the 2-year period.

RESULTS

A total of 1,181 pharmacy records for the selected services were reviewed for the specified time period. A net financial gain for the wellness center was achieved when the services were performed by a pharmacist, a pharmacy resident, or a pharmacist/pharmacy resident combination, respectively. Three of the individual services (BG, BF and TLP) and assays performed using the Cholestech LDX Analyzer had a net financial gain for each sensitivity analysis. Two of the services (BP and AIC) had a net financial gain only when a resident provided the service. One of the services (BD) had a net financial loss for all of analyses.

CONCLUSION

Revenues for these services exceeded their costs from the wellness center perspective when they were performed by a pharmacist, a pharmacy resident, or a pharmacist/pharmacy resident combination.

Understanding practice change in community pharmacy: A qualitative study in Australia

BACKGROUND

Much of the research on cognitive pharmaceutical services has focused on understanding or changing community pharmacist behaviour, with few studies focusing on the pharmacy as the unit of analysis or considering the whole profession as an organisation.

OBJECTIVES

To investigate practice change and identify facilitators of this process in community pharmacy, with specific focus on the implementation of cognitive pharmaceutical services (CPS) and related programs.

METHODS

Thirty-six in-depth, semistructured interviews were conducted with participants from 2 groups, community pharmacies and pharmacy "strategists," in Australia. The interview guide was based on a framework of organizational theory, with 5 subject areas: roles and goals of participants in relation to practice change; experiences with CPS; change strategies used; networks important to the change process; and business impacts of CPS. Interviews were transcribed verbatim and thematically content analyzed, using NVivo software for data management.

RESULTS

Five key themes relating to the change process were derived from the interviews: change strategies (process- and behaviorally oriented); social networks (within and beyond the pharmacy); drivers of change (eg, government policy); motivators (eg, professional satisfaction); and facilitators of practice change (remuneration for implementation or service delivery, communication and teamwork, leadership, task delegation, external support or assistance, and reorganization of structure and function).

CONCLUSION

The use of an organizational perspective yielded rich data from which an understanding of the practice change process in relation to CPS implementation was gained. Current programs for the implementation and delivery of CPS have not taken into account all of the factors that have the ability to facilitate change in community pharmacy. Not only do future programs need to be underpinned by these elements, but policy makers must include them when planning remuneration and dissemination strategies.

Do community pharmacists influence prescribing?

OBJECTIVES

To evaluate whether community pharmacists have the ability to influence prescribing decisions and to determine the extent to which they do so.

DATA SOURCES

International Pharmaceutical Abstracts was searched for articles published between January 1970 and September 2002 and MEDLINE was searched for articles published between January 1966 and September 2002 that contain the terms pharmaceutical care or pharmacist and intervention.

STUDY SELECTION

Selected studies documented pharmacist interventions that resulted in a change in prescribing that required influencing the prescriber, included a complete description of methods and results, and were conducted in community pharmacies in the United States.

DATA EXTRACTION

Selected studies were examined to determine whether, in what ways, and to what extent community pharmacists influenced prescribing.

DATA SYNTHESIS

Community pharmacists in traditional practices regularly, but infrequently, recommend to prescribers that they initiate, discontinue, or change drug therapy. Prescribers usually accept and implement pharmacists' suggestions. Pharmacists are more likely to intervene to correct drug therapy problems when they have been trained to provide pharmaceutical care and have modified their practices to accommodate a more patient-centered style of practice. In the larger reviewed studies, pharmacists intervened to change therapy for the majority of their patients.

CONCLUSION

Community pharmacists routinely intervene to influence prescribing. They do so, for the most part, to correct clinical problems or to provide their patients with more affordable therapy. In the majority of interventions, physicians accept and implement pharmacists' suggestions.

Drug therapy management: an empirical report of drug therapy problems, pharmacists' interventions, and results of pharmacists' actions

OBJECTIVES

To determine the number and types of drug therapy problems identified by pharmacists at six community pharmacies, identify the interventions made by these pharmacists in their attempts to resolve drug therapy problems, and determine the results of the pharmacists' actions taken to resolve drug therapy problems.

DESIGN

Retrospective review of patient records from pharmacies.

SETTING

Six community pharmacies that had participated in Project ImPACT: Hyperlipidemia.

PATIENTS

One hundred sixteen patients from Project ImPACT: Hyperlipidemia.

INTERVENTION

Drug therapy problems, pharmacists' interventions, and results of pharmacists' actions were identified and categorized. Drug therapy problems were classified into seven categories, pharmacists' interventions into six categories, and results were categorized into eight types. Frequencies and descriptive statistics were calculated for the measures.

RESULTS

A total of 512 initial drug therapy problems were reported for 116 patients in the 6 pharmacies. In addition to the initial interventions, pharmacists documented another 545 times in which they intervened on the original problems. There were 354 (69.1%) drug therapy problems associated with hyperlipidemia and 158 (30.9%) with other conditions. Overall, most common types of drug therapy problems were needs additional therapy (39.8%) and nonadherence to therapy (31.1%). The most common discretionary pharmacist interventions were patient education and physician communication, which occurred on average 4.63 and 3.30 times during the project period. The most common consequence of a pharmacist intervention was an increase in patient adherence, which was reported for almost half of the patients.

CONCLUSION

Drug therapy management (DTM) for patients with dyslipidemias identified frequent drug therapy problems associated with both hyperlipidemia and other conditions. Pharmacists used interventions that included laboratory testing, patient monitoring, patient education, and physician communication to influence patient adherence and optimize drug therapy. Although further research is needed, the findings of this analysis are promising for the more widespread adoption of a DTM role by community pharmacists.

Frequency and characteristics of cognitive services provided in response to a financial incentive

OBJECTIVE

To determine the effects of a financial incentive on the number and types of cognitive services (CS) provided by community pharmacies to Medicaid recipients in the State of Washington.

DESIGN

Prospective randomized trial. CS were reported using a problem-intervention-result coding system over a 20-month period.

SETTING AND SUBJECTS

Pharmacists practicing in 110 study (financial incentive) and 90 control community pharmacies.

RESULTS

Study pharmacists documented an average of 1.59 CS interventions per 100 prescriptions over a 20-month period, significantly more than controls, who documented an average of 0.67 interventions (P < .05) per 100 prescriptions. One-half (48.4%) of all CS were for patient-related problems, 32.6% were for drug-related problems, 17.6% were for prescription-related problems, and 1.4% were for other problems that did not involve drug therapy. A change in drug therapy occurred as a result of 28% of all CS documented in this demonstration. Changes were rarely (2.4%) due to generic or therapeutic substitution and almost always (90%) followed communication with the prescriber. The average self-reported time to perform CS was 7.5 minutes; 75% of interventions were < or = 6 minutes. Considerable differences existed between study and control groups in the types of problems identified, intervention activities performed, and results of interventions.

CONCLUSION

A financial incentive was associated with significantly more, and different types of, CS performed by pharmacists.

Ambulatory care pharmacy services: has the agenda changed?

OBJECTIVE

To provide an extensive review of ambulatory care clinical pharmacy services and evaluate the services and research data in the field.

DATA SOURCES

MEDLINE was searched from January 1992 through July 1999. Search terms included pharmacy, clinical pharmacy, and pharmaceutical care, cross-referenced with ambulatory care, primary care, family medicine, and managed care.

STUDY SELECTION

Relevant peer-reviewed studies and reports since our previous article in 1992 were selected and described. Literature prior to 1992 was briefly reviewed.

DATA SYNTHESIS

The relevant literature was reviewed and some examples from the authors' institutions are provided. Much research has continued to be published documenting the value of clinical pharmacy services in ambulatory care, including in community pharmacy, anticoagulation services, family medicine, primary care clinics, Veterans Affairs Medical Centers, and managed care. However, these innovative services are underrepresented in the community at large. The vast majority of the public does not have access to these types of services.

CONCLUSIONS

There will be continued and dramatic expansion of ambulatory care pharmacy services in the new decade beginning in the year 2000. It will be critical that standards of practice be very high. We believe there is a critical need for visible demonstration projects and large multicenter research projects that demonstrate the value of these services.

Characteristics of pharmacies and pharmacists associated with the provision of cognitive services in the community setting

OBJECTIVE

To determine the influence of payment, pharmacy setting characteristics, pharmacist demographics, practice setting, and attitudinal characteristics on whether cognitive services (CS) were performed by pharmacists, and the volume of CS performed.

DESIGN

Prospective randomized trial. Community pharmacies were randomized to a documentation-and-payment group (study group) and a documentation-only group (control). Participating pharmacies and pharmacists were surveyed by mail, and responses were linked to a documented CS database.

SETTING

Community pharmacies serving ambulatory Medicaid patients in the state of Washington, excluding health maintenance organization pharmacies and pharmacies predominantly serving long-term care residents.

PARTICIPANTS

200 community pharmacies and their pharmacists (110 study, 90 control) participating in the Washington State Cognitive Activities and Reimbursement Effectiveness (CARE) Project.

INTERVENTION

Payment for CS. All participants documented CS. Study group pharmacies billed Medicaid for services performed in identifying and resolving drug therapy-related problems.

MAIN OUTCOME MEASURE

Documentation of CS.

RESULTS

Documentation of CS was more likely if the pharmacist was an owner or manager, if documentation was not perceived as burdensome, and if the pharmacy had a low ratio of prescription to total sales. Higher documentation rates were associated with study group status, lower pharmacy prescription volume as a percentage of total sales, and a higher percentage of prescriptions billed to Medicaid. Among pharmacists, two setting variables--medical center location and rural location--were associated with higher documentation rates.

CONCLUSION

Performance of CS was strongly affected by payment and other situational factors, including practice setting and volume of prescriptions dispensed. Pharmacies and pharmacists were also more likely to perform CS if the target patient population represented a relatively large percentage of that pharmacy's patient clientele.