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Radar On Market Access: Pediatric Managed Medicaid ACO Leverages Pharmacists to Improve Care

Posted by Leslie Small on Sep 3, 2019


For a pediatric accountable care organization (ACO) that contracts with Ohio's Medicaid managed care plans, improving care for children would be a much more difficult job without the expertise of pharmacists who understand the unique needs of those patients.

"Our MCO partners are often really well versed in the adult patient population and chronic diseases that afflict their adult patients — but sometimes the pediatric population's chronic conditions are different," Brigid Groves, a clinical pharmacist specializing in population health at Columbus-based Nationwide Children's Hospital, tells AIS Health.
Groves is one of two pharmacists employed by Partners for Kids (PFK), the ACO affiliated with Nationwide Children's Hospital that receives capitated payments from the state's five MCOs to manage care for 330,000 children in central and southeastern Ohio.

As an example of how PFK pharmacists intervened to advocate for pediatric patients, Groves points to when the manufacturer of one type of inhaler shifted to a new, non-child-friendly delivery mechanism for the steroid that’s dispensed by the device.

"MCO plans were just kind of like, 'great new product, put it on there' [their formularies]. And it really impacted a lot of our kids because they weren’t able to get their steroid inhalers or use them appropriately," she says. But PFK's pharmacists explained the situation, and "our plans were then able to make appropriate changes on their formularies."

One of the MCOs that contracts with PFK, CareSource, is currently making changes to how it covers the immunosuppressive drug Remicade (infliximab), and "we've worked with Partners for Kids pharmacists on our clinical criteria for prior authorization with pediatric use of that medication," adds Nicholas Trego, Pharm.D., associate vice president of pharmacy for the insurer’s Ohio market.

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Topics: Specialty, Market Access, Provider, Payer