For the past several years, physicians and health systems have been incentivized to improve quality as the U.S. health care system transitions to a value-based system of care. This shift has occurred mostly through alternative payment models such as accountable care organizations (ACOs), bundled payment arrangements, the Physician Quality Reporting System, and Hospital Value-Based Purchasing—programs that have been set up, in large part, through the Affordable Care Act (ACA).
“New value-based payment models reward providers for the outcomes of their care instead of for the volume of patients they see. As a provider, you are incentivized when your patients meet pre-established quality metrics,” said Anne Burns, BSPharm, Vice President of Professional Affairs at APhA.
The shift to quality-based incentives is beginning to emerge in pharmacy, too. Pharmacists are already being added to health care teams where they are helping patients manage their medications to prevent adverse outcomes and meet clinical goals. In addition, many quality measures that are required by CMS programs and other payers focus on medication use and are growing in importance for pharmacists, pharmacies, health plans, and pharmacy benefit managers alike.
Moving to an outcomes-based system of care means developing clinical measures to assess whether patients are meeting certain specified clinical goals.
The Pharmacy Quality Alliance (PQA), a nonprofit that focuses its efforts on developing performance measures that center on addressing the appropriate and safe use of medications, got its start in 2006 developing measures for the Medicare Part D prescription drug program. However, those same measures are beginning to be used in other sectors, including state-based and private sector programs.
Laura Cranston, BSPharm, PQA’s Executive Director, said medication quality measures for Medicare Part D have generated significant interest. She said what was particularly encouraging is when provisions in ACA called for quality bonus payments within the Medicare Advantage program, to be awarded based on how well health plans execute on a set of performance measures. This program is more commonly known as the CMS star ratings program.
CMS rates Part D prescription drug plans between one and five stars depending on quality and performance, with a five-star rating being the best.
“A pharmacy network can play a critical role in collaboration with Medicare drug plans in terms of helping them achieve higher star ratings on the PQA medication use metrics that are an integral part of the CMS star ratings program,” said Cranston.
Cranston said they are seeing more and more pharmacists, and community-based pharmacy organizations, actively engaged with their local, regional, and national health plan partners to collaborate in ways that improve medication management. This is happening not only in the Medicare space, but in the health insurance exchanges as well.
PQA measures account for close to 50% of Part D summary ratings for stand-alone prescription drug programs and nearly 20% for Medicare Advantage programs.
States are also showing interest in quality measures. Cranston said she has noticed this year that some states are looking to define measures in state-based programs that bring together providers, payers, and employers. For example, the state of Washington convened the Washington Health Alliance, which has developed a core set of measures to use for all health care providers in the state.
“What transpires within the Medicare program generally has a trickle-down effect into other programs as well, which is what we are witnessing in the market today,” said Cranston. “It is critically important for pharmacists to understand not only what is being measured but also which payers are using the measures. Then, pharmacists can determine what role they can play in delivering point-of-care interventions and services that will help drive safer and more appropriate medication use in a measurable way.” (See Table 1.)
PQA measures are also beginning to be used for accreditation. The Center for Pharmacy Practice Accreditation, which accredits community and specialty pharmacies, is in the beginning stages of requiring pharmacies to report on several different quality metrics as part of accreditation.
The metrics used to rate the quality of Medicare Part D plans include five measures PQA developed. Two measures focus on medication safety; these include high-risk medications in older adult patients and appropriate treatment of blood pressure in patients with diabetes. The remaining three measures are adherence-based: oral diabetes medications, cholesterol medication (statins), and blood pressure medications (renin–angiotensin system antagonists). Making sure these adherence measures are met requires engagement with patients as well as working with other physicians if adherence problems are discovered.
The same three adherence measures for diabetes, hypertension, and statin use also apply to the 2015 health insurance exchange plans.
PQA also developed a measure for qualified patients in Medicare Part D programs to receive comprehensive medication therapy reviews (CMRs), but plans have traditionally not scored well on it. This could all be changing in 2016, according to Cranston.
“To help drive improvements on this measure, CMS has proposed to move it into the star ratings program where performance on that measure may also be tied to quality bonus payments,” said Cranston.
PQA is also looking to develop measures around specialty drugs and measures related to opioid overuse, according to Cranston.
“We look at the needs of the health care system, where there are gaps in care, gaps in measurement—and typically align our efforts to best fill those gaps,” said Cranston.
Not only are quality measures becoming more complex, but the goal is to harmonize measure use across various federal programs. Cranston encourages pharmacists to help shape these quality measures, or at least understand them. One helpful tool to be able to understand this space better is by taking one or more of the modules that are available through EPIQ (Educating Pharmacists in Quality). These modules are also available for continuing education credit.
As Medicare star ratings grow in importance as a criterion for inclusion in a preferred pharmacy network, health plans and PBMs are beginning to look at quality metrics. Some prescription drug plans are already implementing pay-for-performance models that include bonus payments to top-performing pharmacies. These plans are partnering with Pharmacy Quality Solutions (PQS), a private company owned by PQA. Using PQS’s Electronic Quality Improvement Platform for Plans and Pharmacies (EQuIPP) system, the pharmacy can track its performance.
David Nau, PhD, BSPharm, FAPhA, President of PQS, said the company is in the process of evaluating how well pharmacies performed for CVS/Caremark SilverScripts plans in 2014. Nau said Silverscripts will then be cutting bonus checks to pharmacies that did well on quality metrics in 2014. Pharmacies are evaluated on four star measures, and the bonus is based on the number of patients at each store in addition to the score on each measure.
“There are additional dollars available if you can perform well on these quality measures,” said Nau.
He said there are also some PBMs planning to use the quality rating for pharmacies to help them form their preferred pharmacy networks. “Performing well may help a pharmacy become part of a preferred network,” said Nau.
The work PQS is doing is designed with an attempt to align the pharmacy level performance metrics with those of health plans that are accountable to the government, according to Nau.
PQS uses many of the same CMS PQA measures. With EQuIPP, pharmacies can view a dashboard that will tell them how they are performing on each quality measure. They can also see trends over time, based on data from health plans and PBMs.
“This is designed to facilitate a collaborative effort between the plans, the pharmacies, and the network,” said Nau.
The data are currently private, although Nau said there is some interest from various groups to make it public.
For more information, see page 49.