The Quality Imperative
Message to federal health plan payers from community pharmacy: We have the systems in place and the professional expertise to help millions of patients to better their health outcomes at a lower cost. Message to pharmacy from the U.S. Department of Health and Human Services and its Centers for Medicare and Medicaid Services: Prove it.
That’s the basic impetus behind the drive to measure and improve patient adherence, safe medication management and other performance benchmarks by both the private health plans that serve Medicare patients and the pharmacies they and their patients depend on. It’s become a bedrock principle for CMS through its Star ratings system for Medicare Advantage, or MAPD, and Part D prescription drug plans.
CMS’ Star ratings system was created by law in 2003 with establishment of the Part D drug benefit program. That system assigns ratings of one to five stars — five being the highest — to a variety of performance measures for every Part D or MAPD plan that serves Medicare beneficiaries.
“CMS has been evaluating health plans on Star measures for years,” said A.J. Caffentzis, SVP sales and marketing for AmerisourceBergen. “The shift in the healthcare industry to performance-based care has made a plan’s Star rating a critical factor for the community pharmacy, especially since five of the performance measures, 48% of the total Part D Star rating, are related to medication management.”
Three of those measures are related to patient adherence, and in particular, how successful a plan’s participating pharmacies are at keeping their patients on track with the medication therapy as measured by “proportion of days covered” for a prescription drug, or PDC. The other two pharmacy-driven performance benchmarks are related to patient safety and the reduction of risk, particularly for elderly patients.
Indeed, the Star rating system puts a lot of weight on the careful management of high-risk medications, or HRMs, by elderly patients. According to CMS’ rating system, the fewer high-risk meds dispensed to older Americans, the better — particularly when lower-risk alternatives are available.
“A plan’s effectiveness in proactively managing the use of HRMs is weighted heavily in the plan’s CMS Star ratings,” Express Scripts noted in a report. “Plan sponsors can achieve healthier outcomes — and a higher CMS Star rating — by strategically using advanced clinical pharmacy benefit management solutions to more effectively monitor and control the high-risk medications that members receive.”
Particularly with the advent of the National Quality Strategy, a framework from HHS for overhauling the nation’s health system to make it more cost-effective and outcomes-driven, the quality and performance measurement efforts embodied in the Star ratings system are key to pharmacy’s future. The reason: retail pharmacy’s ability to participate in the new healthcare system that is emerging from the chaotic soup of health reform, pay-for-performance reimbursement trends and evidence-based medicine will depend on its ability to benchmark and measure pharmacists’ success in providing safe and effective medication therapy to millions of patients and improving adherence rates — and demonstrating improved patient outcomes as a result of those efforts. That benchmarking effort also depends on communicating those quality and safety performance metrics to health plans and payers.
“With the shift to value-based purchasing, the U.S. healthcare system faces significant transformation,” said Robert McMahan, president of United Drugs, a major member-owned pharmacy services administration organization with roughly 1,300 independent pharmacies as members. “Payers are navigating the complexities of a new reimbursement environment, and independent pharmacists must be able to show value by driving quality metrics and positive outcomes.”
Laura Cranston, executive director of the Pharmacy Quality Alliance, agreed. “We are moving to a value-based [healthcare] model, and this model relies on performance measures,” she said. “Performance measures and adoption of measures is about driving value and making value part of the healthcare equation — being able to measure it, and also being able to hold people accountable. So measures are being created to hold entities accountable.”
It’s essential, Cranston told DSN Collaborative Care, that chain and independent pharmacies adopt a system of tracking and communicating performance and quality metrics, and align those metrics with those of the health plans and PBMs they do business with. And that’s particularly true given the increasing reliance by CMS on its Star rating system as a basis for performance-based payments to MAPD and Part D health plans. Also lending urgency to the adoption of performance metrics: the move toward pay-for-performance incentive payments that go directly to pharmacies.
“Pharmacists … want to be recognized [by law] as a healthcare provider. If they are, they are able to bill directly to … payers in government and elsewhere,” Cranston said. However, she added, “you are not going to be recognized as a healthcare provider unless you’re willing to accept accountability, because every healthcare provider recognized by CMS as a distinct healthcare provider has performance measures of accountability. And performance measures are going to be part and parcel of every federal- or state-funded program.”
Formed in 2006, PQA is a public-private alliance that has taken a lead role in the development of medication-related quality measures for evaluating health plans, pharmacy benefit managers and pharmacies. Its goal: To “improve the quality of medication management and use across healthcare settings with the goal of improving patients’ health through a collaborative process to develop and implement performance measures,” the organization said. That vision also means recognizing “examples of exceptional pharmacy quality.”
The group’s new vision statement expands on its original mission, which also includes “reporting meaningful information to consumers, pharmacists, employers, payers and other healthcare decision-makers to help make informed choices, improve outcomes and stimulate the development of new payment models.”
PQA’s performance and quality metrics have been endorsed not only by CMS and its Star rating system for Medicare Advantage and Medicare Part D plans, but also by the National Quality Forum; the National Committee for Quality Assurance; the National Council for Prescription Drug Programs; the National Business Coalition on Health; and URAC, a major independent healthcare accrediting agency. Inland Empire Health Plan also adopted its quality and performance measurement standards for a major pay-for-performance demonstration project in California that involved pharmacies.
PQA’s membership comprises more than 130 organizations, including virtually every pharmacy advocacy group, including the American Pharmacists Association, the National Association of Chain Drug Stores and the National Community Pharmacists Association; retailers Walgreens, CVS Caremark, Rite Aid, Walmart, Target, Kroger and Safeway; and dozens of pharmaceutical manufacturers, pharmacy benefit management firms, colleges of pharmacy, health plans and government agencies.
“We’re moving to a value-based