Laura Cranston, RPh

Adherence measurement can help patients achieve better outcomes. 

A focus on quality measurement—coupled with significant redesign in reimbursement and patient care&mdash;has become a dominant theme over the past 2 decades within the US health care system. Increased quality measurement has resulted in improved patient outcomes, as well as decreased spending in some specific disease areas. Every sector of health care, including pharmacy, has been impacted by this new approach to quality.

In the past, pharmacy reimbursement has centered on a fee-for-service system based on the number of prescriptions dispensed to patients. In the evolving system, pharmacy reimbursement will be increasingly linked to performance on a defined set of medication-based metrics. This includes both pay-for-performance systems and limited networks. The initial measures used to evaluate programs include adherence and medication safety metrics developed by the Pharmacy Quality Alliance (PQA).

After the rollout of the Medicare Part D program in 2006, then-Centers for Medicare & Medicaid Services (CMS) administrator Mark McClellan, MD, recognized the need to measure and evaluate the performance of Part D health plans as related to medication management. The PQA was born based on vision and need. The PQA is a nonprofit organization that strives to facilitate such improvements in health care quality through promotion of appropriate medication use, and the development of strategies for measuring and reporting performance information related to medications and medication management. Today, PQA represents more than 150 pharmacy stakeholders from a variety of fields—community pharmacy, pharmaceutical manufacturers, health plans, pharmacy benefit managers, academic universities, government agencies, long-term care facilities, health solution vendors, associations, and many more.

PQA originally created measures related to appropriate and safe medication use for inclusion in the evaluation of Medicare pharmacy plans. PQA had seen uptake of its measures in the Medicare Star Ratings, with 5 measures included and an additional 4 utilized as display measures. Over PQA’s 8-year history, the utilization of PQA measures has expanded to areas outside of Medicare as well. PQA continues to create measures not only for use at the health plan level, but also for use by community pharmacies, long-term care facilities, and integrated care teams.

High adherence is considered to be a proportion of days covered (PDC) of >80% for most medication classes. One exception is antiretrovirals, where the target adherence goal is PDC >90%. PDC is 1 of 2 key measure calculations of adherence that are utilized in health care: the other is the medication possession ratio (MPR). MPR can be calculated through various methods to obtain a summation of the days’ supply of medication, which commonly results in an overestimation of a patient’s adherence. The lack of standardization in a definition only further complicates this issue. PDC is calculated according to fill dates and day supply, along with measuring for full persistence across the measurement period, not stopping after the last fill as MPR does. The utilization of PDC allows for a more accurate, conservative reflection of a patient’s adherence level. Because of its accuracy, consistent definition, conservative estimations, and extended application to multiple medications, PDC is considered by PQA to be the preferred method of adherence calculation.

Additionally, and equally as important, PDC is considered to be the most appropriate methodology for calculating adherence by a variety of entities, including the National Quality Forum (NQF), the Centers for Medicare & Medicaid Services (CMS), the National Committee for Quality Assurance, URAC, and the Center for Clinical Standards and Quality, for use in health insurance exchanges. PQA encourages all pharmacies to align their adherence calculation methods with national standards.

Medication adherence has been identified as a $290-billion per annum problem in the United States. Several key PQA measures focus on adherence to medications, particularly chronic, high-prevalence disease states. The first measures created by PQA were PDC for antihypertensive agents, non-insulin diabetes medications, and statins. PQA also created additional measures focusing on high-cost medication treatment adherence: antiretroviral medications and non-warfarin oral anticoagulants.

Measurement of adherence is considered to be an intermediate outcome measure by CMS, meaning that these measures target a specific result that can help patients achieve an improved health outcome. These measures are triple-weighted inside the Medicare Stars rating program, indicating CMS’ recognition of the importance of appropriate medication use. For this reason, health plans focus on strategies to improve adherence. Plans are beginning to evaluate the performance of pharmacies on quality metrics and adopting strategies related to underperforming and high-performing pharmacies.

The ability of pharmacists to improve patient outcomes and overall patient health has been accentuated by the integration of quality metrics into pharmacy evaluation. The high level of attention this has received is due in large part to Medicare quality bonus payments (QBPs), which have resulted in an increased focus on medication use and safety measures because of the relative weighting and the importance of the adherence and medication safety measures’ impact on the QBP and overall Star rating. Medicare QBPs are bonuses provided to Medicare Advantage plans that receive a 4- or 5-star quality rating. Health plans and pharmacy benefit managers have begun altering their payment strategies to include performance-based payment mechanisms, determined by the pharmacy’s performance on quality metrics.

In October of 2013, Inland Empire Health Plan (IEHP) initiated a pay-for-performance program for network pharmacies in California, focusing pharmacist involvement in improving these health metrics. IEHP’s quality measurement system for pharmacies consisted of the CMS Part D Stars measures, while also integrating additional quality measures they identified as important to the specific population they serve. IEHP had identified asthma as a targeted disease state in their population and utilized 2 additional metrics focusing on proper treatment of asthma with controller and rescue medications. Program participation is optional for eligible pharmacies (eligibility determined by pharmacy location, prescription volume, and status in their pharmacy network), but eligible pharmacies receive a bonus payment based on the pharmacy’s performance and the number of IEHP prescriptions filled by the pharmacy.

IEHP’s program is not the only example of a health plan realigning incentive for their network pharmacies. An increasing number of health plans and PBMs are focusing on pharmacy quality measurement results, and are evaluating modifications to how pharmacies are included in programs and reimbursed in the future. These modifications include preferred pharmacy networks to include only pharmacies that provide the greatest quality on star metrics. Two additional practices considered by payers include bonuses and withholds. Bonuses can be included in pay-for-performance programs for meeting or exceeding specified quality goals. Withholds occur when payers hold back a portion of the payment depending on whether the pharmacy meets the desired quality metric goals. Public-facing performance report cards for pharmacies are also being considered for future use.

However, this modification is not only expected in Medicare plans, but also in other plans, possibly including Medicaid, commercial and exchange. Adherence metrics have been added to the Health Insurance Exchange Quality Ratings System beta test and will be used in the evaluation of exchange plans.

The position of a pharmacist as the “most accessible health care professional” has facilitated the creation of pharmacy pay-for-performance (P4P) programs. Pharmacists are in an ideal position to intervene with patients pertaining to improved medication use. Pharmacists have demonstrated their ability to impact patient health through improved adherence, and meeting desired guideline-defined disease management goals. This is particularly noted in high-prevalence, high-burden chronic diseases such as hyperlipidemia, diabetes, and hypertension, key focuses of many performance measures.

The future is full of opportunities for pharmacists to deepen their contributions to patient care and work in concert with other providers to address common goals. With health plans becoming increasingly focused on achieving high performance on quality, pharmacists equipped with current quality knowledge will stand at a unique advantage. As experts in medication management, pharmacists are critical to the achievement of positive health care outcomes. These pharmacists will be ready to work in collaboration with other providers, patients, and health plans to optimize health care, and demonstrate the value of their services in achieving improved adherence and medication safety results. 

Laura Cranston, RPh, serves as the executive director of the Pharmacy Quality Alliance (PQA, Inc). In this role, she oversees the development of medication use measures and works with organizations, including health plans, pharmacy benefit managers, community pharmacy organizations, employers, and others to encourage the uptake and implementation of meaningful medication use measures into the marketplace. Additionally, Laura serves as pharmacy’s representative on the National Priorities Partnership, an initiative convened by the National Quality Forum. She also serves on the Quality Alliance Steering Committee.

Prior to her current position, Laura served as the executive director for the Institute for the Advancement of Community Pharmacy. For over a decade, Laura served as the vice president of pharmacy affairs for the National Association of Chain Drug Stores.

Laura currently serves as chair of the dean’s advisory council of the St. John’s University College of Pharmacy and Health Sciences, the Washington DC Alumni President of the St. John’s University Chapter, the University of Notre Dame College of Pharmacy Board of Advisors, and she also serves on the St. John’s Board of Governors for the University.

Laura is a pharmacy graduate of St. John’s University College of Pharmacy and Allied Health Professions in New York.

Laurin Dixon, PharmD, serves as the 2013-14 Pharmacy Quality Alliance (PQA) Fellow. As the inaugural PQA Fellow, Laurin will be instrumental in shaping the PQA custom-tailored, 1-year, postgraduate training program. She will be working with issues related to appropriate medication management and use as well as managing PQA projects and research initiatives. Laurin will also participate in the PQA work group process to support quality metric design and use. Laurin joins PQA as a new Doctor of Pharmacy graduate from the University of Mississippi School of Pharmacy. Laurin has supplemented her formal education with pharmacy experience at Walgreens, including the honor of being selected to Walgreens’ Corporate Internship program.

Articles

Adherence measurement can help patients achieve better outcomes.

Emerging Trends in Adherence and Quality Measurement: What the Future Holds

Accountability and performance metrics are becoming a reality as pharmacists focus on quality of care. Pharmacists must anticipate and respond to the tidal shift.

The American health care landscape is shifting—and the pharmacy profession must shift with it. Health care delivery in the United States is both nuanced and enigmatic.

Our care delivery system has been vilified for its fragmentation, inaccessibility, and waste, while simultaneously praised for its innovation, skilled workforce, and resourcefulness. The changing landscape is full of both challenges and opportunities for pharmacy, which will only increase in the next 12 to 24 months as the hard work of fully implementing the provisions of the Patient Protection and Affordable Care Act (ACA) continues.

As pharmacists, we must anticipate and respond to the tidal shift within the health care marketplace as a result of the ACA rollout. Federal and state governments, payers, and providers are increasingly reframing health care issues in terms of value, rather than strictly in terms of cost. This is reflected throughout the provisions of the ACA, with emphasis and incentives on improved quality and performance measurement serving as drivers of a new paradigm.

Providers and payers are rewarded for assuming population health risks and lowering overall costs while maintaining or improving quality. Emerging delivery models such as accountable care organizations (ACOs), and penal programs such as the Centers for Medicare & Medicaid Services (CMS) Readmissions Reduction Program, share common elements of care coordination requirements and data-driven quality measurement.

Pharmacy needs to answer these questions regarding our integration into the post-ACA environment:

What are the real implications and opportunities for pharmacists within the short and medium terms?

How can we best position ourselves to play a meaningful role in driving improvements in patient care within the evolving system?

In order for pharmacy as a profession—and pharmacists as individual practitioners&mdash;to deepen their collective contributions, there are several key steps that we should take.

The ACA includes several mechanisms that will lead to a substantial number of previously uninsured individuals becoming covered. A March 2010 Congressional Budget Office report indicated that the ACA will increase the number of insured non-elderly Americans from 83% to 94% by 2019. For elderly patients, the gradual closing of the Medicare Part D donut hole by 2020 will increase patient access and the use of pharmacies. The challenge lies in how we handle the increased volume of patients within our health care system—both at the primary care level with the shortage of physicians, and as pharmacists with the increase in the prescription volume. First, it is necessary to recognize that the emerging system is trending to reward 

As a profession, how do we ensure that there is value within the medication use system? Defining that value is critically important.

Value in today’ s health care system is measured through performance metrics. The National Quality Forum has nearly 700 endorsed measures that are used across health care settings. Each year, it reviews hundreds more for recommendation to various agencies within the Department of Health and Human Services. Pharmacy is far from exempt from performance measurement. The CMS has adopted several Pharmacy Quality Alliance measures generated using prescription claims data to calculate star ratings for Medicare D and Medicare Advantage plans.

As pharmacists, are you aware of the development of performance metrics that apply specifically to medication use and medication therapy management (MTM) services? Do you know how medication adherence is measured? Are you aware there are measures that look at how many comprehensive medication reviews are completed within the Medicare program for beneficiaries that qualify for an MTM benefit within their plan?

These measures will begin to shape how pharmacy practice continues to evolve. They are not only used by government agencies. In fact, some employers are already using performance metrics on appropriate medication use as an integral part of the way they evaluate the performance of both the pharmacies they run and the pharmacists they employ.

With the health care system, value is measured for nearly all providers. Doctors, hospitals, nursing homes, home health care agencies, dentists, and others are all directly measured. There are websites dedicated to public reporting of the performance of doctors, hospitals, nursing homes, and more. Pharmacies and pharmacists have thus far existed outside of this paradigm, but are unlikely to be able to do so for much longer. While it may yet be several years before pharmacies’ performance is publicly reported, as it is with other providers, the movement exists for performance to be measured across pharmacy providers in today’ s environment.

The Meaning of Accountability for Pharmacists

Within the health care system, accountability is moving front and center. Accountability for outcomes and performance as well as incentives for meeting certain high levels of quality care is becoming a reality. This accountability is being driven from many angles—by payers, employers, and also the federal government.

For pharmacists, however, there is a key step that we need to achieve before we can have direct accountability for our services and actions. This is a major rationale behind the collective effort amid national and state-based pharmacy organizations to pursue the recognition of pharmacists as health care providers as defined by the Social Security Act.

If we truly want to optimize value in our health care spending, Medicare must include pharmacists’ clinical services that are provided in collaboration with physicians and other providers on the health care team. Recognition of pharmacists’ clinical services in the non-physician part of Medicare Part B would help to improve patient outcomes and assist physicians and other providers in effectively addressing the complex health care needs of patients.

This provider listing is not only used within Medicare Part B, but also by ACOs, state Medicaid programs, and other payers to determine payment policies and services covered. Achieving direct provider recognition of pharmacists would be a giant step forward in terms of being able not only to provide the clinical services that pharmacy has been offering, but also being able to be directly compensated for these services as well.

The change in provider status needs to accompany an accountability mind-set. That accountability extends beyond the 15-minute window when our patients are our customers. Pharmacists must take responsibility for their panel of patients, and think carefully about their contributions to managing the health of individuals and populations. Managing medication therapy includes taking responsibility for medication adherence, talking with patients about their therapy, addressing medication concerns, and making connections with patients who are not coming into the pharmacy when they should be.

Narrowing of Networks: Quality Means Marketability

Pharmacies that ignore the trend lines now run the risk of being increasingly cut out of the game. The narrowing of provider networks is already a prominent feature of the emerging health care landscape. Cost cutting within employer-based plans, increasingly managed care—heavy Medicaid programs, and the naturally narrower options within ACOs and Patient-Centered Medical Homes are becoming more pronounced features of the landscape. Within pharmacy, we see this paradigm unfolding as well.

Plans and payers have created preferred pharmacies—and they are a very prevalent reality in 2013. While the narrowing of preferred pharmacy networks to date has not been based on quality, we are seeing those dialogues beginning to take place in the market. Once quality becomes the determinant in creating networks based on performance against clinical measures, it will become the focal point in maintaining a pharmacy’ s marketability. Individual pharmacists, pharmacies, and the profession as a whole must include a focus on quality to remain viable within the new health care landscape.

Laura Cranston, RPh, serves as the executive director of the Pharmacy Quality Alliance, which is a multi-stakeholder organization established in April 2006 to improve the quality of medication management and use across health care settings with the goal of improving patients’ health through a collaborative process to develop and implement performance measures and recognize examples of exceptional pharmacy quality. Prior to her current position, Laura served as the executive director for the Institute for the Advancement of Community Pharmacy, an organization whose mission was to advance the practice of both independent and chain community pharmacy in the United States. Samuel F. Stolpe, PharmD, is associate director of quality initiatives at the Pharmacy Quality Alliance and an adjunct faculty member at Howard University. Dr. Stolpe collaborates on a number of research and demonstration projects exploring expanded roles for community pharmacists. He plays a key role in developing and implementing intervention strategies that improve medication-based performance metrics.