Pay for outcomes is here to stay. What therapeutic end points to evaluate success are on the horizon?
In last month's editor's note, I traced the origins of health plan adherence measures from the Medicare Modernization Act of 2003, which spurred the creation of the medication-related Star Ratings. Proportion of days covered (PDC) measures became the initial and dominant pharmacy measure owing to the convenience and ubiquity of prescription claims alongside a health system and policy awakening to the problem of medication nonadherence. These PDC adherence measures were developed and specified for use at the health plan level and intended to be used in the Medicare Stars program to evaluate health plan and Part D Plan performance. Over time, PDC adherence measures have been pushed down to pharmacies via contracting and used to measure pharmacy location-level performance, often inappropriately tied to direct and indirect remuneration fees. Importantly, any use of PDC for the Medicare Part D Stars program is not endorsed by Medicare. There is no community pharmacy performance program in place for Medicare.
PDC remains a priority for Medicare Part D stand-alone prescription drug plans and Medicare Advantage prescription drug plans because of triple weighting, which makes those measures more influential in the overall rating. Now the question in front of policy makers is: What should a community pharmacy quality program look like?
What Do Policy Makers, Providers, and Purchasers Want to Accomplish?
The more than 4 billion prescriptions filled each year in the United States should all have a therapeutic goal. Whether the goal is to abate, alter, or cure, each prescription and fill should have a specific, measurable, attainable, relevant, and timely (SMART) measure. Pharmacy performance measures should focus on controlling and improving therapeutic end points, such as glycated hemoglobin (HbA1c), mm Hg, or a reduction in disease progressions, such as diminished heart, kidney, and lung function. Screening and assessment instruments for asthma, behavioral health, and chronic obstructive pulmonary disorder can reliably assess disease progression and the need for referral and treatment. These measurement tools are closely associated with better outcomes for patients and could ultimately motivate a more cost-effective, high-quality pharmacy care system by promoting optimal medication use, not just more medication use.
Difference Between More and Optimal
Yes, we are all filling more medications in higher quantities than we were in 2006, when these measures were first formally considered, and a few years later when they were adopted by the Centers for Medicare & Medicaid Services (CMS). The measurement thresholds for the PDC measures have remained consistent at 80%. The industry’s benchmark for percentage of patients who meet the PDC measure threshold has increased. The 2021 three-star threshold for the percentage of members achieving 80% for diabetes, PDC was 80% of the membership, whereas the commensurate threshold for HbA1c under control was 61% of the membership. The thresholds for 4 stars were 84% and 72%, respectively. That is a large gap between increased prescription filling rates and the desired outcome: achievement of therapeutic goals.
Promising Progress Replaces Excuses
When it comes to excuses for not measuring community pharmacies on therapeutic goals, I have heard it all: community pharmacies are not good sites of frontline care delivery and screening, community pharmacies cannot perform labs or take vitals, and community pharmacists are not real medication experts. Not every community pharmacy can intervene, collect, transmit data, and move meaningful measures, so no pharmacy should be allowed to do it. It is all a ruse to maintain the status quo, using a health plan measure to misapply to pharmacies, and that status quo is breaking the backs of community-based pharmacies. Health insurers should be measured on member access to drug therapies, and PDC can do that well. Health care service providers should be measured on health care service delivery, and to that end, PDC falls short.
The COVID-19 pandemic has brought about a potential inflection point. Consumers now see pharmacies as convenient places to receive care, not just buy things. Plans have started to change the aperture to a wider view of what pharmacy can do to help clinical measures: patient care and quality. Policy makers now understand the scale of community pharmacy. Most vaccines for the past 8 months have been administered in a pharmacy because the public now has a choice of service providers, and pharmacies are their preferred providers.
The Pharmacy Quality Alliance (PQA), the steward of several of the medication-related quality measures used in the CMS Star Ratings program, is piloting a set of standardized pharmacy performance measure concepts in 2022 centered around control, improvement, and reporting of therapeutic end points, such as HbA1C and blood pressure, as well as closing gaps in care for immunizations. Multiple plans are engaging in value-based agreements with pharmacies to address areas of clinical need and therapeutic goals, such as HbA1c, emergency department visits, hospitalizations, mm Hg, psychometric screenings, shared savings, and other quality program initiatives, such as clinical Stars and Healthcare Effectiveness Data and Information Set, to support other care team members’ existing incentive programs and performance. The clinically integrated pharmacies with which I work daily (Community Pharmacy Enhanced Services Network) alone have more than 40 active contractual relationships focusing on these types of outcomes. Big props to PQA and these health plans for seeing and acting on an important change to a more sustainable, patient-centered state of practice.
Using Therapeutic End Points to Measure Pharmacy Success: Start Now
There is a well-worn adage that can often be applied against resistance to health system improvement: the second-best time to plant a tree is today. Detractors to systems change will point to unyielding inertia, complexity, and long-time horizons as reasons to resist evolution. Yet, those minds are never able to answer a simple question: If not now, then when? It is time to evolve, plant the next tree(s), and focus on pharmacist and pharmacy performance using therapeutic outcomes. It’s kind of insane that it has not happened already. We are the medication optimization people after all, aren’t we?
Troy Trygstad, PharmD, PhD, MBA, is the executive director of Community Pharmacy Enhanced Services Network (CPESN) USA, a clinically integrated network of more than 3500 participating pharmacies.
Trends in Part C & D star rating measure cut points. Centers for Medicare & Medicaid Services. Updated October 20, 2020. Accessed January 27, 2022. https://www.cms.gov/files/document/2021-cut-point-trend.pdf