Let Quality Be Our North Star

Pharmacy Times Oncology Edition, March 2015, Volume 2, Issue 1

High-quality care is essential to patient satisfaction.

High-quality care is essential to patient satisfaction.

As the systemwide movement from fee-for-service to fee-for-value accelerates, delivery of high-quality care will become ever more important for providers’ sustainability. There are at least 3 fee-for-value domains that are directly affected by quality. The first, patient satisfaction, is the ultimate representation of quality in the new system of care, as provider star ratings, consumer ratings, and survey results (such as Consumer Assessment of Health Care Providers scores) begin to drive consumerism. Price sensitivity, a combination of price point and satisfaction, is now a focus for employers, legislatures, local municipalities, and the individual marketplace. For no group is this move to value more prominent than in the rapidly increasing percentage of the population that has elected to take part in a high-deductible health plan, where price sensitivity has its greatest influence and each individual insured is making a value-based decision when electing whether or not, or from whom, to receive health care products and services.

The second domain, quality measurement, is meant to provide a mechanism by which purchasers and patients can evaluate providers on their quality. Quality measures are a proxy for value, and at least with respect to purchasing insurance, the latest evidence seems to indicate these measures are effective in channeling customers. Competition among Medicare Advantage plans is intense, and their star ratings (driven in part by patient satisfaction, but mostly by quality measures) are now known to be highly influential in plan selection. The relationship between community pharmacy and pharmacy benefit managers (PBMs) is evolving as the expectations of quality measurement reach the local pharmacy provider. PBMs must now consider value, rather than simply cost, when constructing pharmacy networks. When viewed in its totality, the profession of pharmacy will find itself simultaneously competing with, while also collaborating with, other provider types and professionals as competition for delivery of high-quality, high-value services ramps up and quality measurement and comparative effectiveness across professions becomes a popular area of research and evaluation over the next decade.

The third domain, cost of care, is the primary motivator for most purchasers of health care. To date, the focus of containing growth in the cost of care has been accomplished by restricting access to care through utilization reviews and limitations on coverage. Now, with guaranteed issue, a fixed floor on the medical loss ratio, and mandatory categories of coverage established as the law of the land through the Affordable Care Act, entities that are at risk for health care costs (insurers, employers, and legislatures) are pushing cost sharing to the consumer and turning to quality focus as the means of containing cost and ensuring sustainability.

Lower costs through better, more efficient, and high-quality care: let that be our North Star as we enter the new system of value-driven purchasing.

Troy Trygstad, PharmD, PhD, MBA, is the director of the Network Pharmacist Program and Pharmacy Projects for Community Care of North Carolina (CCNC), a parent organization of 14 regional care management networks. These networks bring together medical practices, county health departments, hospital systems, and mental health providers to integrate care delivery for Medicaid, Medicare, private plans, employers, and the uninsured. CCNC and its networks are responsible for developing and evaluating accountable care systems in North Carolina.Under his direction at CCNC, the Network Pharmacist Program has grown to include pharmacists who are involved in a number of diverse activities ranging from patient-level medication reconciliation to practice-level e-prescribing facilitation to network-level management of pharmacy benefits. Dr. Trygstad also plays an integral role in health information technology adoption and proliferation with CCNC practices and across the state, leading e-prescribing adoption efforts as well as the development and deployment of a statewide medication management platform.He has been involved in novel adherence implementations as well as the development of adherence technologies that use administrative claims data to predict, intervene, and triage adherence interventions and coaching opportunities. Dr. Trygstad received his PharmD and MBA degrees from Drake University and a PhD in pharmaceutical outcomes and policy from the University of North Carolina. He is co-editor-in-chief of the Pharmacy Times series Directions in Pharmacy®.