Watch the Stars and See Yourself Running with Them
Pharmacists play a crucial role in the achievement of health care quality improvement goals.
Pharmacists play a crucial role in the achievement of health care quality improvement goals.
The title of this piece is taken from Marcus Aurelius’ Meditations, where it was intended as an invitation to dwell upon beauty. Here it serves an entirely different purpose. Pharmacists, too, should be watching the stars and preparing to run with them, as the Medicare Part C and D 5-Star Quality Rating System drives increasingly significant changes in pharmacy practice.
Pharmacy is embedded within an evolving quality measure—focused health care environment. With the passage of the Affordable Care Act in 2010 and the establishment of the National Quality Strategy in 2011, the stage has been set for sweeping changes in the way that health care providers—including pharmacists—deliver services and are evaluated and reimbursed. Because of a greater emphasis on the quality and value of health services provided, rather than the quantity, pharmacists have already begun to take on expanded roles in the health care system.
More recently, the signals from the Centers for Medicare & Medicaid Services (CMS) suggest an even more ambitious move toward value-based care. In late January, Health and Human Services (HHS) Secretary Sylvia Burwell announced a goal of tying 85% of fee-for-service (FFS) Medicare payments to quality or value by the end of 2016. HHS’ goal is for 90% of these payments to be tied to quality or value by the end of 2018.1
Secretary Burwell’s announcement was quickly followed by news of the formation of the Health Care Transformation Task Force, a consortium of large health plans and employers whose aim is to shift 75% of their operations to contracts designed to improve quality and lower costs by 2020.2 Bipartisan legislation proposed in both houses of Congress seeks to designate pharmacists as health care providers in medically underserved communities under the Medicare program. Because providers in the new health care environment are held accountable for the quality of care they deliver, pharmacists should expect an increasing expansion of accountability commensurate with their expanding suite of health care services. We should also anticipate increasing changes in the ways in which pharmacists are being reimbursed.
It all adds up to a crucial role for pharmacists in delivering team-based quality health care that aims to improve health outcomes and reduce medical costs and utilization. Pharmacists can expect to see changes both in the scope of services they provide and the ways they are incentivized and reimbursed by health plans over the next few years.
With health care reform, HHS’ National Quality Strategy defined 6 primary quality strategies for US health care, including improvement of the clinical quality of care, patient- and caregiver-centered experiences, care coordination, patient safety, progress in community and population health by reducing health disparities and expanding access to health care services, and enhancing efficiency and reducing costs.
CMS quality and performance programs encompass health care delivered in hospitals through rehabilitation facilities, nursing homes, hospices, and home health agencies, and delivery of services by clinicians. The CMS payment model reporting includes programs like Medicare’s shared savings program and “population-based” reporting that includes ratings for health insurance exchange marketplaces and the star rating system for Medicare Parts C and D.
Medicare Star Ratings
Health plans have tremendous financial incentives to “drive to 5,” meaning to get their ratings as high as possible in the 5-star rating system. Medicare Advantage plans are rewarded with bonus payments for high ratings in the 5-star system, which can mean hundreds of millions of dollars for a health plan each year. Performing poorly can also have a major impact: CMS has the option to remove a plan from Medicare if the plan receives an overall star rating of less than 3 stars for 3 years in a row. With such incentives to achieve high star ratings, health plans have begun to use financial incentives to motivate providers— including pharmacists—to achieve high marks on quality measures.
The star ratings for Medicare Part D drug plans include an overall rating on quality and scores in 4 domains with 13 different measures. These measures assess patient experience, pricing stability and accuracy, and the clinical quality of medication use in the drug plan. Among these quality metrics are 5 measures developed by the Pharmacy Quality Alliance (PQA) that are highly sensitive to pharmacist interventions. Not all measures are created equal; however, due to the higher weighting of clinically relevant measures, these 5 PQA medication-use measures account for 50% of Part D summary ratings for 2015. Among those weighted the most heavily are measures pertaining to the safety of high-risk medications in the elderly and medication adherence for patients with chronic conditions such as diabetes, hyperlipidemia, and hypertension. These measures are in the pharmacist’s wheelhouse. As a result, health plans are increasingly reliant on pharmacies to help them achieve their quality goals.
The Changing Landscape in Pharmacy
These developments mean that reimbursements and payments for pharmacists are changing. Rather than being paid solely based on the quantity of medications prescribed, pharmacies will increasingly receive financial bonuses for achieving top performance in measures of adherence and medication-use safety. High-performing pharmacies are also more likely to be included in health plans’ preferred networks, helping to boost the number of plan beneficiaries that the pharmacies serve.
These changes are already influencing the ways in which some pharmacists practice. Many national plans, such as CVS Health’s Silverscript Part D plan, as well as regional health plans, such as the Inland Empire Health Plan, have already introduced pay-for-performance (P4P) programs for pharmacies. With the Inland Empire Health Plan P4P system that began in 2013, pharmacies are evaluated on quality measures. Financial bonuses are paid twice annually based on pharmacy performance on medication-use measures and the number of patients at each store.
Shifting the focus to quality-related goals rather than quantity of drugs sold improves the quality of health care provided by each pharmacy. This focus on quality and value of pharmacy services will also be supported by the ways in which financial compensation is structured, so pharmacists will not just be performing additional services without reimbursement.
The Electronic Quality Improvement Platform for Plans and Pharmacies
To improve performance, it is important to measure it. One benchmarking tool that can support the movement of pharmacies toward quality-related goals is a platform called EQuIPP, or the Electronic Quality Improvement Platform for Plans and Pharmacies. EQuIPP is a software program now being run within 55,000 pharmacies nationwide. Among other functions, it tracks pharmacy performance on 6 of PQA’s quality measures, including 5 that affect a Part D plan’s star rating and 1 measure that is displayed by CMS on its website (Figure).
EQuIPP tells a pharmacy whether they’re achieving the goals they set for various PQA quality measures, such as adherence to cholesterol medication. The program also identifies achievement gaps—the areas or quality measures in which they are not achieving their goals—and indicates the average performance on a measure within a given organization or state. For example, a pharmacy may set a goal to have 75% of its patients adhere to a cholesterol medication plan. If their EQuIPP scores indicate that just 70% of their patients are adherent, they know they need to improve their quality efforts in this area.
Pharmacists’ Changing Role and Impact on Outcomes
Although performance goals are set by organizations outside of pharmacy, each pharmacy or pharmacy chain has the freedom to design programs aimed at achieving high ratings. To be successful, pharmacists will need to make a cultural shift to focus more on quality. Good practices include offering more services such as comprehensive medication reviews, appointment-based medication synchronization (covered in this issue’s article, “Improving Quality Care: The Appointment-Based Model”), and prescriber outreach programs aimed at improving appropriate safe prescribing practices. Pharmacies may also benefit from having a quality champion on staff to ensure that quality goals remain at the forefront of daily encounters.
The strong influence on quality and patient-centered care may change how pharmacists approach the ancillary services they provide, such as medication therapy management. For example, if a comprehensive medication review with a patient indicates that they have poor health literacy and poor adherence to their medication, taking the time to educate this patient about the importance of their medications may lead to improved adherence and better patient outcomes—and ultimately, greater financial compensation for the pharmacy.
To improve medication adherence and safety, including reducing drug—drug interactions, community pharmacies will likely need to reallocate resources. They may also need to do more community outreach to health care providers, who are also delivering care to patients who patronize the pharmacy. For example, some measures depend on getting prescribers to change a medication to ensure that patients are receiving appropriate therapy that does not put them at an increased safety risk.
The results of improving performance on medication adherence and safety can mean real change in patient outcomes. PQA’s analyses of average plan performance on PQA metrics indicate that adherence to diabetes, cholesterol, and hypertension medications in Medicare Advantage Part D plans has significantly improved since 2012 with quality measures. For example, in 2012, 68% of patients in Part D plans were adherent to their cholesterol medications, whereas the most recent figures indicate that adherence has increased to 74%.
Applicability Within ACOs
Secretary Burwell’s announcement regarding connecting FFS payments to value also included targets for the settings where these payments occur. HHS is now calling for 30% of all FFS payments to occur within accountable care organizations (ACOs) or bundled payment models by 2016, moving to 50% by 2018.1 This represents an important opportunity for pharmacists. Pharmacies currently influence a number of measures in ACOs, including immunization rates, diabetes and heart medication use, and glycated hemoglobin and hypertension control. ACO measures that are likely to be impacted by pharmacists in the future include 30-day hospital readmissions, unplanned admissions for patients with chronic conditions, depression remission, and therapies for coronary artery disease. ACO quality measures are summative, however, and although they can identify whether quality goals are being achieved, they currently do not assess pharmacies’ contributions toward these measures. This is expected to change as ACOs will draw on a wide range of data sources to assess performance, including prescription claims data, e-prescribing, and pharmacy dispensing data. The better prepared pharmacists are at meeting quality goals in the community setting, the better prepared they will be to meet them once ACOs begin to hold pharmacies accountable.
The top performers on quality measures are those pharmacies for which there is a cultural mentality that understands the value of quality improvement; they understand where health care is going. They also understand both the clinical value of quality improvement and the value proposition associated with high performance on quality measures. By becoming facile at measuring progress toward quality improvement and meeting goals for quality measures, pharmacists can not only improve health care outcomes, but also enhance financial payments and cost savings for pharmacies.
Samuel F. Stolpe, PharmD, is the senior director of quality strategies at the Pharmacy Quality Alliance (PQA), an organization that develops scientific methods of measuring safe and appropriate medication use for large patient populations. Sam leads PQA’s efforts in capturing the voice of the patient in PQA’s measurement development process through its Patient Advisory Panel. He also serves as the PQA staff liaison to the PQA Adult Immunization Task Force. Sam is responsible for directing PQA’s research projects and educational initiatives. His most recent work has been focused on the adherence impact of medication synchronization and the use of motivational interviewing techniques by pharmacists at the point of dispensing. Sam’s work on PQA educational initiatives includes oversight of the Academic Affairs Committee, the PQA Ambassador Program, and the Educating Pharmacists in Quality CE training program. He directs both the PQA fellowship program and the PQA advanced pharmacy practice experiences program for fourth-year PharmD students. Sam’s work also includes an adjunct faculty position at Howard University where he teaches health policy, as well as ongoing work as a community pharmacist.
- Better, smarter, healthier: in historic announcement, HHS sets clear goals and timeline for shifting Medicare reimbursements from volume to value [news release]. US Department of Health and Human Services website; January 26, 2015. www.hhs.gov/news/press/2015pres/01/20150126a.html. Accessed March 2015.
- Major health care players unite to accelerate transformation of US health care system [news release]. Health Care Transformation Task Force website; January 28, 2015. www.hcttf.org/releases/2015/1/28/major-health-care-players-unite-to-accelerate-transformation-of-us-health-care-system. Accessed March 2015.