Quality Management News and Information for Pharmacy. Plan Star Ratings. By David Nau, PhD, RPh, CPHQ

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1 URAC spring 2012 Volume 5 Issue 1 AMCP Quality Management News and Information for Pharmacy About URAC About AMCP Best Practices in Pharmacy Management Framework for Improving Medicare Update on Medication Quality Measures Best Practices in Pharmacy Management for Consumer Protection and Empowerment Promoting Innovative Programs That Benefit Consumers As part of the 2011 Quality Summit and Award Program held October 4-6, in Chicago, Illinois, URAC recognized the winners of its Best Practices in Health Care Consumer Protection and Empowerment Awards. [more on page 2] Framework for Improving Medicare Plan Star Ratings Designed by the Center for Medicare and Medicaid Services (CMS), the five-star rating system is a quality and performance scoring method used for certain plans offered to Medicare beneficiaries. This [more on page 4] Sponsored by: Update on Medication Quality Measures in Medicare Part D Star Ratings Understanding the CMS Quality Evaluation System By David Nau, PhD, RPh, CPHQ There are multiple components to CMS evaluation of medicationrelated quality across Medicare Parts C and D. The Centers for Medicare and Medicaid Services (CMS) creates plan ratings that indicate [more on page 8] Readership Questionnaire URAC and AMCP want to better understand how our readers are using the newsletter and what we can do to improve it. Please help us by completing a brief questionnaire. Click here or visit 1

2 Best Practices in Pharmacy Management for Consumer Protection and Empowerment [CONTINUED FROM PAGE 1] The awards recognize health care management programs that engage consumers as partners, including the category of Pharmacy Management. Our Best Practices awards program is a unique celebration of innovative pharmacy management programs. These organizations have implemented leading-edge programs that have made a difference in the lives of the consumers they serve with demonstrable results that matter, said Alan P. Spielman, president and CEO of URAC. This year s winners are recognized for their leadership in delivering on the promise of a quality care system that puts consumers first. Entries were judged by a distinguished 20-member panel of prestigious, independent judges including recognized experts in program evaluation, care coordination, health information technology, employer and purchaser decision making and patient safety. Entries were reviewed and scored by the judges based on objective criteria including whether the program was measurable, if it was reproducible and delivered through a collaborative approach. Honors were awarded in the categories of Consumer Decision-Making and Consumer Health Improvement. The winners of the 2011 Best Practices in Health Care Consumer Protection and Empowerment Awards in the category of Pharmacy Management included Platinum Award winner Catalyst Rx for its program, Empowering Members with Vital Information on Lower Cost Drug Alternatives; Silver Award winner Medco Health Solutions, Inc., for its program, A Specialist Pharmacist Care Model for Improving Medication Adherence, and Bronze Award winner CVS Caremark for its Pharmacy Advisor program. Information about each winner follows. macy, behavioral psychology and technology experts with the goal of lowering costs while improving care. The Generic Advantage Plan has broad applicability. Results show that the combined features of the program improve generic utilization and medication adherence substantially. The expanded plan was introduced in late 2009 on a limited basis and clients that implemented the pilot program experienced significant savings in On average, generic utilization increased ten percentage points and plan costs decreased by 16% across targeted drug categories within a year of initiating the plan. Medco Health Solutions, Inc., A Specialist Pharmacist Care Model for Improving Medication Adherence Medco has developed and implemented a Specialist Pharmacist care model. This model improves medication adherence with essential medications, patient safety and affordability of drug regimens for patients with chronic conditions. Improving medication safety and adherence are primary goals. Secondary goals include improving patient satisfaction with their pharmacy and lowering cost of care. The Medco Specialist Pharmacist care model offers pharmacists who have specialized training and are accredited in one of 15 chronic conditions or therapeutic areas. Specialist training is delivered through accredited continuing education (CE) programs. The Medco Specialist Pharmacist practice experience is focused on addressing the pharmacy needs of patients in the pharmacists area of specialty. In addition, the Medco Specialist Pharmacists are trained in the behavioral approach to improving patient medication adherence. Groups of Specialist Pharmacists are co-located into Medco Therapeutic Resource Centers; i.e., specialized pharmacies dedicated to their specialty, such as diabetes. Within the Medco Therapeutic Resource Centers, the Specialist Pharmacists process prescription orders for patients with needs in that specialty, and they counsel patients and their physicians, in their specialty. Their counseling is supported by information systems that enable review of patient-level data and evidence-based clinical protocols to effectively manage, prioritize and optimize specific therapies for each patient. The focus of the Specialist Pharmacists allows them to improve members medication adherence by monitoring for and closing gaps in pharmacy care. Specialist Pharmacists use evidence-based clinical protocols to identify and address clinically significant gaps in care, including Catalyst Rx, Empowering Members with Vital Information on Lower Cost Drug Alternatives The Catalyst Rx Generic Advantage Plan combines innovative programs and technology to drive generic utilization and lower costs while improving care. The program deploys a series of customizable features, including targeted member and prescriber education initiatives, implementation of Catalyst s Formulary Advantage which enhances formulary compliance and increases generic utilization and promotion of the company s award-winning Catalyst Rx Price and SaveSM, a web-based, transparent drug pricing look-up tool, all of which empower consumers to make more educated purchase decisions. The program was developed after more than a year of consultation with phar- [more on page 3] 2

3 Best Practices in Pharmacy Management for Consumer Protection and Empowerment [CONTINUED FROM PAGE 2] adherence to essential medications and omission of essential medications or testing. They further assist patients in understanding their medications and provide personal support and counseling. When cost is a potential barrier to adherence, Specialist Pharmacists can inform patients about opportunities to lower the cost of their prescriptions, based on each patient s specific benefit plan. CVS Caremark, CVS Caremark s Pharmacy Advisor To manage medical costs, improve medication adherence and close gaps in care for chronic conditions, CVS Caremark developed Pharmacy Advisor, an innovative solution that improves pharmacy care through brief, targeted and proactive consultations across the continuum of care. CVS Caremark engages members according to their expressed preferences and when they are most receptive to messages about their prescribed therapy; face-to-face when members choose to fill prescriptions at a retail pharmacy or by phone when members choose a mail pharmacy. The use of these integrated tactics drives behavior change not only in the short term, but also over time, leading to better clinical outcomes. The program is designed to enhance member engagement in pharmacy care to influence positive behavior change, as well as encourage medication adherence and close relevant gaps in care through individual counseling and follow-up. The program also aims to drive positive, sustained behavior change. Opportunities are identified through the application of rules engine technology and targeting algorithms. Pharmacists trained in chronic condition counseling discuss these opportunities with members during teachable moments, when members are focused on their therapy needs. These discussions take place on the phone with a pharmacist or face-to-face at a local CVS Pharmacy. Pharmacy Advisor identifies both members with suboptimal pharmacy care as well as those at risk to become suboptimal. Targeted first-fill adherence counseling occurs when a new prescription is filled, a time when patients are more receptive to counseling but are also more likely to drop off therapy. Discussions include the rationale behind prescribing the medication and potential issues that may affect adherence, such as side effects. This approach augments traditional reactive approaches that address members who have already dropped off therapy. About URAC URAC is an independent, non-profit organization whose mission is to promote continuous improvement in the quality and efficiency of health care management through the processes of accreditation and education. To support this goal, our Board of Directors represents the full spectrum of stakeholders interested in our health care system, including consumers, employers, health care providers, health insurers, purchasers, workers compensation carriers and regulators. Incorporated in 1990, URAC pioneered utilization management accreditation by creating a nationally recognized set of standards to ensure accountability in managed care determinations of medical necessity. As the health care industry evolves, URAC continues to address emerging issues: we now offer 28 accreditation and certification programs across the health care spectrum. Many states have found URAC accreditation standards helpful in ensuring that managed care plans and other health care organizations are meeting quality benchmarks. Forty-six states and the District of Columbia currently reference one or more URAC accreditation programs in their statutes, regulations, agency publications or contracts, making URAC the most recognized national managed care accreditation body at the state level. At the federal level, four federal agencies recognize URAC accreditation. The Centers for Medicare and Medicaid Services recognize URAC Medicare Advantage Health Plan Accreditation for the Medicare Advantage (formerly Medicare+Choice) Program; the Office of Personnel Management recognizes all URAC accreditation programs under the Federal Employee Health Benefits Program; TRICARE/ Military Health System recognizes URAC s Health Network Accreditation; and the Department of Veterans Affairs recognizes URAC s Health Call Center Accreditation. 3

4 Framework for Improving Medicare Plan Star Ratings [CONTINUED FROM PAGE 1] rating system is used to provide a scored assessment of individual quality components as well as aggregate overall performance of private Part C (Medicare Advantage [MA]) and/or Part D (Prescription Drug Plans [PDP]) plan(s). The Patient Protection and Affordable Care Act and the Health Care Education and Reconciliation Act of 2010 (the Affordable Care Act) introduced quality-based payments and quality bonus payments (QBPs) as an incentive to encourage these plans to accelerate the implementation of quality program improvements. Based on a three-year CMS demonstration project from 2012 to 2014, scaled QBPs will be awarded to plans achieving or exceeding the average performer rating of 3 stars in its overall star rating. During this time, a higher overall rating will correlate to a greater bonus payment percentage, in addition to other plan incentives related to bonus caps, use of new benchmarks and plan enrollment dates. After this demonstration project, bonus payments will only be awarded to plans with at least 4 stars. Regarded as a revenue source, the introduction of QBPs and associating them with several other financial benefits have prompted many health plans to place greater emphasis on quality. By improving quality, QBPs will enable plans to recover much of the anticipated reduction in Medicare payments resulting from recent changes in Medicare law. Plans may use the payment to improve quality, increase benefits or reduce out-ofpocket premiums for plan beneficiaries, which would attract prospective enrollees. In addition, receiving such endorsement from CMS will substantially improve plans competitive advantage in the marketplace. Plans scoring 5 stars will enjoy an extended special enrollment period (SEP) and will be able to market their plans year-round. Furthermore, starting in 2012 and completely phased in by 2014, high scoring plans will receive higher rebates from CMS under the competitive bidding process. Plans scoring 4.5 or higher will receive a 70% rebate while plans scoring 3 stars will only receive a 50% rebate. Finally, plans operating in qualifying counties (based on MA penetration, level of payment and fee-for-service rate) will receive double bonus. Since the pharmacy benefit is the primary objective of Part D plans and a significant component of Part C plans, attention has shifted to the pharmacy department to deliver winning strategies to improve health plans star ratings. In reviewing published star ratings, plans often rank high in the quality metrics for Part C and D that pertain to pharmaceutical care. As such, it is possible to conclude that pharmacy may not have a direct role in additionally impacting quality ratings for these plans. However, in order to positively impact the overall star rating used to determine QBP, it is critical for plans to approach quality as an integrated organization and eliminate fragmentation of efforts resulting from compartmentalization or de-emphasizing the contribution of non-therapeutic elements. Pharmacy can no longer operate in a silo and must integrate fully with all aspects of a health plan. It is no coincidence that Part C and/or D contracts with more integrated health care benefit designs were amongst the highest rated plans in An integrated approach to quality requires a paradigm shift to create a culture of quality in the organization where individuals are champions of quality in their sphere of influence. This requires members at all levels of the organization to have a working knowledge of the star rating system, its quality measures and process. This article does not attempt to discuss the star rating system, nor does it attempt to lay out a stepby-step plan for improving health plans star ratings. Rather, it highlights an overall framework for improving plans quality ratings. A list of resources discussing the star rating system in detail is available to AMCP members online at DownloadAsset.aspx?id=13599 Overall Framework 1. Keep the Main Thing, the Main Thing. CMS objectives for rating plans quality and rewarding high performers include improving patients quality of care and providing objective data to aid beneficiaries in their enrollment decisions. Until the recent institution of QBPs, quality improvement departments within health plans were viewed as cost centers. The potential for high returns with improved quality scores has prompted Part C and Part D plans to place greater emphasis on quality. In addition to individual scores assigned to quality measures, plans are rewarded for consistent quality across all measures. It is also important to note that plans receiving QBPs are required to use these additional dollars towards providing additional services to their members, further boosting quality of plan services. Since achieving quality is a continually evolving process, it is imperative for health plans to maintain a sharp focus on quality pertaining to all aspects of care delivery [more on page 5] 4

5 Framework for Improving Medicare Plan Star Ratings [CONTINUED FROM PAGE 4] including clinical, administrative and operational. Whether tasked with governing or demonstrating quality improvement, marked improvement can be achieved as long as ensuring quality of care for Medicare beneficiaries remains the priority. 2. Understand What Goes Into the Star Rating. The technical complexity of the star rating system may prompt those not involved with the details to defer to outside experts. While it may be necessary to utilize appropriate experts to analyze and devise quality interventions, a general understanding of the main elements of the star rating system will help members at all levels of the organization work collectively toward improving the plan s quality score. For example, realizing that the star rating is assigned at the contract level and applied to multiple plans under the same contract should spur all plans under the contract to work together toward higher quality. Additionally, knowing that the target cut-off for each star rating threshold varies for individual plan measures should initiate conversation around establishing the health plan s benchmarks and measurable goals for improving low star ratings by the next plan year. Furthermore, developing an understanding of the following aspects of the program is fundamental: a. The 5 levels of star rating. The summary star rating used to determine a QBP is derived from multiple levels of rating. i. Detailed contract data is used to evaluate performance; ii. Individual measures level: measures for quality and performance are evaluated and each individual measure is assigned a star rating; iii. Domain level: related measures are grouped together and each domain is assigned an average star-rating; iv. Summary level (derived separately for Part C and Part D contracts): Parts C and D contracts each receive an adjusted average star rating assigned to each contract; and v. Overall level: A combined overall rating summarizing quality and performance for all Part C and Part D measures is given to MA-PDPs contracts. This rating represents an adjusted average of both Part C and D individual measure stars combined into a single star rating. b. Data Sources. CMS utilizes multiple sources of data to derive star ratings including health and plan data, data from contracted sources, administrative data and membership surveys. i. Health and Plan data sources include Healthcare Effectiveness Data and Information Set (HEDIS ) data for measures such as breast cancer screening, Prescription Drug Event (PDE) records for measures such as use of high risk medications, and Plan Finder (PF) pricing files for measures such as accurate pricing; ii. CMS contractor data sources include Independent Review Entity (IRE) and call centers; iii. Administrative data sources include CMS enrollment data files such Part D Low Income Subsidy (LIS) match rates, HPMS complaint tracking module for Parts C and D related complaint rates and CMS audit records; and [more on page 6] 5

6 Framework for Improving Medicare Plan Star Ratings [CONTINUED FROM PAGE 5] iv. Surveys of enrollees include Consumer Assessment of Healthcare Providers and Systems (CAHPS) such as overall plan rating by enrollees and Medicare Health Outcomes Survey (HOS) such as information on improving and maintain health. In most cases, past data is used to evaluate current performance. For example, 2009 data for HEDIS and PDE was used in determining star ratings for the 2011 plan year. c. How Part C and Part D Contracts Are Rated. Quality data for Part C plans is derived from HEDIS, CAHPS, HOS and CMS administrative data, including information about appeals, member satisfaction and audit data. Quality data is categorized into five domains: 1) Staying healthy (screening, tests, and vaccines); 2) Managing chronic conditions; 3) Health plan responsiveness and care; 4) Complaints and appeals; and 5) Telephone customer service. Each measure is assigned a score, and the scores are then averaged to calculate the summary scores. Measures are adjusted for patient characteristics when possible. Measures for prescription drug plans under Parts C and D are derived from CAHPS, PDE and CMS administrative data including customer service, appeals, member satisfaction, LIS and audit data and are grouped into four domains: 1) Customer service; 2) Member complaints; 3) Member experience with drug plan; and 4) Drug pricing and patient safety. Each measure is assigned a score and scores are averaged to derive the summary score. The overall rating is the average for more than 50 quality measures for Parts C and D prescription drug plans. Refer to the CMS website for a list of the individual plan measures and ratings: PerformanceData.asp#TopOfPage d. Star Rating-QBP Award Cycle. When a contract achieves a quality measure, the contract receives a star rating of 3 or better for the measure. Plans are rewarded for consistent quality as well. Payments are paid for the previous plan year s rating which is based on data from yet earlier years. For example, in 2012, QBPs will be based on the quality scores for the 2011 plan year, which was published in late 2010 and calculated using data for time periods in 2009 and According to the Affordable Care Act, plans receiving 4 and 5 stars will receive the same percentage bonus. Plans receiving less than 4 stars will not receive a bonus. CMS is piloting an alternative bonus structure from 2012 to 2014 where contracts receiving 3 stars or higher may also receive QBPs. 3. Connect the Dots. Understanding of the critical elements of the star rating system, the contribution of each of the data sources and the relationship of medication-specific measures to domain and summary scores should be done with an eye on opportunities for improvement (e.g., member experience; prevalence of high risk medication, mail and phone operations, etc.). Since the relationship with non-medication metrics may not be readily apparent, pharmacy directors must be creative in linking the metrics to various components of pharmacy services such as clinical, operational and administrative aspects. Often, the latter two aspects are equally and sometimes more important than pharmaceutical care in influencing the quality of members experience and the star rating. [more on page 7] 6

7 Framework for Improving Medicare Plan Star Ratings [CONTINUED FROM PAGE 6] 4. Leverage Programs and Initiatives with Multiple Impact Points. A critical evaluation of clinical, administrative and operational aspects of existing pharmacy services and their relationship to quality metrics will provide valuable insight into how to leverage existing programs to positively impact quality rating. Programs with multiple impact points such as medication therapy management (MTM) and medication reconciliation have high potential return on investment as they simultaneously impact several quality measures for Part C (e.g., Staying Healthy, Managing Chronic Conditions domains) and Part D (Member Experience with Drug Plan, Drug Pricing and Patient Safety domains) plans. In addition, these programs can be expanded to support achieving quality in less obvious measures such as those pertaining to preventive services in Part C measures. They can also be used to target improvements in areas currently under consideration by CMS for future inclusion such as patient safety and outcomes, giving plans a head start. In implementing quality improvement initiatives, interventions impacting multiple measures will aid in achieving consistency in quality across all measures. 5. Keep an Eye on the Future. Quality measures for the star rating system are constantly evolving and may be revised annually. Therefore, it is necessary to keep abreast of the latest developments and constantly align programs to achieve and maintain highest quality possible. According to CMS, future development of ratings should be aligned with the Institute of Medicine s six aims for improving health care delivery: safe, timely, effective, efficient, equitable, patient-centered. CMS is looking to consensus-building organizations to set criteria and align quality measures with these goals as new measures are added over time linking quality to payment. As this is likely to be a continual process of adaptation and adoption, it is imperative for plans to remain committed to improving the quality of care delivered to their members. Of notice, plans achieving the highest star rating of five stars in the first year of QBP award demonstrated persistent focus on plan members with responsive high touch customer service along with strong emphasis on chronic care management. Adopting Institute of Medicine aims for improving health care delivery provides plans with numerous opportunities to advance on the quality curve ensuring a consistent stream of revenues. Aligning pharmacy programs such as medication adherence and patient safety initiatives with these aims affirms an integrated culture of quality fundamental to meeting future quality targets and maintaining overall plan performance. In addition, establishing clear and well-defined program objectives, self-monitoring and capturing relevant outcomes and data elements are critical to documenting program effectiveness and maintaining an upward trajectory for star rating and the associated revenues. The real impact of QBP for all key stakeholders member, plan or CMS is yet to be determined. In theory, plans with higher star ratings will have a stronger competitive advantage due to the likelihood of enrolling more members based on the ability to offer a better benefit package (supported from bonus payments) and to showcase the coveted official CMS seal of approval on enrollment materials. Though, the value of star ratings and quality-based payments and their effect on plan enrollment and care quality will become clearer with time as information becomes available, the emphasis on plan quality will likely remain unchanged. Therefore, it is imperative for pharmacy to assess its potential role early and continue to monitor for new opportunities to contribute in creating an integrated culture of quality. Prepared by the AMCP Special Projects Committee 7

8 Update on Medication Quality Measures in Medicare Part D Star Ratings [CONTINUED FROM PAGE 1] the quality of Medicare plans on a scale of 1 to 5 stars. The stars are determined through numerous performance measures across several domains of performance. In general, the stars are awarded on the curve so that the plans are judged relative to each other rather than against a fixed benchmark. However, CMS has begun to create fixed thresholds for awarding at least four stars on some measures. Only a small number of plans receive a 5-star rating from CMS, with most plans receiving 3 to 3.5 stars. Medicare Advantage plans that include prescription drug benefits (MA-PDs) are subject to performance measures for Parts C and D. For Part C, the HEDIS measure set from the National Committee for Quality Assurance (NCQA) is used for evaluation. Medicare Part D stars are applicable to MA-PDs and stand-alone prescription drug plans (PDPs). The Part D stars are assigned based on 17 performance measures across four domains. The four domains are: 1. Drug Plan Customer Service; 2. Member Complaints, Problems Accessing Services, and Leaving the Plan; 3. Member Experience with Drug Plan; and 4. Drug Pricing & Patient Safety. Medication safety and adherence measures are in the domain of Drug Pricing & Patient Safety. For the 2012 ratings (released in October 2011), this domain was re-configured to include one measure related to drug pricing, two measures of medication safety and three measures of medication adherence in the following therapeutic categories: Cholesterol (statin drugs), Blood Pressure (Renin-Angiotensin System Antagonists) and Oral Diabetes Medications. Another change for 2012 was the addition of weighting factors for the measures. The safety and adherence measures were weighted 3 times as high as most other measures for Part D. In addition to the plan ratings, CMS also uses the Display Measures to provide further evaluation of Part D plans on medication safety. The Display Measures are not included in the plan ratings, but are used to facilitate quality improvement by the plans. CMS provides monthly safety reports to each plan wherein the plan can view its scores on the display measures and the safety/adherence measures that are included in the plan ratings. National benchmarks are also provided for each measure so that the plan can assess its performance relative to national averages. Two measures of medication safety (drug-drug interactions; excessive doses of oral diabetes medications) are included in the display measures, and in January 2012, CMS also added an adherence measure of antiretroviral medications for HIV. Who Manages the Star Ratings System? Although CMS manages the star ratings system, they contract with Acumen for the analyses of Medicare data to generate the scores on each measure of medication safety and adherence. The Pharmacy Quality Alliance (PQA) developed and maintains the safety/adherence measures and updates the drug-code lists for the measures every six months. PQA provides the updated technical specifications and drug-code lists to CMS when updates are completed. PQA also shares new measures that are endorsed by PQA with CMS and provides some technical guidance on the appropriate use of the measures. PQA is not a CMS contractor and thus receives no payment from CMS. PQA is a non-profit, multi-stakeholder alliance of more than 70 organizations. CMS is a participant in the alliance. What s been proposed for 2013? CMS has proposed several potential changes to the Medicare Plan Ratings for 2013, including the addition of measures and an adjustment of the weighting for measures. One measure that may be added for Part D is the Comprehensive Medication Review (CMR) Rate. This measure was endorsed by PQA and identifies the percentage of MTM-eligible patients who received a [more on page 9] 8

9 Update on Medication Quality Measures in Medicare Part D Star Ratings [CONTINUED FROM PAGE 8] CMR during the eligibility period. The CMR rate in the 2013 ratings will be based on Part D plan reports for their 2011 MTM programs. Another proposed measure will capture the amount of improvement across all performance measures for Part C and Part D. This measure would only apply to plans that have at least two years of data. Several of the existing measures will also be modified as will the weighting system. The 2013 call letter for Medicare Parts C/D (due to be released in early Spring 2012) will provide more details on these changes. A Look at the Safety/Adherence Measures Included in the Part D Ratings High-risk Medications in the Elderly (HRM). The HRM measure identifies the percentage of older adults (>65 y.o.) who receive a medication that is considered to put the patient at high-risk for an adverse drug-related event. The lists of medications in Medicare Part D 2012 Average Rates for Safety/Adherence Measures PQA Measures MA-PD PDP PDC Diabetes 73.0% 74.4% PDC ACEI/ARB 72.2% 74.3% PDC Statins 68.0% 69.1% Diabetes ACEI/ARB Use 84.1% 82.2% High-Risk Medications 20.0% 22.2% PDC = Proportion of Days Covered; the rate indicates the percent of persons on the target drugs who are highly adherent to the drug regimen. Medicare Part D 2012 Star Thresholds for MA-PD Plans PQA Measures 3-star 4-star 5-star PDC Diabetes 70.7% 74.9% 78.8% PDC ACEI/ARB 70.1% 74.8% 77.9% PDC Statins 67.4% 70.8% 75.2% Diabetes ACEI/ ARB Use 83.2% 86.0% 87.3% High-Risk Medications 22.2% 14.0% 9.3% PDC = Proportion of Days Covered; the rate indicates the percent of persons on the target drugs who are highly adherent to the drug regimen. these measures were derived from the Beers List that was originally developed in the 1990s, but updated in The American Geriatrics Society updated the Beers List and issued its final recommendations in December NCQA and PQA adapted the clinical recommendations to the HRM performance measure. [more on page 10] 9

10 Update on Medication Quality Measures in Medicare Part D Star Ratings [CONTINUED FROM PAGE 9] PQA also adjusted the technical specifications in January 2012 so that patients were only included in the numerator if they received at least two fills of a HRM. Thus, one-time fills of a HRM will no longer affect the HRM rate. Appropriate Treatment of Hypertension in Persons with Diabetes. This measure includes patients who have received a medication for diabetes as well as any drug that could be used for treatment of hypertension. Thus, the drugs serve as proxies for a diagnosis of diabetes and hypertension. The measure indicates the percentage of these diabetes-hypertension patients who receive a Renin-Angiotensin System Antagonist (RASA). Proportion of Days Covered (PDC) new for PDC is the PQA-recommended metric for estimation of medication adherence for patients using chronic medications. This metric also is endorsed by the National Quality Forum (NQF). The metric identifies the percentage of patients on a particular drug class that have high adherence (PDC > 80% for the individual). CMS reports three rates; one for blood pressure medications (RASA); one for cholesterol medications (statins) and one for diabetes medications (limited to patients on at least one of the four most common classes of oral diabetes drugs). David Nau, PhD, RPh, CPHQ, is Senior Director, Quality Strategies, Pharmacy Quality Alliance (PQA) Top Performing Plans for 2012 The following plans received a 5-star summary rating for Part D: Contract Organization Name Contract Name MA-PDs: H0524 Kaiser Permanente Senior Advantage KAISER FOUNDATION HEALTH PLAN, INC. H0630 Kaiser Permanente Senior Advantage KAISER FOUNDATION HEALTH PLAN OF CO. H1230 Kaiser Permanente Senior Advantage KAISER FOUNDATION HEALTH PLAN, INC. H9003 Kaiser Permanente Senior Advantage KAISER FOUNDATION HEALTH PLAN NW H1365 Martin s Point Generations Advantage MARTIN S POINT GENERATIONS, LLC H5050 Group Health Cooperative GROUP HEALTH COOPERATIVE H5262 Gundersen Lutheran Health Plan, Inc. GUNDERSEN LUTHERAN HEALTH PLAN H9047 Providence Health Plans PROVIDENCE HEALTH PLAN PDPs: S3521 Simply Prescriptions EXCELLUS HEALTH PLAN, INC. S3994 HMSA s Medicare Rx Plan HAWAII MEDICAL SERVICE ASSOC. (HMSA) S5743 MedicareBlue Rx BCBS MN, MT, NE, ND, WY, SD, WELLMARK IA S5975 ODS Health Plan, Inc. ODS HEALTH PLAN, INC. 10

11 About AMCP The Academy of Managed Care Pharmacy is a professional association of individual pharmacists who use the tools and techniques of managed care in the practice of pharmacy. At the heart of every member is commitment to a simple goal: Provision of the best available pharmaceutical care for patients. As an organization, the Academy strives to achieve its mission of empowering its members to serve society by providing opportunities for continued professional growth, by advancing individual and collective knowledge. Throughout the year, AMCP provides conferences, online learning access, peer-reviewed literature through its Journal of Managed Care Pharmacy, and leadership development seminars. Each is designed with the goal of advancing professional knowledge, improving the design and delivery of pharmacy benefits, and ultimately, patient satisfaction and health outcomes. Patients who receive the correct drug in the correct way achieve better outcomes, improving quality of life, the bedrock of our Vision managed care pharmacy improving health care for all. Equally important to prescribing the right drug, however, is being able to provide adequate access to as many patients as possible. The Academy has been doggedly pursuing strategies to help providers of drug coverage achieve that goal as well, by working in ground-breaking disciplines such as pharmacoeconomics, a branch of pharmacy that seeks to determine the true value of a drug-not product cost, but effectiveness in improving overall health outcomes of patient populations. The focus of the Academy has been to create scientifically designed methodologies for making medical choices as intelligently as current knowledge will allow, supported by evidence-based clinical studies. Some of the Academy s most successful products to date are AMCP s Format for Formulary Submissions and the AMCP Framework for Quality Drug Therapy. The Format is a standardized methodology for assessing drugs scientifically, based on the value they provide. Widely adopted by numerous health plans, governmental agencies such as the Department of Defense and leading pharmacy benefit management companies, the Format has become a de facto industry standard. Managed care organizations employing the Format cover approximately half of all pharmacy care beneficiaries. The AMCP Framework for Quality Drug Therapy was developed over a period of years with the input and review of over 100 stakeholders, including both providers and users of care. It is essentially a reliable, adaptable and scalable methodology for applying quality improvement initiatives to patient care focused on the patient, not the process. There are about 250 individual components of the Framework that can be applied to any health care setting, from which a practitioner may choose the most applicable. A series of evaluative exercises are supplied, through which the practitioner develops an action plan for quality improvement, measurement and evaluation. Two other significant contributions to managed care practice include AMCP s Guide to Pharmaceutical Payment Methods and Sound Medication Therapy Management Programs, V2.0. The Guide is a comprehensive, factual description and analysis of alternative drug payment methods and payment systems, including a review of the history, current application, potential future utility, impact on managed care pharmacy, other stakeholders in the pharmaceutical marketplace and the overall health care delivery system. It includes a glossary of payment terms, tables showing which payers and settings utilize which methods, payment flowcharts to illustrate how the money flows with each of the payment systems and examples of payment calculations. Downloadable in a summary and a comprehensive format from the AMCP website, it is accompanied by a web-based interactive resource library. In 2005, spurred by the Medicare Modernization Act s (MMA s) inclusion of the medication therapy management (MTM) requirement, AMCP and other organizations recognized a lack of clear definition of what specific elements would constitute a sound MTM program. To fill that gap, AMCP assembled a variety of stakeholder organizations that served as a working group to build a consensus document that would define those elements. The Academy issued the consensus document Sound Medication Therapy Management Programs in April Then, in late 2006, AMCP undertook a project to validate the content of that document in the marketplace. AMCP coordinated the project components and the work of the project s advisory panel. The National Committee for Quality Assurance (NCQA) performed the project s field work under contract to the Academy. The Academy believes the final product, Version 2.0, will stimulate the public policy discussion, aid in the evolution of sound MTM programs, enhance patient care and encourage the efficient use of health care resources dedicated to these programs. These and all other AMCP publications, including the Journal, can be found on the AMCP website, 11

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