Healthcare Reform and Value Based Purchasing: Opportunities for Pharmacist Involvement

Transcription

1 Healthcare Reform and Value Based Purchasing: Opportunities for Pharmacist Involvement Jane S. Henry, MBA, RPh Pharmacist Consultant Adverse Drug Event Reduction Project Team February 16, 2013 Centers for Medicaid & Medicare Services CMS Vision: The right care for every person every time CMS Aims: Make care safe, timely, effective, efficient, patient-centered and equitable Institute of Medicine, 2001 Six Aims for Healthcare Transformational Change in healthcare 2 1

2 Where do we want to go? Our Aim: SPREAD Better Outcomes Improvement Cycles Status Quo Drift Current success with Population of Focus Time Transformational Change Widespread changes Change in: Institutional culture Work processes Clinical care Use of information technology 4 2

3 The Need for Transformational Change Harvard Medical Practice Study 1999 IOM report, To Err is Human 2001 IOM report, Crossing the Quality Chasm Medical error/misuse Overuse Underuse 5 Our Health Care Macrosystem: Falls short in ability to translate new knowledge & technology into practice Lacks even rudimentary clinical information capabilities Over-utilizes services with potential risks that outweigh potential benefits Allows physician preference to rule over best practices & evidence based medicine (EBM)» Crossing the Quality Chasm 6 3

4 Our Health Care Macrosystem: Is designed primarily to provide acute care Chronic conditions are the leading cause of illness, disability & death affect almost ½ of the US population account for the majority of health care expenditures.» Crossing the Quality Chasm 7 IOM s Vision: The purpose of Health Care All health care organizations, professional groups, and private and public purchasers should adopt as their explicit purpose to continually reduce the burden of illness, injury, and disability, and to improve the health and functioning of the people of the United States. Crossing the Quality Chasm, (p. 39) 8 4

5 Fiscal Year 2009 and beyond... Value Based Purchasing (VBP) Transform CMS from a passive payer of services to an active purchaser IPPS (Inpatient Prospective Payment System) - Hospitals Only Public reporting and financial incentives for better performance: Clinical quality (pt care processes and outcomes) Patient-centeredness (pt satisfaction) Efficiency (utilization and cost of services) 9 Current Public Reporting Activities Hospital Quality Data Public Reporting Physician Quality Data Reporting (PQRI: Physician Quality Reporting Initiative) Transparency Initiatives- Better Quality Information for Medicare Beneficiaries (BQI) 10 5

6 Public Reporting: Hospital hospitalcompare.hhs.gov Mandated by 2003 Medicare Modernization Act, expanded in DRA Section 5001 (a) -RHQDAPU (Reporting Hospital Quality Data for Annual Payment Update) Hospitals must submit data on: Continues to expand: 42 Quality Measures Medical Record Abstraction Acute MI, Heart Failure, Pneumonia Surgical Care Improvement Project Abx selection and administration, VTE Prophylaxis Appropriate, hair removal prior to surgery Outpatient procedures Hospital 30-day readmission 11 Public Reporting: Hospital cont. hospitalcompare.hhs.gov Hospitals must submit data on: HCAHPS Data (Hospital Consumers Assessment of Hospital Providers & Systems) Patient experience with healthcare and satisfaction Developed by Agency for Health Research and Quality (AHRQ) 27 Questions Mortality Data AMI, HF, PNE 30 day mortality across continuum 12 6

7 Public Reporting: Other Nursing Home medicare.gov/nhcompare MDS Data (Minimum Data Set) Home Health medicare.gov/hhcompare OASIS Data (Outcome & Assessment Information Set) 13 Public Reporting: Physician Legislative: Tax Relief and Health Care Act of 2006-signed 12/06 PQRI (Physician Quality Reporting Initiative) Originally a 5% decrease in Medicare reimbursement for not reporting, now a 1.5% incentive for reporting Code based: G codes or CPT Category National Quality Forum endorsed measures 14 7

8 Pharmacy Quality Alliance (PQA) Mission: To improve the quality of medication management and use across healthcare 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. 15 Pharmacy Quality Alliance Identify claims-based measures that: Improve health care quality and patient safety Collect data in the least burdensome way Report meaningful information to consumers, pharmacists, employers, health insurance plans and other healthcare decision makers Improve ability to make informed choices, improve outcomes and stimulate the development of NEW PAYMENT MODELS. 16 8

9 PQA Medication Quality Measures Proportion of Days Covered (PDC) The percentage of patients who met the PDC threshold of 80 percent during the time period. Beta-blocker (BB) ACE Inhibitor, Angiotensin Receptor Blocker Statin Biguanide Sulfonylurea Thiazolidinedione DiPeptidyl Peptidase (DPP)-IV Inhibitor Diabetes Anti-retroviral (this measure has a threshold of 90% for at least 2 medications) 17 PQA Medication Quality Measures Diabetes Medication Dosing (DOS) The percentage of patients who were dispensed a dose higher than one recommended for the following therapeutic categories of oral hypoglycemics: biguanides, sulfonlyureas, thiazolidinediones, DPP-IV 18 9

10 PQA Medication Quality Measures Medication Therapy for Persons with Asthma Suboptimal Control The percentage of patients with persistent asthma who were dispensed more than 3 canisters of a short-acting beta 2 agonist inhaler during the same 90-day period. Absence of Controller Therapy 19 PQA Medication Quality Measures Use of High-Risk Medications in the Elderly (HRM) The percentage of patients 65 years of age and older who received two or more prescription fills for a high-risk medication during the measurement period. Beers List Medication 20 10

11 PQA Medication Quality Measures Completion Rate for Comprehensive Medication Review The percentage of prescription drug plan members who met eligibility criteria for medication therapy management (MTM) services (multiple medications, multiple chronic diseases, multiple prescribers) and who received a comprehensive medication review (CMR) during the eligibility period. 21 PQA Medication Quality Measures Antipsychotic Use in Persons with Dementia The percentage of individuals (65 years and older) with dementia who are receiving an antipsychotic medication without evidence of a psychotic disorder or related condition

12 Comprehensive Medication Management Critical in Preventable Adverse Events Office of Inspector General Report on Preventable Serious Adverse Events in Hospitalized Medicare patients 1 Cited medication errors as the top preventable cause of serious adverse events Avoidable Hospital Readmissions Medication errors/ lack of reconciliation cited as a top cause of avoidable readmissions Attention to medication management is becoming more critical for providers/hospitals with CMS and commercial carriers lack of willingness to pay for avoidable readmissions 1 oig.hhs.gov/oei/reports/oei pdf 23 Drug Therapy Problems Number of DTP Indica3on Effec3veness Safety Unnecessary Drug Therapy % Needs Addi3onal Drug Therapy 25,898 30% More Effec3ve Drug Available 5,785 7% Dosage Too Low 21,434 25% Adverse Drug Reac3on 8,860 10% Dosage Too High 6,168 7% Compliance Noncompliance 1,342 16% Total 85,957 Only 16% of all drug therapy problems were Adherence related Pharmacists utilized the Assurance IT electronic therapeutic record system and training through Medication Management System, Inc

13 The Pharmacist s Role As these newer models (ACO/PCMH) become more common, will the pharmacist become a member or will others provide the patients drug therapy needs? The answer to this question will impact pharmacy s future significantly. I am concerned that too many pharmacists are spending too much energy holding onto the current dispensing practice model instead of investing time and money on establishing a new model. What advice would I give to those working on the incorporation of pharmacists into the PCMH and the ACO? It would be to make sure you position pharmacists to take care of the patient. Fred Eckel, RPh, MS Professor UNC School of Pharmacy Exec. Dir. NC Assoc. of Pharmacists Pharmacy Times The Patient-Centered Medical Home and ACOs...What Should Be the Pharmacist s Role? What-Should-Be-the-Pharmacistu2019s-Role 25 Current State of Pharmacy in U.S. Workforce (Bureau of Labor Statistics): 275,000 pharmacists 65% Dispensing Use of Robotics Pharmacy Technician Scope of Practice Increasing Dispensing fees decreasing (ex. TX Medicaid)...So, a question to ponder is: What will the pharmacist s role be going forward? 26 13

14 Statutory Mission of the Quality Improvement Organization (QIO) Program The statute authorizes the QIOs to work to improve services to Medicare Beneficiaries with a focus on: Effectiveness Efficiency Economy Quality The QIOs will support and partner with CMS to achieve the aims of: Better health Better health for people and communities Affordable care through lowering costs by improvement Scope of the problem More than 133 million Americans live with chronic illnesses 1 91% of all prescriptions filled for a chronic condition million people are injured each year as a result of medication 3 Uncoordinated care costs an estimated $240 Billion/year 4 1. CDC National Center for Chronic Disease Prevention and Health Promotion: Chronic Disease Prevention 2. American Heart Association. Heart Disease and Stroke Statistics 2008 Update. Dallas, Texas: American Heart Association; Institute of Medicine (IOM), To Err Is Human: Building a Safer Health System, Washington, DC: National Academy Press; Owens, MK The Health Care imperative: Lowering Costs and Improving Outcomes, The Institute of Medicine,

15 29 Patient Safety and Clinical Pharmacy Services Collaborative (PSPC) WHAT: Quality Improvement Collaborative aimed at improving health outcomes and patient safety for high-risk patients (Adapted IHI Breakthrough Series Collaborative Model) Improve the delivery system where there are gaps: Enhance care coordination among the providers and partners involved Fosters multidisciplinary, team based care approach Strengthens patient centered medical home Integrate medication management and other services to minimize harm related to adverse drug events and maximize optimal health outcomes Collaborative Goal Reduce ADE s in the population of focus (PoF); eligible Medicare beneficiaries having met one or more criteria for the high risk population through teamwork and processes that integrate clinical pharmacy services into patient care. 15

16 High Risk Population of Focus Medicare, Medicare Advantage or Duel Eligible Beneficiary Five (5) or more chronic conditions and/or Take eight (8) or more medications on a monthly basis and/or Are seeing 2 or more providers and/or Take warfarin on a regular basis (> 3 months) and/ or Take a hypoglycemic medication for diabetes mellitus and/or Take a short or long-acting antipsychotics Patient Safety and Clinical Pharmacy Services Collaborative (PSPC) Mission: The PSPC is committed to saving and enhancing thousands of lives a year by achieving optimal health outcomes and eliminating adverse drug events through increased clinical pharmacy services for the patients we serve. Formation of care improvement teams with specific involvement of clinical pharmacy services. Started in 2008, now enrolling PSPC

17 PSPC Opportunity for impact The PSPC focuses on high-risk patients (multiple medications, multiple providers) Improve the delivery system gaps: Enhance care coordination among the providers involved Integrate management of the medication process Key Attributes of the PSPC 34 Patient-Centered (Partnership for Patients) Interdisciplinary Care Team Cross-Organizational with Health Homes at the Center Systematically Addresses Medication Management, Safety and Risk -- Huge Issues for Ambulatory Care Patients All Teach, All Learn Align with national efforts Partnership for Patients 17

18 Starting with the end in mind.. The transformational goal of the PSPC: Integrate the healthcare delivery system, across multiple healthcare partners, to create a service delivery system for high-risk patients that will produce breakthroughs in the following three areas: 1) Improved patient health outcomes 2) Improved patient safety 3) Increase cost-effective clinical pharmacy services Data Monitoring, Tracking and Reporting In the identified high risk population, track improvement in health status Number of adverse drug events (ADE) and potential ADEs Number of ER visits, hospitalizations and/or hospital readmissions associated with ADE Number of potentially inappropriate medications prescribed. Patients on warfarin with INR drawn at least monthly Percent of patients with optimal INR Diabetics with HgA1c less than

19 Staying focused our PSPC aim Committed to saving and enhancing thousands of lives a year by achieving optimal health outcomes and eliminating adverse drug events through increase clinical pharmacy services for the patients we serve PSPC s vision: By ,000 communities have an integrated delivery system that assure optimal health outcomes and patient safety Federal Health Care Service (Indian Health Service, VA, DOD) Improving Patient and Health System Outcomes through Advanced Pharmacy Practice Surgeon General Report

20 For More Information Contact Jane S. Henry, MBA, RPh Kenneth Mishler, MBA, PharmD, RPh The Kansas Foundation for Medical Care, Inc SW Wanamaker Drive Topeka, Kansas This material was prepared by the Kansas Foundation for Medical Care, Inc. (KFMC), the Medicare Quality Improvement Organization for Kansas, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. #10SOW-KS-ADE