EVOLUTION OF THE STARS. CMS 2016 Quality Measure Update

Transcription

1 EVOLUTION OF THE STARS CMS 2016 Quality Measure Update

2 OBJECTIVES Explain why quality matters to health care plans Identify changes in 2016 CMS Quality Measures List Ways you can drive your pharmacy s quality measures

3 WHY THE SUDDEN CHANGE? US Ranked #1 on Health Care Spending US is ranked 30 s-40 s for Quality in health care & Life Expectancy Almost 20 cents out of every dollar is spent on health care

4 $2.9 TRILLION DOLLAR PROJECTION

5 The Congressional Budget Office estimates that a 1% increase in the number of prescriptions filled by beneficiaries would cause Medicare s spending on medical services to drop 0.2%. Increase certain pieces of the pie (e.g., drug utilization) IMPACT OF INCREASED MEDICATION UTILIZATION Congressional Budget Office. Report Offsetting Effects of Prescription Drug Use on Medicare s Spending for Medical Services. November 29, and you ultimately decrease the bigger pieces and total spend If a patient takes their medication as prescribed, they don t end up in the hospital!

6 ACA DRIVING CHANGE Affordable Care Act Triple Aim Better Care for Patients Healthier people and healthier communities Lower costs through improvements for the health system Value based, Outcome Driven=Quality 30% of all FFS move to value based ACO by end of 2016 Where does pharmacy fit in?

7 CMS SETTING THE NEW STANDARD Penalty Avoidance Hospital Readmits HRRP, Transitions in Care TC, Value Based Purchasing VBP, Meaningful Use MU, Physician Quality Measures PQRS P4P Accountable Care Organization ACO, Patient Centered Medical Home PCMH, VBP, MU, PQRS, Star Ratings QUALITY

8 PQA IS BORN Pharmacy Quality Alliance established in 2006 Non-profit consensus based with 200+ members Develop strategies to measure and report performance on medication use through a process of work groups Develops and endorses quality measures including several adopted by CMS for the Star Ratings MISSION: Improve the quality of medication management and use across health care settings

9 Centers for Medicare and Medicaid Services (CMS) Star Ratings Annual rating system to grade Medicare plans 2015 bonus payments, based on 2014 ratings, which were based on data Star Rating Performance Level Poor Below Average Average Above Average Excellent Centers for Medicare & Medicaid Services. Prescription Drug Coverage General Information. PerformanceData.asp. Accessed 08/06/

10 2015 Star Ratings: What is the Same? Four key Part D quality measures for pharmacies to focus on remain the same: Adherence: Proportion of Days Covered (PDC) PDC: Statins Alternative Therapy Use of High-Risk Medications in the Elderly PDC: Oral Diabetes Medications PDC: Hypertension (Renin-angiotensin system antagonists or RASA) enters for Medicare and Medicaid Services. Part C and D Performance Data Star Ratings Measure List. Accessed 08/05/14. 10

11 2015 Key Star Rating Measure Goals Measure Goal Direction 5-Star Goal % 1 * 2015 Top 20% 2 ** RASA PDC (ACE/ARB PDC) 85% 92.3% PDC: Statins 83% 91 % PDC: Diabetes 81% 90.4% High-Risk Medications in the Elderly 7% 3.3% *Based on 2015 CMS 5-Star Goals for MA-PD plans, subject to change with each plan year, and in addition, individual payers may set their own goals relative to specific initiatives **Top 20% of retail pharmacies as reflected in EQuIPP (Data Range: October 2014-March 2015). Centers for Medicare and Medicaid Services. Part C and D Performance Data. Trends in Part C & D Star Rating Measure Cut Points. Accessed 5/30/15. Electronic Quality Improvement Platform for Plans & Pharmacies. Accessible at (Data Range: 2015). Accessed 05/30/15. 11

12 Star Ratings: What Is Changing? Centers for Medicare and Medicaid Services (CMS) has made the following changes: Retired Diabetes Treatment Measure New Full Measure Comprehensive Medication Review New Displa y Measu re Statin Use in Diabetes Display 2017 Full

13 EQUIPP EQuIPP Electronic Quality Improvement Platform Owned by PQS Quality Improvement Tool, Report Card 6 month rolling data set, updated every 45 days New feature- Outliers tab

14 EQuIPP: Pharmacy Performance Report Electronic Quality Improvement Platform for Plans & Pharmacies. Accessible at 14

15 EQuIPP is the Industry Standard Domino-Trickle Down Effect Each plan has there own definition of Quality Leads to hundreds of Quality Measures GDR (Generic Disp Rate) 90 Day Supply PDC s for CHF, Depression, Osteoporosis, Breast Cancer, Non- RASA HTN, Respiratory, HIV Medicare Managed Care Medicaid Private/ Commercial Health Exchange Accreditation

16 UNDERSTAND THE NEEDS OF YOUR CUSTOMER By % of Health care spending will be government sponsored One-third of health care spending is estimated to be wasteful

17 DRUGS DON T WORK IN PATIENTS WHO DON T TAKE THEM - C Everett Koop, US Surgeon General

18 ADHERENCE PDC Proportion of Days Covered Hospitalization costs due to non-adherence estimated at $100 billion annually Rates of adherence for chronic illness 50-60% Adherence measures triple weighted Primary non-adherence (patient never acquires new Rx) Currently Display Measure for some chronic illness medications

19 MED SYNC DRIVES ADHERENCE Proactive Outreach Initiate patient contact, review changes, obtain refill authorizations Assess need for adherence coaching= Schedule CMR Increased Efficiency Inventory control, consolidate deliveries, avoid repackaging Manage workload== Increased time for CMR s Drives Quality Measures Target Patients on Oral Diabetes Agents, Statins, RASA Sync drives PDC Completion Rate for CMR s

20 PHARMACY OPTIONS FOR MED SYNC PROGRAMS Paper-Based Technology - Low cost - Can be as low as $30 for binder, file folders and sheet protectors 1 - Works for self-starters PROS - Increases efficiency - 35% higher enrollment rate than manual sync programs 2 - Integrates with MTM vendors - Manual workflow - Limited options to automate and scale - Smaller efficiency gains CONS - Potential additional upfront expense - System training 1. American Pharmacist s Association Foundation. Pharmacy s Appointment-Based Model: Implementation Guide for Pharmacy Practices Alexander A. Drug Store News. Study: Med sync programs a win-win win. July 1, Accessed 07/06/15. 20

21 PHARMACY OPTIONS FOR MED SYNC PROGRAMS Paper-Based Technology NCPA: Simplify My Meds APhA Foundation Appointment- Based Model Implementation Guide Do it yourself Star Wellness -PrescribeWellness Time My Meds - Ateb SYNCHRO Script - Voice Port Pharmacy management system solutions 21

22 HIGH RISK MEDS Beer s List Medications potentially inappropriate in 65 and over Measure requires physician and patient buy in CMS relaxed threshold for 2015 EQuIPP uses a subset of the Beer s List

23 HRM List 23

24 HRM ALTERNATIVES 2 Fills for the year dings the measure (Hint start working now for 2016) Pick your low hanging fruit first Communicate recommendation effectively s/pharmacy/elderly.pdf

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27 CMR COMPLETION RATE Measures completion rate for eligible MTM patients who received a CMR with a written summary LTC beneficiaries included, Hospice excluded Call centers less successful than community based with pharmacist-patient relationship Sync provides opportunity to predict best appointment time, identify gaps in care and immunize Mirixa & Outcomes

28 STATIN USE IN DIABETES New Display Measure 2017 (2015 Data) Measure the % of patients aged who were dispensed a statin medication for diabetes that receive a statin medication CDC Atlas Diabetes and Obesity Rates

29 RECOMMENDATIONS FOR STATINS IN DIABETICS American College of Cardiology/American Heart Association 2013 National Lipid Association American Diabetes Association American Association of Clinical Endocrinologists Age, CAD/ASCVD Risk Factors, cholesterol

30 DIABETES EPIDEMIC Diabesity Epidemic in US and Worldwide Leading cause of chronic disease Diabetic 2-4 times higher risk of cardiac disease Complications include neuropathy, blindness, kidney failure, amputations

31 PREVENTION 1 in 3 Americans have Pre-Diabetes 9 out of 10 do not know they have it 15-30% pre-diabetes patients will develop T2DM within 5 years Are you at risk for pre-diabetes? tion/pdf/prediabetestest.pdf

32 DISPLAY MEASURES Oral Diabetes Medications Ex. Metformin max daily dosage 2550mg, Glipizide 40mg daily Drug interactions Ex. NSAID s and warfarin, amiodarone and simvastatin Keep these on your radar: Newly Endorsed by PQA: Multi-provider, high dosage opioids in non-cancer patients Concept Triple Threat Opioid, benzodiazepine, muscle relaxer

33 HOW WILL YOU DEFINE QUALITY? Services People Process

34 EVOLUTION OR EXTINCTION