Medicare star ratings: Stakeholder proceedings on community pharmacy and managed care partnerships in quality

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1 SPECIAL FEATURE Medicare star ratings: Stakeholder proceedings on community pharmacy and managed care partnerships in quality American Pharmacists Association and Academy of Managed Care Pharmacy Abstract Objectives: To describe the Medicare star rating system, created by the Centers for Medicare & Medicaid Services (CMS) in 2007; identify quality measures that can potentially be improved through collaboration between health plans and community pharmacy; provide examples of current collaboration between health plans and community pharmacy; and identify collaboration goals, challenges, components, and strategies. Data sources: National thought leaders at a conference titled CMS Star Ratings: A Stakeholder Discussion, held on March 21, 2013, supplemented with related information from the literature. Summary: The Medicare star rating system is part of CMS s efforts to define, measure, and reward quality health care. Approximately one-half of the star rating performance measures can be influenced directly by community pharmacists working in conjunction with payers that must meet the quality measures. In 2012, a weighting system for star ratings was implemented. Of 10 triple-weighted ratings, 8 are related directly and indirectly to medication therapy and thus have the potential to be improved by pharmacist intervention. Plan ratings can have a substantial impact on beneficiary enrollment. Since very small improvements in performance measures can translate into large effects on star ratings, concerted efforts to improve pharmacy-related measures could move a plan to a higher star rating; conversely, inattention to areas such as high-risk medications, antidiabetic pharmacotherapy, and medication adherence could lower a plan s star rating. Topics discussed in this article include the Electronic Quality Improvement Platform for Plans and Pharmacies, or EQUIPP, the payer perspective on pharmacies, programs currently under way in community pharmacies, and ways plans and pharmacies can better collaborate with each other. Received August 29, 2013, and in revised form January 28, Accepted for publication February 19, Published online April 25, Correspondence: James A. Owen, BSPharm, PharmD, BCPS, Associate Vice President, Professional Practice, American Pharmacists Association, 2215 Constitution Ave., NW, Washington DC Acknowledgments: Cynthia Knapp Dlugosz, BSPharm, in conjunction with staff from the American Pharmacists Association, for manuscript preparation. Disclosure: Ms. Knapp and APhA staff involved in this project declare no conflicts of interest or financial interests in any product or service mentioned in this article, including grants, employment, gifts, stock holdings, or honoraria. Funding: Amgen, Teva Pharmaceuticals, Mylan Specialty, L.P., and Merck. Conclusion: The pharmacist s ability to work directly with patients to improve medication use is a critical factor in improving health plan Medicare star ratings. Health plans and community pharmacies must forge partnerships based on well-defined goals and innovative tactics to ensure care quality consistent with evolving public and private payment models. Keywords: Medicare, star ratings, adherence, pharmacists, pharmacy, health plans, prescription drug plans. J Am Pharm Assoc. 2014;54: doi: /JAPhA JAPhA 54:3 MAY/JUN 2014

2 medicare star ratings SPECIAL FEATURE The health care system in the United States is moving toward rewarding positive outcomes while reducing or eliminating unnecessary services. Devising strategies for measuring costs associated with quality outcomes has been relatively straightforward, but the idea of quality in particular, quality measurement is a new phenomenon in health care. How is it possible to define and quantify something that historically has been viewed as much art as science? Medicare is the federal health insurance program for adults 65 years of age or older (as well as certain younger people with disabilities or end-stage renal disease). 1 By 2030 when all members of the Baby Boom generation will have reached 65 years of age fully 18% of Americans will be eligible for Medicare. 2 As the steward for health care services for these individuals, the Centers for Medicare & Medicaid Services (CMS) must ensure that Medicare beneficiaries have access to high-quality care. 3 This mission becomes even more critical as Medicare costs continue to skyrocket. CMS has shed its previous identity as a passive agency that pays providers based solely on the volume of services provided. Today, CMS is an active purchaser of services that achieves consensus-based performance measures at an affordable cost. 4 The Medicare star rating system is part of CMS s efforts to define, measure, and reward quality health care. Approximately one-half of the star rating performance measures can be influenced directly by community At a Glance Synopsis: This article summarizes a 2013 stakeholder discussion of the challenges and opportunities associated with the Medicare star rating system, which was created in 2007 by the Centers for Medicare and Medicaid Services (CMS) to inform beneficiaries enrollment decisions and reward quality health care plans. Of the 10 quality measures now used by CMS to evaluate plan performance, 8 are related to medication therapy and thus may be influenced by pharmacist intervention. The stakeholders discussed plan strategies for improving medication safety and adherence and concluded that payers and community pharmacies must collaborate to achieve optimal success for health plans, providers, and patients alike. Analysis: In discussing the necessity for payer community pharmacy collaboration, the stakeholders identified a path forward. Recommendations included taking a closer look at current community pharmacy efforts to promote adherence, using new clinical information systems to capture and share health plan and pharmacy data, fostering collaboration among student pharmacist organizations, and eliminating regulatory roadblocks to having pharmacists play a greater role in the health care system. pharmacists working in conjunction with payers that must meet the quality measures. In fact, pharmacists can make the strongest contributions to the performance measures that are weighted most heavily for medication use, adherence, and chronic disease outcomes. Tables 1 and 2 list the 2012 Medicare Advantage and Medicare prescription drug plan star ratings measures and weightings. When the star rating system was created, all of the performance measures were weighted equally, implying equal importance. 5 As of 2012, outcome and intermediate outcome measures are weighted three times as much as process measures; patient experience and access measures are weighted 1.5 times as much as process measures (Table 3). 5 The new weighting system for performance measures holds particular importance for pharmacists. Of the 10 triple-weighted measures, 8 are related directly or indirectly to medication therapy and thus have the potential to be improved by pharmacist intervention. Three of the triple-weighted measures are health services (Part C) measures in the Managing Chronic Conditions domain: Diabetes care blood sugar controlled (i.e., plan members with diabetes whose blood sugar is under MAY/JUN :3 JAPhA 229 control) Diabetes care cholesterol controlled (i.e., plan members with diabetes whose cholesterol is under control) Controlling blood pressure The other five triple-weighted measures are drug services (Part D) measures in the Drug Pricing and Patient Safety domain: High-risk medication (plan members 65 years of age and older who received prescriptions for certain drugs with a high risk of side effects, when there may be safer drug choices) Diabetes treatment (using the kind of blood pressure medication that is recommended for people with diabetes) Part D medication adherence for oral diabetes medications (taking oral diabetes medication as directed) Part D medication adherence for hypertension (taking blood pressure medication as directed) Part D medication adherence for cholesterol (taking statins as directed) All five of the triple-weighted Part D performance measures were developed by the Pharmacy Quality Alliance (PQA) a consensus-based nonprofit alliance established by a broad group of stakeholders in April 2006 that currently has more than 100 members comprising health plans, pharmacy benefit management companies, professional associations, federal agencies, pharmaceutical manufacturers, consumer advocates, technology and consulting groups, and universities. PQA-supported measures are weighted heavily; they accounted for 45% of the Part D plan summary rating in 2013.

3 SPECIAL FEATURE medicare star ratings Table Medicare Advantage plan measures Measure Weighting Breast cancer screening 1 Colorectal cancer screening 1 Cardiovascular care cholesterol screening 1 Glaucoma testing 1 Annual flu vaccine 1 Pneumonia vaccine 1 Improving or maintaining physical health 3 Improving or maintaining mental health 3 Monitoring physical ability 1 Access to primary care doctor visits 1.5 Adult body mass index assessment 1 Care for older adults medication review 1 Care for older adults functional status assessment 1 Care for older adults pain screening 1 Osteoporosis management in women who had a fracture 1 Diabetes care eye exam 1 Diabetes care kidney disease monitoring 1 Diabetes care blood sugar controlled 3 Diabetes care cholesterol controlled 3 Controlling blood pressure 3 Rheumatoid arthritis management 1 Improving bladder control 1 Reducing the risk of falling 1 Plan all-cause readmissions 1 Getting needed care 1.5 Getting appointments and care quickly 1.5 Customer service 1.5 Overall rating of health care quality 1.5 Overall rating of plan 1.5 Complaints about the health plan 1.5 Beneficiary access and performance problems 1.5 Members choosing to leave the plan 1.5 Plan makes timely decision about appeals 1.5 Reviewing appeals decisions 1.5 Call center foreign language interpreter and TTY/TDD availability 1.5 CMS Star Ratings: A Stakeholder Discussion On March 21, 2013, the American Pharmacists Association (APhA) and the Academy of Managed Care Pharmacy (AMCP) convened a gathering of stakeholders for a meeting titled CMS Star Ratings: A Stakeholder Discussion. The 15 representatives of independent and chain pharmacies, managed care organizations, pharmacy associations, and CMS (Appendix A) were charged with identifying current challenges and opportunities with the star ratings systems and identifying ways in which these various stakeholders could work together for mutual benefit. Table Medicare prescription drug plan measures Measure Weighting Call center pharmacy hold time 1.5 Call center foreign language interpreter and TTY/TDD availability 1.5 Appeals auto-forward 1.5 Appeals upheld 1.5 Enrollment timeliness 1 Complaints about the drug plan 1.5 Beneficiary access and performance problems 1.5 Members choosing to leave the plan 1.5 Getting information from drug plan 1.5 Rating of drug plan 1.5 Getting needed prescription drugs 1.5 Medicare Plan Finder composite 1 High-risk medication 3 Diabetes treatment 3 Part D medication adherence for oral diabetes medications 3 Part D medication adherence for hypertension 3 Part D medication adherence for cholesterol 3 Table 3. Categories and weighting of performance measures Measure Description Weighting Outcome measures Focus on improvement to a beneficiary s health as a result of the care that is provided 3 Intermediate outcome measures Patient experience measures Access measures Process measures Concentrate on ways to help beneficiaries move closer to achieving a true outcome 3 Represent beneficiaries perspectives about the care they receive 1.5 Reflect processes or structures that may create barriers to receiving needed health care 1.5 Capture a method by which health care is provided 1 Understanding Medicare and the Star Quality Rating System Traditional Medicare (Original Medicare) encompasses Medicare Part A (hospital insurance) and Medicare Part B (medical insurance), and it has been administered primarily by the federal government. 1 Medicare Advantage plans (Medicare Part C or MA plans) are administered by private insurers but regulated by the government. 6 These plans must offer coverage comparable to Original Medicare Part A and Part B benefits. 6 The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) made it possible for Medicare beneficiaries to obtain outpatient prescription drug coverage through private insurers (primarily managed care organizations). 7 Medicare prescription drug plans (Medicare Part D) add comprehensive prescription drug coverage to Original Medicare; these plans are 230 JAPhA 54:3 MAY/JUN 2014

4 medicare star ratings SPECIAL FEATURE referred to as PDPs. 7,8 Most Medicare Advantage plans include prescription drug coverage; these plans are referred to as MA-PDs. 7,9 CMS created the star rating system in 2007 as a way to inform beneficiaries enrollment decisions and spur improvement in the Medicare Advantage marketplace. 10,11 The star ratings incorporate data from Healthcare Effectiveness Data and Information Set (HEDIS) quality measures, Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys, the [AU: Medicare?] Medicare Health Outcomes Survey (HOS), and CMS administrative data. 10,12 A five-point scale is used to score plans on the level of quality provided: Five stars = excellent Four stars = above average Three stars = average Two stars = below average One star = poor Plans are rated according to the types of services offered. 13 Plans covering health services are rated on 37 different Part C performance measures in five domains 13 : Staying healthy (screenings, tests, and vaccines) Managing chronic conditions Member experience with the health plan, including ratings of member satisfaction Member complaints, problems getting services, and improvement in the health plan s performance Health plan customer services Standalone PDP plans are rated on 18 different Part D performance measures in four domains: 13 Drug plan customer service Member complaints, problems getting services, and improvement in the drug plan s performance Member experience with plan s drug services Patient safety and accuracy of drug pricing MA-PD plans that cover both health and drug services are rated on all 55 measures. 13 The star ratings for individual performance measures are factored into increasing levels of aggregate ratings. Star ratings for individual performance measures within each of the nine domains are averaged to calculate domain star ratings. Medicare Advantage plans receive a summary star rating that reflects all 37 Part C performance measures. 12 PDPs receive a summary rating that reflects all 18 Part D performance measures. 14 MA-PDs receive an overall star rating that incorporates the 37 Part C performance measures as well as the 18 Part D performance measures. These single-star summary and overall ratings cumulative indicators of quality of care, access to care, responsiveness, and beneficiary satisfaction are intended to make it easy for beneficiaries to compare plans. 12,15 A plan s star rating is calculated each year, and results are posted on the CMS website each fall. 16 CMS does not publish star ratings for a plan if certain data elements to calculate a score for a given measure or component of the summary score are missing or incomplete. 10,12 Newer plans and smaller plans are more likely to be missing the necessary data. 10,12 Plans can improve their summary or overall star rating from one year to the next. 15,17 However, all plans cannot improve their star rating significantly during a given year, because each performance measure is scored on a relative scale (i.e., a curve ). 17 The Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 (collectively known as the Affordable Care Act [ACA]) introduced a quality-based payment structure for Medicare Advantage plans. 17,18 CMS is required to use the star ratings to reward highly rated plans with higher payments. 17,18 In addition, Medicare Advantage and MA-PD plans with a rating of four or more stars receive quality bonus payments (QBPs). 17,18 Consequently, improving star ratings to obtain higher payments and QBPs has become an important priority for many insurers. 10 Plans are required to use QBPs to provide extra benefits for enrollees (e.g., eyeglasses, transportation to and from medical appointments). 19 In theory, plans with higher star ratings that receive QBPs should be able to offer a more attractive set of benefits than their competitors, leading to greater enrollment in plans with higher quality ratings. 19 High star ratings are also important for reasons not directly related to payments. Plans that receive five stars may market to and enroll Medicare beneficiaries throughout the year and are not limited to the specified open enrollment period. 19,20 The Medicare.gov website highlights five-star plans with a special icon to encourage beneficiary enrollment in these plans. 15 Conversely, plans that receive fewer than three stars for 3 or more consecutive years are designated by a warning symbol. 11 Beneficiaries enrolled in low-ranked plans are notified and given the option to switch to higher-quality plans. 20 After 2014, plans with fewer than three stars for the last 3 consecutive years will not be permitted to enroll beneficiaries through the Medicare website and run the risk of being dropped from Medicare altogether. 11 Plan ratings can have a substantial impact on beneficiary enrollment. In a cross-sectional study by Reid and colleagues of 2011 Medicare Advantage enrollments, a one-star-higher rating was associated with a 9.5 percentage-point increase in the likelihood that first-time enrollees would select the higher-rated plan. 10 A one-starhigher rating was also associated with a 4.4 percentagepoint increase in the likelihood that enrollees switching plans would select the higher-rated plan. 10 A closer look at PQA-supported performance measures Of the five PQA-supported performance measures adopted by CMS, two (high-risk medication and diabetes treatment) relate to medication safety and three relate to medication adherence. MAY/JUN :3 JAPhA 231

5 SPECIAL FEATURE medicare star ratings High-risk medication The performance measure for high-risk medication use specifically, use of high-risk medications in older patients was adapted from the HEDIS measure known as Drugs to be Avoided in the Elderly (DAE). 14 The DAE measure identifies the percentage of adults older than 65 years of age who receive at least two prescriptions (i.e., two fills) for a medication that is considered to put the patient at high risk for an adverse drug-related event. 14 The list of medications in this measure is derived from (and thus represents a subset of) the Beers criteria for potentially inappropriate medication use in older adults, which were updated most recently by the American Geriatrics Society in Diabetes treatment The performance measure for diabetes treatment actually focuses on the appropriate treatment of hypertension in patients with diabetes. It targets patients who have received a medication for diabetes as well as any medication that could be used for the treatment of hypertension; the drugs serve as proxies for a diagnosis of diabetes and hypertension. 14 The measure indicates the percentage of patients with coexisting diabetes and hypertension who are being treated with a renin angiotensin system antagonist (ACE inhibitor, angiotensinreceptor blocker, direct renin inhibitor), consistent with American Diabetes Association recommendations and other clinical guidelines. 14 Medication adherence The three medication adherence performance measures target oral antidiabetic medications, antihypertensive agents (renin angiotensin system antagonists), and statins. The PQA-recommended metric Proportion of Days Covered (PDC) is used as the measure of adherence. This metric defines high adherence as >80% of days covered; each performance measure indicates the percentage of patients in a plan with high adherence to the medications of interest. Medication adherence is especially important for star ratings because it contributes to the three tripleweighted Part C measures mentioned earlier: diabetes care blood sugar controlled, diabetes care cholesterol controlled, and controlling blood pressure. A glimpse of plan performance Table 4 shows the percentage of MA-PDs and PDPs that met the criteria for each of the five triple-weighted Part D performance measures. The data reveal opportunity for improvement in all five areas. For example, the reported percentages for adherence to oral antidiabetic medications show that approximately 26% 27% of MA- PD plan members with diabetes are not highly adherent (i.e., have fewer than 80% of days covered) and most likely are not refilling their prescriptions regularly. Even small improvements in performance measures can translate into large effects on star ratings. In 2013, MA-PDs earned three stars if at least 72.0% of patients with diabetes were highly adherent to oral medication, four stars if at least 75.7% of patients were highly adherent, and five stars if at least 79% of patients were highly adherent. The distance between these ratings is not huge; some concerted effort by the MA-PD and its pharmacy network conceivably could move the plan into a higher star category and help the plan qualify for QBPs. Similarly, lack of action could easily knock the plan into a lower star category. Display measures In addition to plan ratings, CMS uses display measures to further evaluate and facilitate quality improvement in MA-PDs and PDPs. 9 Display measures are not part of the plan ratings; they are used to establish benchmarks and provide feedback to plans. The 2013 display measures include three PQA-supported measures of medication safety: Drug drug interactions Table national averages for triple-weighted Part D performance measures a Percentage of plans meeting performance criteria Part D performance measure MA-PDs PDPs High-risk medication 7.8% 8.8% Diabetes treatment 84.3% 82.3% Adherence oral diabetes medications 73.7% 75.8% Adherence blood pressure medications 73.9% 76.8% Adherence statins 69.0% 71.0% Abbreviations used: MA-PDs, Medicare Advantage plans with prescription drug coverage; PDPs, prescription drug plans. Source: Reference 9 a 2013 averages represent data collected in Excessive doses of oral diabetes medications Completion rate of Comprehensive Medication Reviews Completion of Comprehensive Medication Reviews is a carryover from 2012 that may become part of the star ratings in According to a CMS report based on initial data collected in 2011, only approximately 10% of patients who were eligible for a comprehensive medication review actually completed one. Figuring out ways to increase this percentage is expected to be a focus of activity for many insurers. The EQuIPP Initiative Given the importance of medication adherence in the star ratings, plans are constantly seeking new and innovative strategies for improving their performance on 232 JAPhA 54:3 MAY/JUN 2014

6 medicare star ratings SPECIAL FEATURE adherence measures. Might it be possible to leverage the power of community pharmacists to engage patients in ways that increase star ratings? EQuIPP the Electronic Quality Improvement Platform for Plans and Pharmacies was designed to facilitate an environment in which prescription drug plans and community pharmacies can engage in strategic relationships to address improvements in the quality of medication use, especially medication adherence rates. 22 EQuIPP is a performance information management platform that makes unbiased, benchmarked performance data available to health plans and community pharmacy organizations. 22 The goal of EQuIPP is to bring a level of standardization to the measurement of the quality of medication use and make this information accessible and easy to understand. The EQuIPP initiative has its roots in a PQA-sponsored demonstration project in Pennsylvania a collaboration between Highmark Blue Cross/Blue Shield and Rite Aid Pharmacy. During the project, pharmacists received star ratings information that helped them understand how they were doing at a local level. Investigators worked with the pharmacists to develop strategies that would drive improvements in Medicare adherence measures; preliminary analyses indicated significant increases in adherence rates. Highmark also saw increases in its star ratings for adherence measures during the study time period, although causality cannot be established. EQuIPP incorporates all of the triple-weighted Part D performance measures as well as the drug drug interaction display measures. Pharmacists can see how their pharmacy is faring compared with established benchmarks for each measure (e.g., the threshold required for a four-star rating); they also can see how their performance compares with that of other pharmacies within the company (e.g., chain) or state. Graphs display trends over time, so pharmacists can easily tell whether changes they are making are translating into performance improvements. EQuIPP also provides access to relevant information and resources available from other organizations. The payer perspective Effective strategies for improving medication safety and medication adherence are of paramount importance to health plans. For many MD-PAs and PDPs, the performance measure for diabetes treatment poses the greatest challenges. Understanding the rationale for this helps to illuminate an inherent drawback to the Part D performance measures. Ostensibly, the diabetes treatment performance measure should be one of the easiest to meet: it requires a patient with coexisting diabetes and hypertension to have at least one fill of a renin angiotensin system antagonist. But what about patients who cannot take an ACE inhibitor, angiotensin-receptor blocker, or direct renin inhibitor because of contraindications, adverse effects, or other clinical considerations? Those patients are counted as not meeting the performance measure, rather than as exceptions to the performance measure. A similar problem exists with the medication adherence measure for cholesterol and patients who are unable to tolerate statin medications. Efforts to improve adherence scores can also be complicated by patients interpretations of what it means to be highly adherent. When the question Are you taking your medications as directed? is posed to a typical patient, he or she invariably will respond yes. Additional questioning exposes a different actuality. Some patients consider themselves to be adherent if they take a medication 70% of the time; others consider themselves to be adherent if they miss only one or two doses per week. The question On average, how many times a week or month do you miss a tablet? can elicit widely varying responses from patients who confidently label themselves as adherent. As a result, getting patients to buy into the need for better adherence can be a long, uphill struggle. MD-PAs and PDPs face particular challenges when they reach out to prescribers. A patient may be receiving care from multiple general practitioners (not a single, true primary care provider who manages all care) as well as multiple specialists (e.g., endocrinologist, cardiologist). Determining who exactly is responsible for the patient which provider should be contacted to implement a specific intervention can be difficult. Prescribers also tend to view health plans and their motives with suspicion: Why would a plan be interested in improving the care of an individual patient, rather than simply treating the patient as a claim coming through the system? Surely it must be about money. Many prescribers remain unaware that QBPs received by plans for achieving higher star ratings must be used to enhance benefits for enrollees; they cannot be added to a company s bottom line. Interacting with the older adult population may pose the greatest challenge of all. Approximately one in eight Americans is 65 years of age or older; 2 however, today s Medicare beneficiary is not yesterday s senior citizen. The typical baby boomer believes that old age does not begin until 72 years of age. 2 Older adults are as likely to be technology-savvy as they are to be technology-phobic; many are part of the Yelp generation that has been conditioned to respond to and rely on ratings (such as star ratings). Given this heterogeneity, no single type of outreach is guaranteed to engage the entire Medicare population. If any commonality exists, it may be in the difficulties associated with managing a complicated drug regimen. From the payer perspective, the community pharmacist is ideally positioned to help plans overcome MAY/JUN :3 JAPhA 233

7 SPECIAL FEATURE medicare star ratings many of these challenges. Pharmacists in community settings have frequent contact with beneficiaries and are most likely to see the totality of a patient s care, rather than view the patient with the tunnel vision of a specialist. Patients are far more likely to talk with a trusted health care practitioner than a representative from a health plan; patients increasingly view pharmacists as knowledgeable health care providers who administer vaccines and interact with them to improve medication use. Community pharmacists have access to adjudication and prescription data at their pharmacy. Community pharmacies are rapidly developing and employing technology, especially to communicate with patients. Engaging members at the local level and establishing relationships with providers are perhaps roles better filled by the community pharmacist than the health plan. The community pharmacy perspective Today s pharmacists express an unprecedented desire for involvement in direct patient care, education, and research activities. Since 2011, pharmacists who practice in ambulatory care settings (including community pharmacy) have been able to pursue board certification and earn a credential (board certification in ambulatory care pharmacy [BCACP]) that recognizes the importance of this role. The growth of community pharmacy residency programs is accelerating the development of clinical programs and patient care services. The advent of community pharmacy accreditation (e.g., through the Center for Pharmacy Practice Accreditation and URAC, formerly known as the Utilization Review Accreditation Commission) promises to bring greater awareness and attention to the concept of patient care pharmacies places where patients can avail themselves of a wide array of services beyond prescription drug dispensing. The critical importance of active and effective engagement with networks of community pharmacists becomes evident when one reconsiders the statistics presented earlier about the star rating thresholds for the Part D performance measure on medication adherence for oral antidiabetic medications. As shown in Table 5, an MA-PD with 100,000 patients with diabetes would need to have 72,000 patients qualify as highly adherent for the plan to earn a three-star rating. If the MA-PD engaged with a network of 3,700 pharmacies, each pharmacy would need to produce just one additional adherent patient for the plan to exceed the four-star threshold. A total of 7,000 additional adherent patients spread over the pharmacy network would shift the rating from three stars to five stars. The Thrifty White Pharmacy Med Sync appointment-based model (ABM) program provides a powerful example of what can be achieved through community pharmacist interventions. 4 Thrifty White Pharmacy is an employee-owned regional pharmacy chain with locations throughout Iowa, Minnesota, Montana, North Dakota, South Dakota, and Wisconsin. The ABM program seeks to improve patient adherence by synchronizing all of a patient s chronic fill medications to come due on a single day of the month. Patients make an appointment to meet with a pharmacist when they come to pick up the medications, providing an opportunity for the patients to ask questions about their medications, as well as for pharmacists to review all of the medications and offer recommendations for nonprescription medications, immunizations, lifestyle behavior changes, or home health equipment. Researchers at Virginia Commonwealth University School of Pharmacy performed a retrospective analysis of data from the Thrifty White prescription claims database, comparing patients in the ABM program with control patients over a 12-month period from 2011 to Adherence (as measured by proportion of days covered) was significantly higher for the ABM patients; depending on the drug class, patients enrolled in the program had 3.4 to 6.1 times greater odds of adherence than control patients. 23 Control patients had a 52% to 73% greater likelihood of becoming nonpersistent compared with the ABM group, depending on drug class. Although much attention is paid to medication adherence, health plans should not overlook other performance measures that could be improved with community pharmacist support. These include the following process measures (weight 1): Annual influenza vaccine Cardiovascular care cholesterol screening Care for older adults medication review Care for older adults pain screening Colorectal cancer screening Diabetes care cholesterol screening Diabetes care eye exam Osteoporosis management in women who had a Table 5. Number of highly adherent patients needed to achieve various star ratings for the Medicare Part D medication adherence for oral diabetes medications measure Star rating 2013 star threshold No. patients a 3 stars 72.0% 72,000 4 stars 75.7% 75,700 5 stars 79.0% 79,000 a Assumes a plan with 100,000 patients with diabetes. fracture Reducing the risk of falling Certainly, a number of challenges must be overcome for community pharmacies and health plans to work together effectively. The patient data available to pharmacists is limited largely to medications dispensed at their specific pharmacy. The power of the pharmacist to contribute in a positive way would be much greater if pharmacists had access to both pharmacy and medical claims data and laboratory test results. Without such 234 JAPhA 54:3 MAY/JUN 2014

8 medicare star ratings SPECIAL FEATURE access, pharmacists must draw inferences regarding patients diseases and health status a highly unreliable approach. It is also unreliable to assume that simply because a patient requests or receives a medication refill that he or she is actually using the medication as prescribed. Assessing and sharing a patient s clinical status is the ultimate determinant of whether a specific drug is working as intended. In order for pharmacists to provide quality-based outcomes, they need connectivity to the health information exchange and data exchange capabilities so that they can send information to other health care providers and receive information from providers. Creating a successful payer community pharmacy collaboration Collaborations between payers and community pharmacists have the potential to augment and improve the quality of care. But what does collaboration look like, and how does it begin? Configuring the collaboration The literature on collaboration identifies a simple first step having all parties involved agree that they do indeed want to collaborate. Collaboration will not be successful if any of the parties is reluctant or unwilling. After the decision to collaborate is made, the next steps are Establishing a common goal Identifying metrics Allowing innovation to occur Establishing a common, measurable goal is critical, because it allows each party to focus on the actions that are most likely to achieve the goal. The goal must be important enough that all parties will be motivated to work toward it. The goal should also focus on outcomes, not activity. Simply putting a program in place in a community pharmacy (e.g., a medication adherence program) can look and feel like success, especially if pharmacists engage many patients in discussions about adherence. From the health plan perspective, however, such programs are meaningless unless they result in actual behavior change or a different outcome for a particular member (e.g., improved adherence). Part of establishing a common goal is determining which patients to target. Budget considerations frequently dictate that interventions be limited to subsets of patients often those at greatest risk, for whom the impact and return on investment are likely to be greatest. Ideally, each party will also have incentives that are aligned with and tied to achieving the common goal. Part of the model has to be a clear return on investment for every party. Perhaps most important is the realization that misplaced incentives can undermine a collaboration before it gets off the ground. For example, volume-based incentives (i.e., those tied to the number of prescriptions dispensed) are more likely to interfere with community pharmacists efforts to improve adherence rates than they are to motivate pharmacists to spend time talking with patients. With a shared goal in place, all parties must determine precisely what will be measured, how it will be measured, and what success will look like. In other words, how will everyone involved know that the shared goal has been achieved? All parties must be looking at the same data and assessing each other in the same way to ensure that all parties are heading in the same direction. Arguably, this is one of the problems with medication therapy management (MTM) services. MTM is difficult to define and quantify; performing a comprehensive medication review is the only concrete shared metric. In contrast, programs targeted to improving star ratings for Part D triple-weighted performance measures are an obvious and straightforward area for collaboration, because the measures are discrete and well-defined for both health plans and community pharmacists. Being too prescriptive with measures could hinder successful health plan community pharmacy collaborations on a national scale. Using medication adherence as an example, baseline rates differ across the country. The goal for pharmacists in Alabama and California may be to have adherence rates in the top 20% of pharmacies in the state, but the absolute adherence rates could be very different. Simply put, pharmacists in Alabama are not competing with pharmacists in California. Once the groundwork is laid, each party should have some freedom to find creative ways to achieve the goal. Many different paths lead up the mountain and to the summit. Strategies that arise from the existing work culture, environment, and routines have a much greater chance of being successful. Strategies also need to account for regional variations in patient characteristics, health literacy, health beliefs, and lifestyle. Too much freedom can backfire, however. Again, using medication adherence as an example, a health plan cannot simply direct a pharmacy to increase adherence rates. There needs to be partnership and dialogue about best practices for improving adherence. Otherwise, health plans may get complaints from unhappy members, and those complaints could in turn affect scores related to member satisfaction. Examples of successful collaborations The previously mentioned PQA-sponsored demonstration project in Pennsylvania the collaboration between Highmark Blue Cross/Blue Shield and Rite Aid Pharmacy is an example of how the agree establish identify allow approach can work. The shared goal was improving adherence to antidiabetic medications and statins. The metrics were the Medicare star rating adherence measures. Allowed the freedom to innovate, Rite MAY/JUN :3 JAPhA 235

9 SPECIAL FEATURE medicare star ratings Aid pharmacists developed a new model for engaging patients at the point of service that was neither overly time consuming nor required hiring additional staff. In brief, every patient with diabetes and every patient receiving a cardiovascular medication was asked a few key questions by the pharmacist that were aimed at assessing medication-related problems. Pharmacists tailored their responses to address each patient s specific concerns. The district managers held the pharmacists accountable and rewarded those who were very good at delivering the new model by identifying an outstanding pharmacy in each district. The Wisconsin Pharmacy Quality Collaborative (WPQC) is another model of successful coaction. 24,25 The Pharmacy Society of Wisconsin reached out to nine payer/purchaser organizations (including Wisconsin Medicaid) that collectively insured more than one-half of Wisconsin citizens. Each group was asked the same question: Are you satisfied with the medication use in your plan? In every case, the answer was no all of the organizations believed they were paying too much for too little value. The Pharmacy Society of Wisconsin invited the payer/purchaser organizations to work with the association to brainstorm possible solutions to these problems. A workgroup consisting of payer/purchaser representatives, community pharmacists, and pharmacists from other practice sites met every other month for more than 1 year. The group conceived a network of chain, independent, and health system (i.e., clinic) pharmacies committed to improving medication use by patients enrolled in the participating health plans and reducing health care costs for payers and patients. The pharmacies agreed to implement certain quality-based best practice requirements as a condition of participation, with pharmacists compensated for services provided. Two of the payers estimated that they saved more than $2.50 in drug costs for every $1 paid to pharmacists in Insights and challenges Throughout the course of their discussion, the panelists made many cogent observations about issues relevant to Medicare star ratings and possible collaborative initiatives. They also identified a number of challenges that could interfere with success. Insights and challenges related to medication adherence Adherence programs, professionalism, and payment. Because medication nonadherence has multiple and complex causes, successful behavioral change requires ongoing patient engagement. Continuous monitoring is also necessary from a practical perspective. If a medication is taken daily, 80% adherence translates to 292 out of 365 days. On a calendar-year basis, a patient would need to take that medication daily from January until sometime in October to achieve 80% adherence. Adherence messaging cannot ease up after that point (e.g. no saying It s November, we re done here ) because the counter resets to zero in January. The concept of adherence as taking medications every day, rather than 3 or 4 days a week, must be reinforced with patients during every interaction. Ideally, community pharmacists who are involved in efforts to achieve high levels of medication adherence would be responsible for a panel of patients, just as physicians are responsible for their patients. Pharmacists need to feel a professional obligation to those patients and take ownership of the desired outcomes. Part of that will come from providing feedback about performance: Here is your panel of patients, and here s how they are doing. If the true value of pharmacist services is to be realized, the thinking cannot be physicians, pharmacists, and plans ; it needs to be providers of service and payers (i.e., plans). Such thinking is paramount because it would lead to proper reimbursement for providing a pharmacy-based service, not just dispensing a product. The reality is that financial incentives must be in place to make adherence services a viable business venture for pharmacists. The incentive does not necessarily have to be a fee-for-service payment, but there must be some sort of monetary reward for achieving the goal. Missing claims data. A number of pharmacies offer certain generic medications to patients at no or minimal cost (e.g., $4). There is a great deal of speculation about what will inspire community pharmacists to submit a claim for such transactions so that a prescription drug event (PDE) record will be generated and counted toward adherence metrics. No one is able to quantify the impact of unreported data, and that affects plans star ratings as well as their ability to make informed decisions. Perhaps most importantly, incomplete data affect how health plans interact with members and can erode plans relationships with members. For example, when a health plan draws on claims-based adherence data to contact members and their prescribing physicians regarding nonadherence, both the patient and prescriber may respond, But that s wrong the medication is being taken as prescribed! However, without complete data, the health plan has no corroborating evidence, and the contact will continue. Situations such as these ultimately can elicit warnings from CMS about harassing patients. Part of the problem with these types of claims may involve confusion about the Medicare Part D coverage gap. Patients who are in the doughnut hole may pay cash for a $4 medication because they assume it is their least expensive option. However, if they used their Part D benefit for the medication, they could actually pay less than $4 because only 79% of the cost is an out-of-pocket 236 JAPhA 54:3 MAY/JUN 2014

10 medicare star ratings SPECIAL FEATURE expense for the patient. When community pharmacies offer such $4 plans, patients may be hurt financially, and the problem of missing claims data will continue. Another aspect of the problem is misaligned incentives. Historically, pharmacies have not had a compelling reason to channel patients into the claims system instead of providing free medication. Free medication was a loss leader that brought patients into the pharmacy or retail outlet, where they were likely to spend money on other purchases. Why go to the trouble of working through the claims system to improve a health plan s star ratings just so the plan can earn a QBP? Additionally, some smaller regional chain or independent pharmacies are charged transaction fees for submitting claims. Not only are the incentives missing, but the pharmacy must actually pay to do something that seemingly benefits only the health plan. Pharmacist incentives are also misaligned. Imagine a pharmacist working in a busy, high-volume pharmacy. A patient presents a prescription for a medication that is included in the pharmacy s $4 program. The transaction generates an alert such as refill too soon. The pharmacist then notices a blinking red light on the computer, indicating that 40 prescriptions are waiting to be processed. At that moment, the pharmacist is incentivized to process the prescription through the $4 cash program (rather than adjudicate it through the claims process) just to dispatch it as quickly as possible. Even patient incentives are misaligned. Patients present with all manner of complicated and justifiable exceptions to health plan rules. One example is a patient who travels frequently in addition to spending time at a primary residence and a vacation residence. What happens if the patient wants to keep a supply of medication at home, at the vacation house, and in a travel bag all in the interest of supporting adherence? In most existing systems, the easiest approach for the patient is to go out of network and pay cash for some of the medication, just to avoid having to provide an explanation that will override the inevitable alerts. Awareness may grease the wheels of change. In the EQuIPP initiative, pharmacies are able to see how they compare with other pharmacies. Some pharmacies that have been providing free medications realize, Oh, so this is how we look to the plans? Now we understand why they ve been bugging us. Zero copayments. All existing evidence points to the conclusion that a zero-dollar copayment is not an effective incentive for increasing patient adherence. A zero-dollar copayment primarily leads to wasteful medication stockpiles; it does not guarantee that a patient will actually take any of the medication. As noted above, it also does not guarantee that the patient will procure the medication through the health plan. It may be important to assign some monetary value to a prescription, even if that value is only $1. Insights and challenges related to measures Benefit design fragmentation. Health plans currently offer coverage with pharmacy benefits either as part of the benefit design or carved out, within a preferred network or a high-performance network. Because patients often still use their local pharmacy, this can result in fragmented services. Working to minimize and coordinate this kind of benefit design fragmentation would help to ensure more focused and better quality care. Accurate measures to inform pathways to outcomes. As one panelist observed, everyone is trying to achieve the same end, but the route that is navigated to get there depends on the particular incentives in a particular arena. Consider the example of pharmacies seeking to create a high-performance network. One payer wants to waive copayments for chronic medications because that payer is primarily interested in reaching goals for star ratings, HEDIS measures, and similar metrics. For another payer, the most important feature in a highperformance network is a waste management program. If the pharmacies create a network focused on an active waste management program, that network could end up at a competitive disadvantage in the scoring or in the quality metrics compared with a network that is not attempting an active waste management program. How does a network juggle competing priorities? Perhaps the answer is to work aggressively on defining a larger set of precise, accurate measures that can be trusted to lead to the best, most efficient pathways for producing desired outcomes. Emerging care models. As the electronic health record environment evolves, health plans need to be thinking about how to draw better measures from that environment, as well as how to create a team-based performance assessment across neighborhoods of care for example, How is that neighborhood or how is that accountable care organization (ACO) doing? There needs to be shared accountability and shared rewards for success with enhanced clinical measures. In this regard, the perfect must not become the enemy of the good. Current incentives for ACOs do not emphasize medication adherence directly. The four key performance indicators are preventable admission, readmissions, emergency department visits, and total cost of care. These performance indicators can often be linked to medication adherence, but ultimate dollars are not determined by the adherence rate directly. Because the risk is around the medical spend and utilization, ACOs need data beyond just prescription drug claims to understand patient behaviors and clinical response surrounding medication adherence. Standardization of measures. Entities other than Medicare are beginning to issue their own ratings of health plans, pharmacies, and other providers. Efforts to harmonize these ratings must begin now; otherwise, the parties being rated may end up struggling to make MAY/JUN :3 JAPhA 237

11 SPECIAL FEATURE medicare star ratings sense of and comply with different sets of measures that define quality in disparate ways. Insights and challenges related to reimbursement Reimbursement for patient interaction, not drug dispensing. Community pharmacists clearly are the missing variable in this entire equation. Unfortunately, community pharmacists often are at odds with payers; pharmacists view health plans through the lens of you re killing my cost, you re not paying me anything. Pharmacists need to step outside of their traditional box and stop viewing themselves as dispensers. In the community pharmacy arena, a model with financial incentives that emphasize and reward pharmacist information services (as opposed to dispensing services) will impact staffing levels and the amount of pharmacist time available for consultations. Health care is business. All of the barriers that have to do with money can be overcome easily with some simple recognition. Health plans customarily pay pharmacists a set amount for providing a service, such as MTM. In emerging payment models, involved health providers share risk at various levels. For example, in a pay-for-performance structure, health plans may direct pharmacies to increase adherence rates because the plan is being held accountable for adherence. The health plan may provide a performance bonus to a pharmacy for reaching the target. Health plans must recognize that pharmacists may spend a great deal of time on activities that do not affect adherence. Payment needs to account for and incorporate certain cost of doing business activities. Opportunities and next steps What needs to happen to stimulate collaboration between payers and community pharmacists aimed at influencing star ratings? What future developments might shape these collaborations? Some possible answers are summarized below. Characterize current programs According to one pharmacy benefits manager with a pharmacy network, the question posed most frequently by health plans is, What are community pharmacies doing today to drive adherence? More information is needed about the status and scope of existing adherence programs. Which pharmacy chains and networks have programs, and which do not? What do these programs look like? Are they based on reminder calls, letters, or something else? A survey capturing even self-reported data of this nature would be extremely valuable. Bring more data EQuIPP will likely expand beyond medication-related measures to include other performance information, such as HEDIS measures, A1C test results, and other similar data. Before that happens, robust clinical information systems that can pull information efficiently must be in place. The systems must also be able to share data back and forth in a user-friendly way. A situation may arise in which a health plan sends an alert to a community pharmacy about a particular patient s medication use, and the community pharmacist indicates that the patient cannot use a specific drug because of an allergy or contraindication. The health plan needs to be able to capture such data and remove the patient from the contact pool to prevent repeated and unwarranted contacts with the patient s health care providers. Community pharmacies have data and data systems; health plans have data and data systems. How can these two groups meet in the middle to make the best use of those data? Inculcate collaboration Pharmacy schools should encourage collaboration among student pharmacists so that new practitioners emerge with an understanding of how to work together. In particular, pharmacy schools should foster collaboration among the many different student organizations. How can each group best contribute to achieving a common goal? Student pharmacist groups need to learn to recognize their unique perspectives as part of a unified whole. The most harmful and counterproductive situation would be for student groups to view each other as competitors or even antagonistic elements. Impart important skills Principles of behavioral change and practice in evidence-based approaches such as motivational interviewing must be part of the curriculum in every pharmacy school. The pharmacy workforce must be ready to embrace the challenge of improving medication adherence. This cannot happen unless pharmacists are aware of the many factors that influence adherence and are adept at interacting with patients in a way that motivates action. Facilitate dialogue Pharmacy associations should seize the opportunity to facilitate collaboration. All parties need to know what every other party is doing and what their incentives are. All parties also need to think about what they bring to the collaboration and how every other party can contribute to what they are trying to achieve. Pharmacy payers and providers are connected by professional associations. As much as the Pharmacy Society of Wisconsin cultivated the WPQC, other state and national associations can initiate dialogues that serve as the springboard for collaboration. Pharmacy associations could also help to encourage collaboration among student pharmacist organizations. One idea is to sponsor a competition in which several student groups at a school collaborate on a health care 238 JAPhA 54:3 MAY/JUN 2014

12 medicare star ratings SPECIAL FEATURE reform case, and the submissions from each school are judged by a panel of stakeholders. Winners could receive recognition at a national meeting, and the winning submissions could be published in a journal. Eliminate regulatory roadblocks Stakeholders interested in fostering collaboration need to work in a unified fashion to advance state pharmacy practice regulations. Pharmacists will not be able to transition away from the traditional dispensing role until pharmacy technicians are authorized to take on greater responsibility for drug distribution, thereby freeing up pharmacist time. The expansion and acceptance of pharmacy-based immunizations provide valuable lessons in this regard. Stakeholders recognized a public health crisis in the form of poor immunization rates; they united to find ways to make it possible for a wider array of health care providers, including pharmacists, to offer immunization services. This included expanding state practice acts and ensuring that existing regulations were not hindering the ultimate goal of increased vaccination rates. The United States currently has a public health crisis in the form of poor medication adherence. Stakeholders must ensure that the laws are not contributing to the crisis by preventing patients from achieving excellent outcomes. Involve chief executives of health plans The catalyst for meaningful health plan community pharmacy collaboration most likely will be strategic discussions among chief executives at stakeholder companies. Creating a realization in the highest parts of these organizations about the interrelationships and interdependencies among all parties and the mutual benefits of working together to bring about change will be the ultimate win. Conclusion As the health care system embraces a quality focus, health plans and community pharmacies must learn to thrive in this new arena. Change is bringing a realization of the likely mutual benefits of working together. Payers need to achieve the highest possible star ratings; community pharmacists have an unparalleled opportunity to influence performance measures at the patient level. Although much work will be required to get to the next level, health plans and community pharmacies that forge partnerships based on well-defined goals and innovative tactics will discover that the whole truly is greater than the sum of its parts. References 1. What is Medicare? Medicare.gov website. sign-up-change-plans/decide-how-to-get-medicare/whatsmedicare/what-is-medicare.html. Accessed June 28, Baby boomers retire. Pew Research Center website. Published December 29, Accessed June 28, Centers for Medicare and Medicaid Services. CMS roadmaps overview. Assessment-Instruments/QualityInitiativesGenInfo/downloads/RoadmapOverview_OEA_1-16.pdf. Accessed June 28, Centers for Medicare and Medicaid Services. Roadmap for implementing value driven healthcare in the traditional Medicare fee-for-service program. tives-patient-assessment-instruments/qualityinitiativesgen- Info/downloads/vbproadmap_oea_1-16_508.pdf. Published Accessed June 28, Oates V. CMS star ratings program. Talk presented at: National Association of Chain Drug Stores Regional Chain Conference; February 5, 2013; Fort Lauderdale, FL. org/presentations/using_star_ratings.pdf. Accessed June 28, Young CI. Medicare vs. Medicare Advantage: how to choose. U.S. News & World Report website. health-news/medicare/articles/2012/12/04/how-to-choose-between-medicare-and-medicare-advantage-health-insurance. Published December 4, Accessed June 28, Cline RR, Worley MM, Schondelmeyer SW, et al. PDP or MA- PD? Medicare part D enrollment decisions in CMS Region 25. Res Social Adm Pharm. 2010;6(2): How to get drug coverage. Medicare.gov website. Accessed June 28, Medicare Advantage plans. Medicare.gov website. www. medicare.gov/sign-up-change-plans/medicare-health-plans/ medicare-advantage-plans/medicare-advantage-plans.html. Accessed June 28, Reid RO, Deb P, Howell BL, et al. Association between Medicare Advantage plan star ratings and enrollment. JAMA. 2013;309(3): Serafini MW. Second guessing Medicare s star rating system. Kaiser Health News website. stories/2012/may/21/medicare-star-ratings-quality.aspx. Published May 20, Accessed June 28, Kaiser Family Foundation. What s in the stars? Quality ratings of Medicare Advantage plans, 2010 [issue brief]. Published December Accessed June 28, Star ratings help. Medicare.gov website. find-a-plan/staticpages/rating/planrating-help.aspx. Accessed June 28, Green J. PQA measures used by CMS in the star ratings. Pharmacy Quality Alliance website. Accessed June 28, star special enrollment period. Medicare.gov website. www. medicare.gov/sign-up-change-plans/when-can-i-join-a-healthor-drug-plan/five-star-enrollment/5-star-enrollment-period. html. Accessed June 28, MAY/JUN :3 JAPhA 239

13 SPECIAL FEATURE medicare star ratings 16. Part C and D performance data. Centers for Medicare and Medicaid Services website. Drug-Coverage/PrescriptionDrugCovGenIn/Performance- Data.html. Updated December 18, Accessed June 28, Kaiser Family Foundation. Quality ratings of Medicare Advantage plans: key changes in the health reform law and 2010 enrollment data [issue brief]. files.wordpress.com/2013/01/8097.pdf. Published September Accessed June 28, Academy of Managed Care Pharmacy Special Projects Committee. Framework for improving Medicare plan star ratings. December Accessed June 28, Kaiser Family Foundation. Medicare Advantage plan star ratings and bonus payments in 2012 [data brief]. Published November Accessed June 28, Weixel N. CMS says 11 Medicare Advantage plans receive five-star rankings for Bloomberg BNA website. www. bna.com/cms-says-11-n Published October 17, Accessed June 28, American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012;60(4): EQuIPP website. Accessed June 28, Holdford DA, Inocencio TJ. Adherence and persistence associated with an appointment-based medication synchronization program. J Am Pharm Assoc. 2013;53(6): Knapp Dlugosz C. Building the bridge to partnership: fostering the community and managed care pharmacy relationship. Pharmacy Today. 2010;16(10): Trapskin K, Johnson C, Cory P, et al. Forging a novel provider and payer partnership in Wisconsin to compensate pharmacists for quality-driven pharmacy and medication therapy management services. J Am Pharm Assoc. 2009;49(5): Appendix A. Participants and their affiliations at the time of the conference Rebecca Chater, BSPharm, MPH, FAPhA* Executive Healthcare Strategist Ateb, Inc. Raleigh, NC Stephanie Childress, PMP Clinical Quality Strategic Consultant Humana Pharmacy Solutions Louisville, KY Ed Cohen, PharmD, FAPhA Senior Director, Clinical Solutions Walgreens Deerfield, IL Lisa Erwin, BSPharm, CGP Senior Director, Medicare Client Strategies Catamaran Lisle, IL Brian Hille, BSPharm Vice President for Patient Care Safeway Pleasanton, CA Victoria Losinski, PharmD, PhD Professional Services Manager Medication Therapy Management Target Minneapolis, MN Allison Lowry, PharmD, CGP Clinical Pharmacist Blue Cross Blue Shield of Tennessee Chattanooga, TN David Nau, PhD, BSPharm, CPHQ, FAPhA* President Pharmacy Quality Solutions Springfield, VA Carolyn Scott Center for Medicaid and Medicare Services (CMS) Baltimore, MD Steve Simenson, BS Pharm, FAPhA President/Managing Partner Goodrich Pharmacy Anoka, MN Rebecca Snead Executive Vice President and Chief Executive Officer National Alliance of State Pharmacy Associations (NASPA) Richmond, VA Troy Trygstad, PharmD, MBA, PhD Vice President, Pharmacy Programs Community Care of North Carolina Raleigh, NC Mitzi Wasik, PharmD, BCPS* Director, Medicare Pharmacy Programs Coventry Health Care Bethesda, MD Nicole Woods, PharmD Clinical Pharmacist Pharmacy Stars Group HealthSpring Nashville, TN Moderator: Harry Hagel, BSPharm, MSPharm Independent Consultant Washington, DC *Presenter 240 JAPhA 54:3 MAY/JUN 2014

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