Quality Improvement: Opportunities beyond Medicare. David Nau, RPh, PhD, FAPhA PQS President

Transcription

1 Quality Improvement: Opportunities beyond Medicare David Nau, RPh, PhD, FAPhA PQS President

2 The shift to Value-Driven Healthcare The U.S. health care system is rapidly moving to valuebased purchasing or value-driven healthcare Value is the balance of quality and costs, thus we can optimize value by improving quality while reducing costs One of the biggest challenges in driving better quality is that we can t always agree on how to define and measure quality PQA takes the lead on development of medicationrelated quality measures for evaluation of health plans, PBMs and pharmacies, and EQuIPP allows pharmacies to track their performance on quality metrics

3 Pharmacy Quality Alliance Established in April 2006, as a public-private partnership Now a consensus-based, non-profit, alliance with >150 member organizations, including: Health Plans & PBMs Pharmacies & professional associations Federal agencies (CMS, FDA) Pharmaceutical mfrs Consumer advocates Technology & consulting groups Universities Mission: Improve the quality of medication management and use across health care 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.

4 PQA s Role Develops quality medication performance measures for pharmacy services and drug plans - Started in Medicare, branching out to other sectors Demonstration projects for pharmacy quality measures and improving outcomes Education for pharmacists on quality measures and performance improvement Connecting pharmacy to healthcare quality initiatives Recognizing examples of exceptional quality in medication use (pharmacy, health plan, PBMs)

5 Who Uses PQA Measures? Medicare Part D Plan Ratings Star measures: Medication adherence (diabetes, BP, cholesterol) Medication safety (HRM) MTM (CMR Completion Rate) Display measures (3 safety measures) State Insurance Exchanges / Marketplaces Medication adherence URAC and CPPA Accreditation PBM, mail/specialty pharmacy, community Rx

6 Medicare Star Ratings Annual ratings of Medicare plans that are made available on Medicare Plan Finder and CMS website Ratings are displayed as 1 to 5 stars Stars are calculated for each measure, as well as each domain, summary, and overall (applies to MA-PDs) level Two-year lag between year of service and reporting year for Star Ratings (e.g., 2013 drug claims are used for 2015 Star Ratings) 2015 Star Ratings were released in October 2014 to inform beneficiaries who were enrolling for 2015

7 Part D Stars Medicare drug plans receive a summary rating on quality as well as four domain, and individual measure, scores (15 individual measures) Five measures are from PQA (2015): 2 measures of medication safety High risk medications in the elderly Appropriate treatment of blood pressure in persons with diabetes ** 3 measures of medication adherence Non-insulin diabetes medications Cholesterol medication (statins) Blood pressure (renin-angiotensin system antagonists) Due to the higher weighting of clinically-relevant measures, the PQA measures account for 50% of Part D summary ratings for 2015

8 *New* Star Ratings Measure for 2016 Medication Therapy Management Program Completion Rate for Comprehensive Medication Reviews (CMRs) Highlights: - PQA-endorsed measure - Measures the percentage of beneficiaries who met eligibility criteria for the MTM program and who received a CMR with a written summary in the CMS standardized format stars will be based on 2014 measurement period - This measure will be assigned a weight of 1 - For complete measure details, please see the PQA measure listing on the website

9 CMR Completion Rate 2015 Display Measure Performance (based on 2013 data) Star Ratings Best Guesses at Thresholds MAPD 4-star: 35 % PDP 4-star: 30 % Significant opportunity for community pharmacists to help improve CMR Completion Rate

10 2017 and Beyond Potential new measures: Statin Therapy in Diabetes - PQA endorsed this measure in Tracks the use of statins in diabetes patients aged yr - CMS stated that the measure will be a 2017 Display Measure (based on 2015 data) and may become a Star measure for Opioid Overutilization - PQA recently endorsed 3 measures evaluating multi-provider, high dosage opioid use among individuals 18 years and older without cancer and excluding hospice

11 Part D Star Thresholds Change

12 High Stakes for Part D Stars Enrollment Implications Quality Bonus Payments (MA-PD) Poor and high performers identified by CMS Low-performer icon High-performer icon Removal from Medicare for continued poor overall performance (< 3 stars for 3 years in a row)

13 Higher-rated plans attract more enrollees A study published in JAMA on January 16, 2013, concluded that Medicare's 5-star rating program for Medicare Advantage is associated with beneficiaries' enrollment decisions. Among first-time enrollees, a 1-star higher rating was associated with a 9.5 (95% CI, ) percentage-point increase in likelihood to enroll. Among enrollees switching plans, a 1-star higher rating was associated with a 4.4 (95% CI, ) percentage-point increase in likelihood to enroll. Star ratings were less strongly associated with enrollment for black, rural, low-income, and the youngest beneficiaries.

14 Quality Bonus Payments The star ratings now affect payment to Medicare Advantage plans wherein higher-rated plans get higher payment Quality Bonus Payments (QBPs) are being awarded on a sliding scale according to star ratings QBPs were created by PPACA but have been phased in via a demonstration project 2016 payments will be based on 2015 ratings which are based on 2013 data QBP opportunity for large MA-PDs (Humana, United Healthcare, Aetna/Coventry, CIGNA/HealthSpring) may exceed $100 million

15 Health Insurance Marketplaces Launched in 2014 Combination of state-operated and federal- operated exchanges (or marketplaces) Federal exchanges were plagued by enrollment difficulties in first year, and some of these problems persist in 2015 Enrollment continues to increase Qualified Health Plans (QHPs) must be deemed by NCQA or URAC, and must submit QRS results

16 Quality Rating System (QRS) The QRS for the marketplace program will begin with a beta phase wherein QHPs must submit data on quality measures using data from 2014 Beta phase consists of 19 clinical measures plus a member survey Plans must report if enrollment > 500 members Results on beta-phase measures must be submitted to CMS by June 15, 2015 In future years, CMS will publicly post a star rating of each QHP based on these measures

17 2015 QRS Clinical Measures

18 How are Health Plans and PBMs responding? Formularies, clinical strategies, network contracts, marketing/promotions, aligning with star measures and QRS More telephonic outreach to members and more targeted MTM activities Contract strategies for pharmacy networks Pay for Performance (P4P) pharmacies may be eligible for bonus payment based on star performance Preferred pharmacy network based partly on star performance of chain or stores

19 Pharmacy Pay-for-Performance Programs Inland Empire Health Plan (IEHP) - Launched in October 2013 based on Star measures plus asthma and GDR - Pharmacies will receive bonus depending on their performance on each measure: 3-star attainment = small bonus 5-star attainment = large bonus Caremark-SilverScript - Ongoing program based on PDC-adherence and ACE/ARB in Diabetes measures - Combination of payment for gap closures delivered through Mirixa and bonus on reaching performance goals as measured by EQuIPP Healthfirst of NY - Program launched October 2014 based on PDC-adherence measures - Combination of payment for program commitment and for reaching performance goals as measured by EQuIPP More programs on the way for PQS estimates that over 7 million lives will be covered by P4P or similar incentive programs in 2016

20 IEHP: Impact of P4P

21 Pharmacy Quality-Based Networks Quality has become one criterion for selection of preferred pharmacies Minimum quality expectations spelled out in preferred contracts May lead to adjustment of DIR rates Quality scores could be used to identify pharmacies that can fill geographic gaps in existing networks Some PBMs are creating Quality-Based Networks (QBNs) May be a subset of preferred pharmacy network May include requirements / incentives related to quality

22 Need for Neutral Intermediary As Health Plans and PBMs create financial consequences for pharmacies related to the star ratings, there is a need for a neutral intermediary to ensure accuracy, consistency and transparency. EQuIPP, from PQS, is increasingly being tapped to serve as the neutral intermediary. In this role, EQuIPP Ensures that the star measure scores for pharmacies are calculated accurately (i.e., according to PQA/CMS specifications), Ensures that star measure scores are calculated consistently across plans/pbms so that pharmacies can avoid dueling report cards, Provides transparency in the calculation of the star measure score calculations so that pharmacies understand how their scores were calculated.

23 What is EQuIPP? EQuIPP is a multi-plan, multi-pharmacy, collaborative to: Support collaboration of health plans, PBMs and pharmacies for Quality Improvement related to medication use Allow consistent, standardized assessment of community pharmacy performance on Part D stars and other quality measures Enable faster, more-refined, benchmarking of Part D stars performance in key market areas EQuIPP provides a neutral assessment of quality for trusted performance assessment and benchmarking by all parties. EQuIPP lays the foundation for performance-based contracts and payment systems for pharmacy networks

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26 Outlier List

27 Preview: New Pharmacy Display for QI Programs

28 Pharmacy Accreditation URAC has implemented a community pharmacy accreditation program and has accredited CVS/pharmacy. More to come? The Center for Pharmacy Practice Accreditation (CPPA) is a collaboration of APhA, ASHP and NABP. Several independent pharmacies have been accredited. Both accreditation programs require pharmacies to measure quality and have QI programs in place Both programs anticipate that pharmacies will need to report quality data for re-accreditation at some point in the future Implications of these programs is not yet clear since no payer has signaled an intent to require accreditation for network participation

29 Pharmacy Star Ratings In Development PQA and PQS have partnered on creation of an Overall Rating of a pharmacy that can be derived from the individual PQA measures in way that is scientifically valid as well as efficient Project is funded by the Community Pharmacy Foundation and the modeling phase just concluded: Stakeholder input was solicited Consumer input was solicited to assess usefulness for public reporting on pharmacy quality EQuIPP data were used to pilot-test various models for the ratings May move to a 2-state pilot project for public reports in Stay tuned

30 Summary Pharmacies are being evaluated NOW on quality measures related to Part D stars Medication adherence is being measured in ACA marketplaces and pharmacies that serve these plans A few health plans have already implemented P4P for pharmacies and many more will begin in 2016/17 Some PBMs have formulated strategies for moving towards preferred networks that only include top-performers on quality measures (price will still matter, but quality will also matter) EQuIPP serves as a neutral intermediary for calculation of pharmacy quality scores and makes the information available to pharmacies Know your quality scores!

31 Discussion

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