Quality Measures for Pharmacies
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1 PL Detail-Document # This PL Detail-Document gives subscribers additional insight related to the Recommendations published in PHARMACIST S LETTER / PRESCRIBER S LETTER January 2016 Quality for Pharmacies Payers are recognizing the value of pharmacists in improving quality of patient care. For example, Advantage and Part D plans get Star Ratings, based on quality measures. Some of these measures address medication adherence and patient safety, including prescribing of appropriate therapies. Plans in the health insurance exchange must also report performance on adherence measures. Other payers or organizations may also evaluate performance on medication-related measures. Pharmacies will stand to benefit from contributing to improvement on these types of measures. A plan s performance is the sum of all of its providers, including pharmacies, and plans can see how pharmacies are contributing to their ratings. Pharmacies don t get Star Ratings, but pharmacies that help improve medication use and boost Star Ratings put themselves at an advantage for obtaining preferred pharmacy network status, which may allow them to offer lower copays to patients. Plus, more pay-forperformance programs for pharmacies are cropping up. These programs offer financial bonuses to pharmacies that demonstrate improved performance on quality measures (which may or may not include the measures used for Star Ratings). For example, some pay-for-performance programs may reward pharmacies based on asthma or COPD management, generic dispensing rate, or drug-drug interactions. Note that for Star Ratings, plans are scored on data from two years prior. For example, 2016 data will be used to determine Star Ratings for This document lists resources to help familiarize pharmacists with quality measurement, including key organizations, acronyms, and applicable resources from Pharmacist s Letter. Centers for & Medicaid Services (CMS), Star Quality measures are used by CMS to establish Star Ratings, with a scale Ratings of one to five stars (five stars is considered excellent). These Star Ratings are used for Advantage plans (Part C, or MA), Advantage plans with Part D coverage (MA-PD plans), and stand-alone Part D plans (PDP). The ratings are an indicator of the quality of the plan, and are available to the public. Sources of data for establishing Star Ratings include the plans themselves, CMS contractors, surveys of enrollees, and CMS administrative data. Plans with higher ratings get incentives, such as better marketing and year-round open enrollment for five-star plans. Advantage plans with high ratings are also eligible for quality bonus payments. On the other hand, plans with less than three stars for the past three years in a row are penalized, such as by being excluded from online enrollment or possibly losing their CMS contract. For more information about Star Ratings, see our PL CE, Quality : What Pharmacy Teams Need to Know. Note that each individual measure has a weight of anywhere from one to three. Many measures count only once (e.g., colon cancer screening, annual flu vaccine, etc) toward the summary and overall Star Rating. related to customer service or patient satisfaction have a weight of 1.5. All three adherence measures are tripleweighted, whereas comprehensive medication review (CMR) completion rate has a weight of 1. In other words, some medication-related measures count more toward the overall or summary rating for the plan than some other measures. Plans are especially interested in improving performance on these particular measures because they have a higher impact on overall performance.
2 (PL Detail-Document #320101: Page 2 of 7) Part D Continued Selected quality measures for Part D Star Ratings related to drug therapy for 2016 (with resources from Pharmacist s Letter). (NOTE: The measure for use of an ACEI or ARB in diabetes patients with hypertension is now retired, due to updated hypertension guidelines.) Annual comprehensive medication review (CMR) for patients enrolled in a medication therapy management (MTM) program Medication Therapy Management o PL Worksheet Worksheet for Med Review Mastering Med Lists and Histories Adherence to non-insulin diabetes meds, statins, and renin angiotensin system antagonists (ACEIs, ARBs, and aliskiren) o This measure looks at the percent of plan members who have two or more fills of these medications and who have a proportion of days covered (PDC) of at least 80%. Medication Adherence Toolbox Medication Therapy Management s Guide for Helping Patients Afford Their Medications The Basics of Med Sync o PL Patient Education Handouts Tips for Sticking With Your Meds Blood Pressure Medications and You What You Should Know About Statins Understanding Your Blood Sugar Numbers Heart Failure Meds and More Using Motivational Interviewing to Create Change Helping Patients Make the Most of Their Medications Enhancing Patient Counseling with Effective Communication Skills Implementing MTM into a Community Pharmacy Practice Med Adherence 101 Appropriate use of high-risk medications in patients 65 years and older o This measure looks at the percent of plan members 65 and older who receive two or more fills for the same high-risk medication when there may be safer choices. (Note that this measure may be removed from Star Ratings and changed to a Display Measure for 2017.) s Potentially Harmful Drugs in the Elderly: Beers List STARTing and STOPPing Medications in the Elderly
3 (PL Detail-Document #320101: Page 3 of 7) Part D Continued Part C Continued A Note from Your Pharmacist: Avoiding the Use of High-Risk Meds in Elderly Patients Drug Therapy Issues for Aging Patients Drug Therapy in the Elderly: Balancing Risks and Benefits Ensuring statin use in patients with diabetes age 40 to 75 years o This measure will look at the percentage of plan members between 40 and 75 years who receive at least two diabetes medication fills and a statin. (Note that this measure is not in effect for 2016 Star Ratings, but is proposed as a Display Measure for 2017 and a full measure for 2018, when it will be scored based on 2016 data.) Improving Diabetes Outcomes Statins for Patients with Diabetes s Lipid Treatment FAQs Statin Muscle Symptoms: Managing Statin Intolerance Characteristics of the Various Statins 2013 ACC/AHA Cholesterol Guidelines A Note from Your Pharmacist: Using a Statin for Your Patient with Diabetes Caring for Patients with Diabetes Tips for Counseling Patients with Type 2 Diabetes Patient experience in getting a needed medication Suggestion to Switch Medication Collaborative Drug Therapy Management (CDTM) Optimizing Pharmacy Workflow Communicating With Other Health Care Professionals Selected measures for Advantage ( Part C) Star Ratings related to drug therapy for 2016 (with resources from Pharmacist s Letter). Note that Advantage plans with the Part D drug benefit are also evaluated on the Part D measures. Annual influenza vaccine Flu Vaccines for Immunization: Influenza Immunization Update for 2015/2016 The Basics of Immunization and Vaccines o PL Patient Education Handout No More Excuses: You Need a Flu Vaccine
4 (PL Detail-Document #320101: Page 4 of 7) Part C continued Annual medication review for older adults (for Special Needs Plans) Medication Therapy Management o PL Worksheet Worksheet for Med Review Osteoporosis management in women who have had a fracture s Managing Suboptimal Response to Bisphosphonates Optimal Duration of Bisphosphonate Therapy o PL Patient Education Handout What I Need to Know About My Bisphosphonate Glucose control in diabetes patients o PL Algorithm Stepwise Approach to Selecting Treatments for Type 2 Diabetes (ADA) Improving Diabetes Outcomes s Drugs for Type 2 Diabetes Comparison of Insulins and Injectable Diabetes Meds Diabetes 101 Blood pressure control s Treatment of Hypertension: JNC 8 and More Antihypertensive Combinations o PL Algorithm Stepwise Treatment of Hypertension Hypertension 101 Fall risk reduction Fall Prevention in the Elderly Colorectal cancer screening Increasing Colorectal Cancer Awareness in the Pharmacy The Pharmacist s Role in Colorectal Cancer Screening o PL Patient Education Handout What You Should Know About Colon Cancer Comparison of Bowel Preps Bowel Preps 101 Rheumatoid arthritis management Using Methotrexate Safely for Rheumatoid Arthritis Managing Rheumatoid Arthritis
5 (PL Detail-Document #320101: Page 5 of 7) CMS Display CMS also uses Display to provide further evaluation of Advantage and Part D plans. The Display are not included in the plan Star Ratings, but CMS uses Display to evaluate and monitor the plans and facilitate quality improvement. Display may eventually become Star Ratings measures. Part D Display for 2016 include these med-related measures. Avoidance of drug-drug interactions s P-glycoprotein Drug Interactions Cytochrome P450 Drug Interactions What You Need to Know About Drug Interactions Avoidance of excessive doses of oral diabetes medications Drugs for Type 2 Diabetes Rate of chronic use of atypical antipsychotics by elderly beneficiaries in nursing homes Pharmacotherapy of Dementia Behaviors A Note from Your Pharmacist: Avoiding the Use of High-Risk Meds in Elderly Patients Display for Advantage plans for 2016 include these med-related measures. Administration of pneumococcal vaccine Pneumococcal Vaccination in Adults: Who Gets What and When? Drug treatment of COPD with bronchodilators or systemic corticosteroids as appropriate Improving COPD Care Using Oral Corticosteroids Inhalers for COPD Corticosteroids for COPD Exacerbation CMS Resources for Star Ratings Continued Plan Finder displays Star Ratings for patients o Part C and D performance data and information about Star Ratings o Coverage/PrescriptionDrugCovGenIn/PerformanceData.html
6 CMS Resources for Star Ratings continued (PL Detail-Document #320101: Page 6 of 7) Part C and D Star Ratings and corresponding weights o Coverage/PrescriptionDrugCovGenIn/Downloads/2016_Star_Ratings_M easure_list.pdf Quality Initiatives-general information o Instruments/QualityInitiativesGenInfo/index.html Pharmacy Quality Alliance (PQA), PQA PQA is a nonprofit, multi-stakeholder, consensus-based membership Resources organization that promotes appropriate medication use and develops strategies for measuring and reporting performance related to medication use. Information on PQA-endorsed measures used for the Health Insurance Marketplace ( Pharmacy Quality Solutions (PQS) Pharmacy Quality Solutions (PQS) is a venture of PQA that provides EQuIPP (Electronic Quality Improvement Platform for Plans and Pharmacies), which is a performance information management platform used by health plans and pharmacies to track performance on quality measures. Users of this PL Detail-Document are cautioned to use their own professional judgment and consult any other necessary or appropriate sources prior to making clinical judgments based on the content of this document. Our editors have researched the information with input from experts, government agencies, and national organizations. Information and internet links in this article were current as of the date of publication.
7 (PL Detail-Document #320101: Page 7 of 7) Project Leader in preparation of this PL Detail- Document: Stacy A. Hester, R.Ph., BCPS, Assistant Editor. Cite this document as follows: PL Detail-Document, Quality for Pharmacies. Pharmacist s Letter/Prescriber s Letter. January Evidence and Recommendations You Can Trust 3120 West March Lane, Stockton, CA ~ TEL (209) ~ FAX (209) Copyright 2016 by Therapeutic Research Center Subscribers to the Letter can get PL Detail-Documents, like this one, on any topic covered in any issue by going to or
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