Health Systems

Connecting Care With Value


Transitional care, CMS Star Ratings and a health system’s bottom line.

029_Ambulatory PharmacyValue is often defined as the balance between quality and cost. In an effort to strike that balance and deliver the best care for patients while reducing stress on the healthcare system, the last decade has been markedly focused on how to measure value across the healthcare continuum. And as the health system landscape continues to change as a result of shifts toward value measurement, including those from The Center for Medicare and Medicaid Services (CMS) and Accountable Care Organizations (ACOs), the impact on pharmacy services - and for ambulatory pharmacy in particular - is clear.

What is the impact in terms of the effect of CMS' Five Star Quality Rating System on health system ambulatory pharmacies? What is the connection to accountable care, and what do hospital pharmacies need to know to improve performance and prove value?

The birth of value measurement
Understanding these correlations starts with a look at the driving forces behind value measurement. To begin with, Star Ratings are part of a broader phenomenon toward value-based purchasing, which has been widely driven by the federal government's focus on trying to reduce the costs associated with medication errors, medication non-adherence and poor care transitions. The launch of Medicare Part D plans made CMS the largest payer of drug benefits in the world, and an important model for how to measure value and quality in terms of what is spent on hospitals, medications and more. 

The Medicare Part D Star Ratings system measures Part D plans, which in turn measure pharmacies as a way to drive performance improvements.
In response to value-based initiatives, a number of stakeholders have become involved in helping the healthcare system measure quality. Specifically as it relates to the focus on medication, the Pharmacy Quality Alliance (PQA) was formed to guide the measurement of quality of medication utilization with a focus on Medicare Part D. A consensus-based nonprofit alliance consisting of pharmacy associations, health plans, pharmacy benefit managers and pharmacies, PQA's more than 150 members contribute to industry dialogue while helping develop and endorse new performance measures - many of which have been taken up into the Medicare Part D Star Ratings. And since medication matters to outcomes, and outcomes are what drive improved value (and ultimately shared payments for health systems), defining good ways of measuring quality care is now more important than ever for the healthcare system.

The current reality of value measurement
As evidence that the impact of measurement is spreading, there are an increasing number of examples of value-based purchasing, or value-driven healthcare, across the continuum. CMS has spurred the growth of ACOs with initiatives such as the Medicare Shared Savings Program, and ACO pioneers are getting a lot of attention. But there's been uneven success across the ACO landscape. In fact, some ACOs have not paid attention to the medication component that underlies some outcomes, while those that do are seeing improvements in outcomes. Overall, the impact of accountable care on quality has not been maximized.

As for contracting and quality, inpatient value-based purchasing programs mean health systems may lose money - up to 2 percent per admission - for suboptimal quality. Nursing homes and physicians aren't immune either. CMS has physician quality reporting systems, and providers are starting to experience pay-for-performance programs that both reward quality care and penalize those providers who aren't meeting quality standards. In addition, plans within healthcare insurance exchanges (HIE) have a new quality ratings system that will be an important mechanism of quality. Testing and reporting will begin for 2015, and ratings will appear in 2016 so that patients signing up in HIEs will be able to see both cost and quality ratings.

Why quality measures matter
The medication measures PQA has helped to define - those used in medication-related Star Ratings - are likely to be actionable by ambulatory pharmacists. Moreover, the Utilization Review Accreditation Commission (URAC) and other accreditation agencies are starting to use these measures in evaluating pharmacies.

In addition to the Star Ratings measures, CMS' display measures - three medication safety measures for drug-drug interactions, excessive doses of oral diabetes medications and the completion rate of Comprehensive Medication Reviews (CMR) - are used to identify plans with poor performance, but not calculated in Star Ratings. The CMR measure will move into the ratings this year, and completion rates under this measure have not been high overall.

Why does it all matter? Star Ratings can ultimately lead to bonus payments or exclusion from Part D plans, so there is significant incentive for pharmacies to demonstrate improvements. And value measurement is driving change in contracting strategies between plans and pharmacies. It's clear there are bottom-line implications when it comes to measuring quality.

Perhaps that is why there is an upward trend across the three adherence measures for pharmacies. PDPs' and Medicare Advantage plans' adherence measures have improved every year since CMS started reporting on them, which is even further evidence that plans are taking action. Improvements in Star Ratings present an additional challenge, though, as the threshold for what a pharmacy must do to achieve a five-star rating on any measure raises as averages improve. This is a good thing from CMS' perspective, as it means overall quality of care is improving for Medicare beneficiaries.

What can health systems do?
With medication utilization becoming such a key component of measuring value, time is of the essence to drive results. It is now more necessary than ever for health system outpatient pharmacies to leverage their advantageous position in the continuum of care with the goal of improving patient outcomes across the entire system. Specifically, ambulatory pharmacies can accomplish quality care objectives by looking more closely at:

  • Admissions and readmissions. Are patients using medications correctly? How is the health system averting adverse drug events such as injuries, infection and post-procedure complications - the top barriers to reducing readmissions?
  • Transitions. Are patients starting and discontinuing the appropriate medications when they leave the hospital? The most successful health system pharmacies avoid poor care transitions by communicating with outpatient pharmacies and providers about discharge meds. 
  • Adherence. Will patients continue with their prescribed medications after discharge? Will barriers such as cost or side effects prevent them from continuing drug therapy? Outpatient pharmacies are well positioned to detect and help resolve adherence issues before they result in a readmission or adverse outcome.

Both of these areas demand that health systems carefully consider their transitional care strategies. The plans that show the most success in medication-related measures are those with integrated facilities - hospitals connected with physician practices and those that own their own outpatient pharmacies. Ambulatory pharmacy, as part of an overarching transitional care strategy for health systems, is a tremendous opportunity for driving accountable care and helping plans "cash in" on Stars.

"Ambulatory pharmacy is a tremendous opportunity for driving accountable care."

To that end, it is essential for health system pharmacies to know their scores on performance measures. For this purpose, PQA functions as a neutral intermediary by providing health plan data within the EQuIPP™ platform that pharmacies can use to self-evaluate and monitor performance. Within the EQuIPP platform, pharmacies can see standardized data and benchmarked performance on:

  • Three Adherence Performance Measures
    • ACE/ARB Proportion of Days Covered (PDC)
    • Statin PDC
    • Oral Diabetes Meds PDC
  • Three Medication Safety Performance Measures
    • Drug-Drug Interactions
    • HTN Tx with ACE/ARBs for Diabetics*
    • High Risk Meds/Medications that tend to cause adverse events in older adults

* Starting in mid-2015, the HTN Tx for Diabetics measure will be replaced with a measure that tracks Statin Use in Persons with Diabetes. PQA and CMS retired the measures of HTN Tx for Diabetics and CMS will add the Statin Use in Persons with Diabetes measure into the Display Measures.

 What is EQuIPP? PQA provides the EQuIPP platform as a way for pharmacies to view their performance on Star Measures, along with localized benchmarks for improvement. Pharmacies can access EQuIPP through their wholesaler, pharmacy network or PSAO. In 2015, the number of health plans utilizing EQuIPP will expand significantly. 

Health system-owned outpatient pharmacies are uniquely positioned to effect positive change in prescribing habits across the continuum - improving PDC scores, decreasing drug interactions and educating prescribers to avoid high risk meds. Tight integration means outpatient pharmacies are able to collaborate with health system prescribers in ways that traditional community pharmacies cannot.

With the goal of guiding improvement efforts, the platform allows pharmacies to see their impact on patient care in terms of what they are accountable for - and ultimately how they've improved or whether they are at risk of exclusion from Part D plans.

Medication matters
For pharmacies across the continuum, focusing on optimizing medication usage as a way to connect quality care with demonstrating value is a very good bet in the current environment of accountable care. For health system pharmacies, a solid transitional care strategy can be the key to doing just that.


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