Understanding Your Patient Care Opportunity Report (PCOR)

Transcription

1 Understanding Your Patient Care Opportunity Report (PCOR) Use your January/February 208 PCOR to help improve performance on Medicare Part D Clinical Star Ratings measures. Your January/February 208 Patient Care Opportunity Report (PCOR) can help you improve health outcomes for your patients who are UnitedHealthcare Medicare Advantage plan members by identifying open care opportunities early in the year. Your PCOR provides practice-level data that shows the progress you re making in helping to address those care opportunities. This guide walks you through a sample PCOR for Medicare Part D Clinical Star Ratings measures. Accessing Your Report. Open your PCOR. 2. Go to the PATH Member Adherence Report tab. 3. Review the DMD5, DMD6 and D-D3 measures to see current information for specific UnitedHealthcare Medicare Advantage plan members. DMD6 D-3 DMD5 Definitions of Centers for Medicare & Medicaid Services (CMS) Star Ratings Measures DMD5 DMD6 D D3 Statin Use in Persons With Diabetes (SUPD) Measures the percentage of members with diabetes ages who receive at least one fill of a statin medication in the measurement year. Higher is better. Refer to specific four and five Star Ratings threshold % targets. High-Risk Medication (HRM) Measures the percentage of members ages 65 and older who have had at least two fills of qualifying HRMs or exceeded specified doses or cumulative dosing within the year. Lower is better. Refer to specific four and five Star Ratings threshold % targets. Medication Adherence: Diabetes, Hypertension (RAS Antagonists), Cholesterol (Statins) Measures the percentage of members who adhere to their prescribed diabetes, hypertension (RAS antagonist) and cholesterol (statin) medications more than 80 percent of the time during the year. Higher is better. Refer to specific four and five Star Ratings threshold % targets. Medicare evaluates plans based on a 5-star rating system. Star Ratings are calculated each year and may change from one year to the next. PATH

2 Understanding Your PCOR: Summary Tab The Summary Tab provides a high-level overview of how your practice is performing on CMS Part C and Part D measures. The information below can help you understand the data in the Health System Summary, DSNP Health System Summary, Group Summary, DSNP Group Summary and Physician Summary. For medication adherence measures D-D3, the Current Rate and Quality Rating represents plan members who were compliant in 207 (prior year).» Plan members in your practice who don t have a prior year result because they re new to UnitedHealthcare in 208 or to the D-D3 measures will be in the Pharmacy Detail Report, but not in the Summary Reports. The 208 data will be available in March. For the SUPD (DMD5) and HRM (DMD6) measures, the Current Rate and Quality Rating represent plan members who are compliant in 208 (current year). 2

3 Understanding Your PCOR: Pharmacy Detail Report Tab The Pharmacy Detail Report provides your practice with patient-level prescription drug information for those who are eligible for Medicare Part D measures. It includes drug names, last prescription fill date, prescriber name and pharmacy information. You can use this report to help patients improve medication compliance, address open care opportunities for the SUPD measure and decrease high-risk medication use. DMD5 SUPD Provides patient detail on SUPD When the SUPD care opportunity is addressed, the information shown includes prescription details such as statin drug name, last fill date, quantity, days supply, prescriber name and more. Plan members with an open care opportunity have a No statin filled YTD message. Key: Red (R): Red isn t applicable for this measure in the January/February PCOR. Yellow (Y): No permanent gap at this time. Member has filled prescriptions commonly used to treat diabetes, but no prescription activity has been identified for a statin or statin combination medication. Green (G): No gap. Member has filled a prescription for a statin or statin combination this year. DMD5 Calls to action:. Please focus on the members in yellow. 2. Consider prescribing a statin, as appropriate, before Dec. 3. If you determine a statin medication is appropriate, please send a prescription to the member s preferred pharmacy. Statins shown in this table are available on a member s UnitedHealthcare Medicare Advantage formulary: 2 Formulary Tier Statins 4 Tier 3 Atorvastatin Rosuvastatin Simvastatin Pravastatin Lovastatin Fluvastatin Amlodipine/ Atorvastatin Tier 3 Ezetimibesimvastatin Livalo Member may use any pharmacy in the network but may not receive preferred retail pharmacy pricing. Pharmacies in the Preferred Retail Pharmacy Network may not be available in all areas. Copays apply after deductible. 2 The formulary and pharmacy network may change at any time. ³ Lowest copay of all tier levels 4 Medication adherence tip taken from package inserts: Atorvastatin, rosuvastatin, pravastatin and Livalo can be taken at any time during the day. Simvastatin, lovastatin and fluvastatin must be taken in the evening. Please see each medication s package inserts for specific details. All product names are registered trademarks of their respective holders. Use of them does not imply any affiliation with or endorsement by them. 3

4 Understanding Your PCOR: Pharmacy Detail Report Tab (continued) DMD6 HRM Provides patient detail on HRM The information shown includes prescription details such as the HRM drug name, last fill date quantity, days supply, prescriber name and more. Key: Red (R): Permanent gap. Patients are considered a permanent gap when they have at least two fills of a HRM drug or when they ve surpassed the maximum duration or dosage allowed by the measure (e.g., greater than 90 days of cumulative use of a sedative hypnotic during the benefit year). Yellow (Y): Patient at risk for a gap. Patient has at least one prescription fill of a HRM. This will remain yellow through the end of the year. Green (G): Green isn t applicable for this measure in the January/February PCOR. DMD6 Calls to action:. Please consider not prescribing HRM(s). See the HRM Rx Alternatives tab in your PCOR. 2. If you re not the prescribing physician, consider addressing this open care opportunity with the prescriber and discuss alternatives for your patient. 3. Know your HRMs. Please avoid starting your patients ages 65 and older on HRMs when appropriate. 4

5 Understanding Your PCOR: Pharmacy Detail Report (continued) D 3 Medication Adherence Measures Provides patient detail on adherence to diabetes, hypertension (RAS antagonist) and cholesterol (statin) medications The information shown includes prescription details such as drug name, last fill date, quantity/days supply, days missed in the last 45 days, refill due date, and pharmacy and prescriber information. D D3 Key: Red (PDC %): Proportion of days covered (PDC) is less than 80 percent and less than zero allowable days remain. Patient is non-adherent with a permanent gap.. Yellow (S): Patient was non-adherent for measure in 207, with a PDC of less than 80 percent, and hasn t yet filled any qualifying adherence medications in 208. Claim information provided reflects the last fills from 207. Patient may be at risk for non-adherence in 208 if continuing therapy. Yellow (X): Patient has one fill of a qualifying adherence medication in 208 and was at risk for non-adherence in 207. Patient may be included in the measure with the second fill. Patient may be at risk for non-adherence in 208 if continuing therapy. Yellow (PDC %): Patient has qualified for the measure, with at least two fills of qualifying adherence medications in 208, and is at risk for non-adherence. PDC is less than 95 percent and allowable days remaining to end the year with a PDC of 80 percent or more is greater than zero. Patient is at risk for non-adherence. No Color (X): Patient has one fill of a qualifying adherence medication in 208 and was on track for adherence in 207 green at the end of 207. Patient may be included in the measure with the second fill. Green (G): Patient has qualified for the measure, with at least two fills of a qualifying adherence medication in 208, and is on track for adherence. Patient is either at or above 95 percent PDC, or there are more allowable days remaining than there are days between the next refill due date and the end of the measurement period. After a patient qualifies for the measures, the following fields are important to help track adherence: Days of therapy missed year-to-date (YTD): Number of days of drug therapy missed year-to-date. To be adherent, patient can t miss more than 20 percent of days in a measurement period. This number must be used with allowable days remaining to assess adherence status. Allowable days remaining: Number of days of therapy a patient may miss from now until the end of the year to still achieve 80 percent PDC and be considered adherent for the Star Ratings measure. Patient must have more than zero allowable days remaining at the end of the measurement period to be considered adherent. Otherwise, they re mathematically unable to achieve 80 percent PDC. Calls to action:. Please focus on the members in yellow because they may be at risk for non-adherence in 208. The goal is to prevent them from becoming red during the course of the year. 2. Counsel patients on the importance of taking medications as directed and getting timely refills. Please discuss medication adherence barriers at each visit. Ask patients about concerns related to side effects, costs and health benefits of the applicable therapy. 3. When clinically appropriate, consider writing 90-day prescriptions for chronic conditions to help improve adherence. 4. Prescribe low-cost generic medications when clinically appropriate. Many generic medications available in the U.S. for diabetes (non-insulin diabetes medications), hypertension (RAS antagonists) and cholesterol (statins) are included in Tier the lowest copay tier of UnitedHealthcare s Medicare Advantage formularies. 5

6 Understanding Your PCOR: Pharmacy Detail Report (continued) 5. Ensure active prescriptions accurately reflect current dosing. 6. Review the following alerts: S (Suspect): Because patient was non-adherent in 207, follow up with them proactively if they re due or past due for a refill to determine if therapy should be continued. New start to medication (X): If ongoing therapy is determined to be appropriate, please address adherence barriers early and follow up proactively to help ensure patient s next fill is timely. X: If ongoing therapy is appropriate, counsel patient on getting timely refills to prevent large fill gaps, particularly between the first and second fills. Patients qualify for the measure with the second fill, but the measurement period starts with the date of the first fill. 7. Ensure patients who qualified for the adherence measure(s) have more than zero allowable days remaining at the end of the measurement period. Patients can t attain 80 percent PDC when the allowable days they can miss in the year is zero or less. Allowable days remaining must be more than zero for the patient to be adherent. 8. If cost is a concern for your patient and is affecting medication adherence: UnitedHealthcare offers $0 copays for Tiers and 2 medications for most plans when members use home delivery through OptumRx. Before entering the coverage gap, members in these plans pay $0 for the most commonly used maintenance medications. Group MAPD members are excluded from the $0 benefit at home delivery. If you have any questions about home delivery, please call OptumRx at or contact your UnitedHealthcare representative. 9. Encourage patients to use their UnitedHealthcare insurance card at the pharmacy to get the best value. Only prescription fills processed with a member s UnitedHealthcare insurance card are used to measure adherence. Samples or information on cash prescriptions can t be submitted to CMS in supplemental files for Part D Star Ratings measures. Contact us to learn more. For more information about how our programs can help support your patients who are UnitedHealthcare Medicare Advantage plan members, please contact your UnitedHealthcare representative. Thank you. $0 copay may be restricted to particular tiers, preferred medications or mail order prescriptions during the initial coverage phase and may not apply during the coverage gap or catastrophic stage. 208 United HealthCare Services, Inc. 6