Medicare Star Ratings and the Shift to Quality- Based Payment Models. David Nau, RPh, PhD, FAPhA PQS President

Transcription

1 Medicare Star Ratings and the Shift to Quality- Based Payment Models David Nau, RPh, PhD, FAPhA PQS President

2 The shift to Value-Driven Healthcare The U.S. health care system is rapidly moving to value-based 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 medication-related quality measures for evaluation of health plans, PBMs and pharmacies, and EQuIPP allows pharmacies to track their performance on quality metrics

3 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 PQA measures in Star Ratings (e.g., 2013 drug claims for 2015 Ratings) Star Ratings were released in October 2014 to inform beneficiaries who were enrolling for 2015

4 Part D Stars Medicare drug plans receive a summary rating on quality as well as four domain, and individual measure, scores (13 individual measures) Five measures are from PQA: - 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 >Oral 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

5 2015 Medicare Part D: Display Measures Display measures are not a part of the Star Ratings, but are used to provide benchmarks and feedback to plans CMS also monitors display measures to assess plan performance; poor performance can lead to compliance actions by CMS Display measures (from PQA): Drug-Drug Interactions Excessive doses of oral diabetes medications Comprehensive Medication Review (CMR) Completion Rate HIV antiretroviral medication adherence (only in safety reports) New Display measure (NOT from PQA) Use of atypical antipsychotics

6 *New* Star Ratings Measure for 2016 Medication Therapy Management Program Completion Rate for Comprehensive Medication Reviews (Part D Measure). 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 score 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

7 2017 and Beyond Potential new measures: Statin Therapy in Diabetes - As of November 21, 2014, PQA has endorsed Statin Use in Persons with Diabetes measure. CMS stated that if the measure is endorsed by PQA in 2014, the measure would be considered as a new 2017 Display Measure and a 2018 Star Rating. Asthma Measure Suite - NCQA is currently testing three asthma measures, all for members 5-64 years of age. The three measures are: > Use of Appropriate Medications for People with Asthma > Medication Management for People with Asthma > Asthma Medication Ratio Opioid Overutilization - PQA is currently developing 3 measures evaluating multi-provider, high dosage opioid use among individuals 18 years and older without cancer and excluding hospice

8 Part D Stars Table G-2: Part D Measure Weights Measure ID Measure Name Part D Summary MA-PD Overall D01 Appeals Auto-Forward D02 Appeals Upheld D03 Complaints about the Drug Plan D04 Members Choosing to Leave the Plan D05 Drug Plan Quality Improvement 5 5 D06 Rating of Drug Plan D07 Getting Needed Prescription Drugs D08 MPF Price Accuracy 1 1 D09 High Risk Medication 3 3 D10 Diabetes Treatment 3 3 D11 Medication Adherence for Diabetes Medications 3 3 D12 Medication Adherence for Hypertension (RAS antagonists) 3 3 D13 Medication Adherence for Cholesterol (Statins) 3 3 From CMS 2015 Star Ratings Technical Notes

9 Part D Star Thresholds Change

10 Improvement in Adherence Rates Part D Measure MA-PD PDP PDC - Diabetes 73.0% 73.7% 75 % 77 % 74.4% 75.8% 77 % 79 % PDC - Hypertension 72.2% 73.9% 76 % 78 % 74.3% 76.8% 78 % 81 % PDC - Cholesterol 68.0% 69.0% 71 % 74 % 69.1% 71.0% 73 % 77 % Average across all contracts for each year

11 High Stakes for Part D Stars Enrollment Implications Quality Bonus Payments (MA-PD) Poor performers identified by CMS - Low-performer icon Removal from Medicare for continued poor overall performance (< 3 stars for 3 years in a row) - For 2014, CMS chose not to execute its authority to terminate poor-performing plans since these plans were showing signs of improvement - Still maintains this authority in future years

12 How are MA-PD plans responding? Formularies, clinical strategies, network contracts, marketing/promotions, aligning with star measures Significant investments in drive to 5 Contract strategies for pharmacy networks Pay for Performance (P4P) pharmacies may be eligible for bonus payment based on star performance Preferred pharmacies based partly on star performance

13 Pharmacy Pay-for-Performance Programs Using EQuIPP 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 in 2014 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 launching October 2014 based on PDC-adherence measures - Combination of payment for program commitment and for reaching performance goals as measured by EQuIPP

14 Pharmacy Quality Ratings PQA, PQS and the University of Arizona are exploring whether an Overall Rating of a pharmacy can be created from the individual PQA measures in way that is scientifically valid as well as efficient Project is funded by the Community Pharmacy Foundation Stakeholder input and consumer input are being solicited EQuIPP data will be used to pilot-test various models for the ratings Many issues will need to be addressed to determine how this rating system would be appropriately implemented. Stay tuned

15 Partnering for Quality How does your pharmacy use quality metrics today? What information do you need to help with conversations about quality of medication use with both physicians, patients, AND your pharmacists? Is your pharmacy positioned to play a role in moving quality forward? Is your pharmacy positioned to participate in qualitybased preferred networks?

16 EQuIPP Performance Measurement and Assessment for Pharmacy & Health Plans Pharmacy Health Plans How do we compare vs. peers? How do we compare vs. state? How can we compete to participate in value based, shared risk or tiered networks? How is my network performing? How do we compare as a plan? How can we create networks to properly share value based on high performance? Overview PQS is a Joint Venture (for profit) between CECity and Pharmacy Quality Alliance (non profit), trusted licensor of medication use quality measures CECity platform leveraged to present unbiased performance at provider, organization, state, national and payor network level Includes core measures that matter Medicare Stars (Part D) Major health plans and Chain Pharmacies are all in

17 Participants Existing Plans - Humana - Aetna - Coventry - Wellcare - Cigna HealthSpring - Caremark: > Silverscript > More to come in Inland Empire Health Plan (CA) - UPMC Health Plan (PA) - Gateway Health Plan (PA) - Healthfirst of NYC EQuIPP Statistics: Over 15 million lives in dataset Over 55,000 participating pharmacies New for Tenet Health Plans - BCBS of Michigan - Express Scripts > Highmark BCBS > Others TBD - Prime Therapeutics > Florida Blue > Capital Health Plan (FL) > Horizon BCBS (NJ) > BCBS Alabama > BCBS North Carolina > BCBS South Carolina > BCBS Arkansas > BCBS Minnesota > HCSC Blues plans TX, OK, MT, NM, IL

18 Store Dashboard

19 Patient Outlier Capability Outliers are patients who represent improvement opportunities Outliers can be identified from a standard EQuIPP data feed or based on supplemental file provided by clients Include a brief documentation function to allow pharmacists to track outreach - Outlier documentation can be provided to clients to help determine future interventions

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21 Click on Medication Adherence: READ MORE

22 Click on FAQ tab

23 Tactics Check your EQuIPP scores every month (data are updated on the 15 th of each month). Identify your biggest opportunity for improvement Which measure has the biggest gap with Top 20% or State Average? Which plans have created incentives for improvement? How can you find some easy wins to start? Pick one quality measure to get started and talk with your staff about ways to impact that measure Come up with an improvement plan then orient all your staff and pick a day to start

24 Adherence Ideas Focus on Medicare patients with diabetes Many will also be on statins and ACE inhibitors Connection of adherence to outcomes is strong Implement refill synch program Start with a few high priority patients (e.g., diabetics enrolled in Medicare plans that have a P4P program) Use technology to help you scale up Screen high-priority patients to identify non-adherence risk Talk to your Medicare patients on diabetes, ACEI, or cholesterol meds Can take 10 seconds to ask if they have any concerns about: Side effects Costs Lack of effectiveness (i.e., isn t really helping me)

25 High Risk Med (HRM) Ideas Make sure that all pharmacy staff know the common HRMs - Glyburide, Zolpidem, or whatever else is common with your physicians - If you re not sure which ones are common, have a tech/intern run usage reports on some of the HRMs - Identify physicians who are top prescribers of specific HRMs Anytime an older patient (>65yo) presents a NEW prescription for a HRM, the technician should flag this script for review by RPh - Consider use of HRM Fax form within EQuIPP resources Where available, use the EQuIPP Outlier list to identify specific patients who have received an HRM Pick an easy win for your first initiative; then talk with a physician about a change in future Rxs, or conversion of existing patients - Easy win: glyburide conversion to glipizide or glimepiride; or if already on metformin, consider a combo product

26 Summary Quality metrics are driving action amongst health plans and PBMs A growing number of prescription drug plans are implementing performance-based incentives for network pharmacies, such as: - Pay-for-performance models that include bonus payments to topperforming pharmacies - Preferred networks that include star-performance as a criterion for inclusion as a preferred pharmacy EQuIPP continues to expand the number of plans and pharmacies who use this platform as a neutral intermediary for calculation of pharmacy quality scores Pharmacies need to track their quality to compete in a value-based contracting environment and will need clinical decision support tools that prompt efficient, effective action.

27 Questions?