116th Annual Convention

Transcription

1 116th Annual Convention Date: Tuesday, October 21, 2014 Time: 8:30 am 10:00 am Location: Austin Convention Center, Room 17AB, Level 4 Title: Activity Type: Speaker: Medicare Part D Star Ratings What They Will Look Like Shining on Long Term Care ACPE # L04-P 0.15 CEUs ACPE # L04-T Application-based Carol Sirianni, Consultant, Pittsburgh, Pennsylvania John Haugen, PharmD, Merwin LTC Pharmacy Pharmacist and Pharmacy Technician Learning Objectives: Upon completion of this activity, participants will be able to: 1. Discuss the impact projected for Medicare Part D Star Ratings for the Long Term Care market. 2. Summarize pertinent ratings measures for Long Term Care pharmacists. 3. Describe effective process strategies to address star ratings measures. Disclosures: Carol Sirianni is receiving an honorarium for this program. The conflict of interest was resolved by peer review of the slide content. John Haugen declares no conflicts of interest or financial interest in any product or service mentioned in this program, including grants, employment, gifts, stock holdings, and honoraria. NCPA s education staff declares no conflicts of interest or financial interest in any product or service mentioned in this program, including grants, employment, gifts, stock holdings, and honoraria. NCPA is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. This program is accredited by NCPA for 0.15 CEUs (1.5 contact hours) of continuing education credit.

2 NCPA Disclosure Statement The National Community Pharmacists Association (NCPA) Office of Continuing Education makes every effort to develop continuing education activities that are scientifically based, accurate, current, and objectively presented. In accordance with the Accreditation Council for Pharmacy Education Standards for Commercial Support NCPA has implemented a mechanism requiring everyone in a position to control the content of an educational activity to disclose any relevant financial relationships with any proprietary entities producing health care goods or services and mange/resolve any conflicts of interest prior to the activity. Individuals must disclose to participants the existence or non-existence of financial relationships. NCPA does not view the existence of interests or relationships with commercial entities as implying bias or decreasing the value of a presentation. It is up to the participants to determine whether the interest or relationships influence the presenter with regard to exposition or conclusions. If at any time during this activity you feel that there has been commercial or promotional bias, please inform us by reflecting the information on the session evaluation form.

3 Medicare Part D Star Ratings What They Will Look Like Shining on Long Term Care John Haugen, R.Ph. Manager, Consulting Services Merwin LTC Pharmacy New Brighton, MN John Haugen declares no conflicts of interest or financial interest in any product or service mentioned in this program, including grants, employment, gifts, stock holdings, and honoraria. Learning Objectives Discuss the impact projected for Medicare Part D Star Ratings for the Long Term Care market. Summarize pertinent ratings measures for Long Term Care pharmacists. Describe effective process strategies to address star ratings measures. 1

4 Current SNF 5 Star Quality Ratings Nursing home ratings come from: Health Inspections Staffing Quality Measures Current Quality Measures / Star Ratings in Long Term Care (sample) Percent of long-stay residents: Who received an antipsychotic medication assessed and given, appropriately, the seasonal influenza vaccine assessed and given, appropriately, the pneumococcal vaccine. Current Quality Measures / Star Ratings in Long Term Care (sample) Percent of long-stay residents who lose too much weight. Percent of residents experiencing one or more falls with major injury Percent of long-stay residents who self-report moderate to severe pain. 2

5 Health Inspections (l) Unnecessary Drugs F General. Each resident s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used: (i) In excessive dose (including duplicate therapy); or (ii) For excessive duration; or Health Inspections (l) Unnecessary Drugs F329 (iii) Without adequate monitoring; or (iv) Without adequate indications for its use; or (v) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or (vi) Any combinations of the reasons above. Health Inspections (l) Unnecessary Drugs F Antipsychotic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that: (i) Residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and 3

6 Health Inspections (l) Unnecessary Drugs F Antipsychotic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that: (ii) Residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Health Inspections (l) Unnecessary Drugs F329 Table 1 MEDICATION ISSUES OF PARTICULAR RELEVANCE Health Inspections (l) Unnecessary Drugs F329 Table 1 Medication Muscle relaxants All muscle relaxants, e.g., baclofen carisoprodol chlorzoxazone cyclobenzaprine dantrolene metaxalone methocarbamol orphenadrine 4

7 Health Inspections (l) Unnecessary Drugs F329 Table 1 Muscle relaxants Indications/Adverse Consequences Most are poorly tolerated by older individuals due to anticholinergic side effects (see Table II), sedation, or weakness Long-term use in individuals with complications due to multiple sclerosis, spinal cord injuries, cerebral palsy, and other select conditions may be indicated, although close monitoring is still warranted Abrupt cessation of some muscle relaxants may cause or predispose individuals to seizures or hallucinations Health Inspections (l) Unnecessary Drugs F329 Table 1 Antidiabetic & Antihypertensive Medications Multiple examples listed Focus on Monitoring and Adverse Consequences Medicare Part D Medication Quality Measures Use of High-Risk Medications in the Elderly (HRM) Whether members 65 and older are taking certain drugs with a high risk of side effects, when there may be safer drug choices. 5

8 Diabetes: Appropriate Treatment of Hypertension Whether members with diabetes who also have high blood pressure are given a type of blood pressure medication that is recommended for people with diabetes. Medication Adherence Taking Diabetes Medication as Directed Taking Blood Pressure Medication as Directed Taking Cholesterol Medication as Directed Medicare Part D Medication Display measures Drug-drug interactions Excessive doses of oral diabetes medications Comprehensive Medication Reviews 6

9 Quality Assessment and Assurance (QAA) provision at 42 CFR, Part (o) (F501) specifies the QAA committee composition and frequency of meetings in nursing facilities Guidelines to implement Quality Assurance (QA) and Performance Improvement (PI) requirements are pending 7

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11 Medicare Part D Star Ratings What They Will Look Like Shining on Long Term Care Carol Sirianni, RPH Vice President and General Manager Aureus Health Services October 20, 2014 Disclosure Carol Sirianni is receiving an honorarium for this program. The conflict of interest was resolved by peer review of the slide content. Medicare Part D Star Ratings What They Will Look Like Shining on Long Term Care OBJECTIVES Describe Value Driven Health Care; Describe the CMS Star ratings process as it relates to medications; Explain the reasoning for measuring the quality of medication use; Discuss where plans are headed related to the quality of medication use; Identify performance improvement strategies related to medication measurement in the Star ratings process; Review new technology programs and dashboards which highlight metrics for Health Plans, PBMs, and Pharmacies 1

12 Pre session Questions True or False Medication related metrics account for approximately 50% of the summary score for the Medicare Advantage Part D CMS 5 STAR rating program Patients can access information on any Medicare Part D plan to see the plans CMS 5 STAR rating Beneficiaries can move between any Part D Medicare plans without penalty at any time The threshold minimums a plan must reach are equivalent across all metrics HRM (high risk medications) are those medication that elderly (65 and older) should not take at any time PDC (proportion of days covered) is the adherence metric used by CMS? Value-Driven Healthcare Topics Pharmacy Quality Initiatives in the Community and Long Term Care Setting CMS Star Ratings Technology and measurement dashboards Q&A / Discussion 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 Nursing homes, hospitals, physicians and health plans have all moved to value-based contracts; now Part D plans are starting to use value-based models for pharmacy Value-based contracts require measurement of quality, through the development of medication-related quality measures for use by health plans, PBMs and pharmacies 2

13 Pharmacy Quality Alliance (PQA) Established in April 2006, as a public-private partnership Consensus-based, non-profit, alliance with >145 member organizations, including: Health Plans & PBMs Pharmacies & professional associations Federal agencies (CMS, FDA) Pharmaceutical manufacturers 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 Who Uses PQA Measures Medicare Part D Plan Ratings Star measures: medication adherence (diabetes, BP, cholesterol) medication safety (HRM, Diabetes/RASA) Display measures: 2 safety measures and 1 MTM measure URAC accreditation programs Health plan, PBM, mail/specialty pharmacy Health Plan Accreditation National Business Coalition on Health (NBCH) -evalue8 measure set State Insurance Exchanges/Marketplaces Medicare Star Ratings Annual ratings of Medicare plans 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., 2012 drug claims are used for 2014 Star Ratings) 2014 Star Ratings were released in October 2013 to inform beneficiaries who were enrolling for 2014 Ratings of all Medicare plans can be found at: Coverage/PrescriptionDrugCovGenIn/PerformanceData.html 3

14 Medicare Plan Ratings Part D Medicare drug plans receive a summary rating on quality as well as four domain, and individual measure, scores (15 individual measures in total) 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 - PDC (proportion of days covered) 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 48% of Part D summary ratings in 2014 HRM Measure The measure of High-Risk Medications (HRM) in older adults is derived from the Beer s list of drugs to be avoided in older adults which is maintained by the American Geriatrics Society The HRM performance measure contains a subset of the Beers List drugs (e.g., it doesn t contain some drugs that may have appropriate uses for some older adults benzodiazepines) The numerator of the HRM measure is only triggered when the patient has received at least 2 fills of a HRM. Commonly dispensed HRMs include: Non-benzodiazepine hypnotics (e.g., zolpidem) > 90 days Glyburide Estrogen 2014 Star Thresholds: MA PD Plans MAPD 2014/ Star 2014/ Star 2014/ Star 2014/ Star HRM 11% / 17% 8% / 13% 5% / 9% 3% / 7% PDC Diabetes 67% / 69% 71% / 73% 74% / 77% 77% / 81% PDC Hypertension 68% / 72% 72% / 76% 75% / 81% 79% / 85% PDC Cholesterol 63% / 59% 68% / 68% 76% / 76% 75% / 83% Diabetes Treatment 82% / 79% 85% / 83% 86% / 86% 87% / 90% 4

15 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 (moving to stars!) HIV antiretroviral medication adherence (only in safety reports) New Display measure (NOT from PQA) Use of atypical antipsychotics Atypical Antipsychotics in LTC This measure is defined as the percent of Medicare Part D beneficiaries 65 years and older who are continuously enrolled in a nursing home and who received atypical antipsychotic (AA) medication fills during the period measured. Denominator = number of beneficiaries who meet all of the following: Had Long-Term Institutional (LTI) status * for all months of the measurement period or until death, Were alive for at least 90 days at the beginning of the measurement period, Were enrolled in Part D for all months of the measurement period that they were alive, and Whose first reason for Medicare enrollment was aging-in. Numerator = number of Part D beneficiaries in the denominator who received at least a 90 days supply of AA medication(s) during the nursing home stay in the measurement period. High Stakes for Part D Stars Enrollment Implications Quality Bonus Payments (MA-PD) Poor performers identified by CMS Low-performer icon Worst Performers for Part D: 39 Medicare contracts received a low performer icon which means that they have consistently been below 3 stars 107 contracts had 2 stars or lower on all PDC measures Removal from Medicare for continued poor overall performance (< 3 stars for 3 years in a row) 5

16 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. 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 2015 payments will be based on 2014 ratings which are based on 2012 and 2013 data QBP opportunity for large MA-PDs (Humana, United Healthcare, Aetna/Coventry, CIGNA/HealthSpring) may exceed $100 million Which Part D Plans are the Best/Worst in your Town? If one of your patients asked you which Part D plans had the best star ratings, or worst star ratings, would you know how to find the information? If you wanted to target the Part D plans that are in most need of improved rates for adherence or safety, where do you find the information? Coverage/PrescriptionDrugCovGenIn/PerformanceData.html 6

17 How are Medicare 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 pharmacy network based partly on star performance of chain or stores Opportunity for LTCP P4P: Health plans are looking at LTCP Star Performance Quality bonus payments* Higher reimbursement rates Network inclusion Marketing Advantage Star Performance = Quality Care + Cost Control Support facility Star Performance Clinical consulting and operations collaboration *MAPD Plans Only LTCP Pharmacy P4P A few health plans have already implemented P4P for pharmacies, INCLUDING LTCP and several more have announced their impending launch Example: Inland Empire Health Plan (IEHP) Launched in October 2013 Pharmacies are evaluated on Star measures plus asthma and GDR EQuIPP allows pharmacies to track their performance Pharmacies will receive bonus payments every six months depending on their performance on each measure: 3-star attainment = small bonus 5-star attainment = large bonus Bonus is based on number of patients at each pharmacy in addition to score on each measure IEHP may also do public recognition of top performers 7

18 Part D Stars Changes for 2014/2015 High-Risk Medications in the Elderly (HRM): New list in effect for 2015 STARs (based on 2013 PDE) Comprehensive Medication Review (CMR) completion rate 2013 performance included in 2015 star ratings Partnering for Quality When looking at your own pharmacy, how do you define quality? What aspects of quality are in the forefront? What quality metrics is your pharmacy using today? What information do you need to help with conversations about quality of medication use? Will your pharmacy play a role in moving quality forward? Dashboard Technology Multi-plan, multi-pharmacy Enable faster, more-refined, benchmarking of Part D stars performance in key market areas Create more robust assessment of retail pharmacy performance on Part D stars Enhance engagement of retail pharmacies for stars improvement in regions where participating plans have significant opportunities for stars improvement 8

19 Dashboards for Plans, PBMs, and Pharmacies Health plans & PBMs: Access to performance dashboards that display their performance and relevant benchmarks on Star Ratings metrics across lines of business and across geographic regions Visibility into the performance of their pharmacy network Pharmacies: Access to performance dashboards that report their scores and relevant benchmarks across the same key quality measures Technology supported multi-tier views of a pharmacy organization s performance from the individual pharmacy, through districts/regions, to the corporate rollup Dashboards Options 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 Where is this Going? As the pressure builds on Medicare plans to improve Star Ratings, they are looking to many different options for improving medication adherence and safety Health plans are used to rewarding top-performing physicians through Pay-for-Performance (P4P) models P4P is NOT payment for performing a service (FFS). It is typically an adjustment in overall payment to a provider based on achieving quality goals or being in the top 20% of providers Now is the time to start assessing whether your pharmacy is meeting quality goals and how you rank compared to peers 9

20 What Should You Do? Learn What are the Part D star measures? What is your pharmacies performance for each star measures? Align efforts with quality measures Educate all of your staff on the key quality measures [FOCUS] Determine your touch points for quality measures [Rx drop-off, pick-up] Revise dispensing process to facilitate touch points Create prompts or reminders for staff at key touch points Track your performance Are you improving after implementing changes? Resources 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. Home Page 30 10

21 Pharmacy Dashboard Health Plan names here PQA 11

22 27 of 35 (77.1%) patients are on ACE/ARB; to reach goal, you need 30 diabetes patients on ACE/ARB Patient Outlier App available in Sept 2014 Patient Outlier List History List of Patients displayed here 12

23 Improvement Strategies FAQ tab 13

24 Summary Pharmacies are being evaluated NOW on quality measures related to Part D stars A few health plans have already implemented P4P for pharmacies Some PBMs have formulated strategies for moving towards preferred networks that only include top-performers on stars (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! Post session Questions True or False 1. Medication related metrics account for approximately 50% of the summary score for the Medicare Advantage Part D CMS 5 STAR rating program 2. Patients can access information on any Medicare Part D plan to see the plans CMS 5 STAR rating. 3. Beneficiaries can move between Part D Medicare plans without penalty at any time 4. The threshold minimums a plan must reach are equivalent across all metrics 5. HRM (high risk medications) are those medication that elderly (65 and older) should not take at any time 6. PDC (proportion of days covered) is the adherence metric used by CMS Medicare Part D Star Ratings What They Will Look Like Shining on Long Term Care Discussion 14

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