6/18/2015. Disclosure. Objectives. Star Ratings. Understand the current climate of healthcare reform

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1 Star Ratings John A. Galdo, Pharm.D., BCPS, CGP (Jake) Assistant Professor of Pharmacy Practice Community Practice Residency Director Disclosure I do not have (nor does any immediate family member have) actual or potential conflict of interest, within the last twelve months, a vested interest in or affiliation with any corporate organization offering financial support or grant monies for this continuing education activity, or any affiliation with an organization whose philosophy could potentially bias my presentation. I sit on workgroups for PQA and am a PQA Ambassador Objectives Understand the current climate of healthcare reform Describe the principles of quality metrics for healthcare Apply quality measures to geriatric patients Empower technicians to work at the top of their licensure 1

2 Active Learning In 2011, how much did the US spend on healthcare? 1. $500 billion 2. $1,000 billion 3. $1,500 billion 4. >$2,000 billion Public Health GDP $12.96 Trillion Reached $2.7 Trillion in 2011 For healthcare $8,680 per person $1.2 Trillion is Government $848.9 Billion due to hospital costs $320 Billion on medications Expected $4.78 Trillion (2021) Accessed online 10 September Top Therapeutic Classes by U.S. Spending. IMS data updated February 23, Available from Line%20Market%20Data%20&%20Trends/2011%20Topline%20Market%20Data/Top_Therapy_Classes_by_Sales.pdf Accessed online 9 March Healthcare in the US is Broken Medications do not work in patients that do not take them. C. Everett Koop, M.D., Former U.S. Surgeon General Primary non-adherence in post-mi ~24% 34% discontinue at least 1 medication 12% discontinue all medications Industry average adherence ranges from 40 to 80% Ho P, Bryson C, Rumsfield J. Medication Adherence Its Importance in Cardiovascular Outcomes. Circulation. 2009; 119: Forissier, T., Firlik, K. Estimated Annual Pharmaceutical Revenue Loss Due To Medication Non-Adherence, CAPGEMINI CONSULTING

3 Quality in the Health- System Hospital Quality Alliance (HQA) Joint Commission on Accreditation of Healthcare Organizations aka Joint Commission Centers for Medicare and Medicaid Services (CMS) American Hospital Association And others Established in 2001 Performance data sent to CMS Voluntary Friedberg MW, Landon B. Measuring quality in hospitals in the United States: Core process measures. In: Basow DS, ed. UpToDate. Waltham, MA: UpToDate. Accessed March 25 th, Medicare Modernization Act of 2003 Receipt of hospital s full Medicare payment contingent upon reporting the initial 10-measures to CMS Still voluntary Initial starter set of measures reflected three health conditions Acute Myocardial Infarction Heart Failure Pneumonia Friedberg MW, Landon B. Measuring quality in hospitals in the United States: Core process measures. In: Basow DS, ed. UpToDate. Waltham, MA: UpToDate. Accessed March 25 th,

4 Why the fuss? Quality of care delivered by the US healthcare system is suboptimal Principle of quality improvement is that what is not measured cannot be improved Ergo, performance measurement and reporting is vital Documentation is nothing without engagement to understand and improve Friedberg MW, Landon B. Measuring quality in hospitals in the United States: Core process measures. In: Basow DS, ed. UpToDate. Waltham, MA: UpToDate. Accessed March 25 th, Measures of Quality of Healthcare Structure Characteristics of individual healthcare providers, organizations, or facilities Possession of electronic medical record, percentage of board certified Healthcare Processes Delivery of specific clinical services Percentage of patients status post MI who receive a beta blocker Outcomes Ultimate goal of healthcare Affected by healthcare, but also influenced by patient factors 30-day mortality rate Friedberg MW, Landon B. Measuring quality in hospitals in the United States: Core process measures. In: Basow DS, ed. UpToDate. Waltham, MA: UpToDate. Accessed March 25 th, Donabedian A. Evaluating the quality of medical care. Milbank Q 1966; 44:166. Current Health-System Measures Acute myocardial infarction 8 Measures statin at discharge Heart Failure 3 measures ACE or ARB Pneumonia 1 measure Surgical Care 10 measures Emergency department 7 measures Preventive Care 2 measures Children s asthma care 3 measures Stroke Care 8 measures Blood clot prevention and treatment 6 measures Pregnancy and delivery care 1 measure Outpatient imaging efficiency 6 measures Friedberg MW, Landon B. Measuring quality in hospitals in the United States: Core process measures. In: Basow DS, ed. UpToDate. Waltham, MA: UpToDate. Accessed March 25 th, Updated March

5 COMMUNITY BASED QUALITY MEASURES History of PQA PQA was established in 2006 as a public-private partnership with CMS Consensus-based, non-profit alliance with >110 member organizations Work to improve the quality of medication management and use across healthcare settings PQA s measures being used not just in star ratings Nau D. Medicare Star Ratings for Pharmacy Quality Alliance Quality Forum Lecture Series. Webinar aired live October 31, Pharmacy Quality Alliance The Mission: To improve the quality of medication management and use across healthcare 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 Accessed March 25th,

6 PQA Measures Proportion of Days Covered (PDC) 18 years or older, threshold of 80 percent Reported for the following medication classes Beta-blocker Renin Angiotensin System Antagonist Calcium Channel Blocker Statin Biguanide Sulfonylurea Thiazolidinedione Dipeptidyl Peptidase-IV Inhibitor Anti-retroviral* *Threshold must be 90% Accessed March 25, 2014 PQA Measures, II Antipsychotic Use in Children Under 5 Years Old Percentage of children Adherence to Non-Warfarin Oral Anticoagulants Still PDC Diabetes Medication Dosing Percentage of patient dispensed a dose higher than the daily recommendation Accessed March 25, 2014 PQA Measures, III Diabetes: Appropriate Treatment of Hypertension Percentage of patients receiving medication for diabetes and hypertension that are receiving an angiotensin converting enzyme inhibitor (ACEI) and angiotensin II receptor blocker (ARB) Medication Therapy for Persons with Asthma Percentage of patients with asthma dispensed more than 3 canisters of shortacting beta2 agonist over a 90-day period and no controller therapy Accessed March 25,

7 PQA Measures, IV Use of High-Risk Medications (HRM) in the Elderly Percentage of patients 65 years of age or older and received two or more prescription fills for a HRM Drug-Drug Interactions Percentage of patients who received a prescription for a target medication during measurement period and dispensed a concurrent prescription for a precipitant medication Accessed March 25, 2014 PQA Measures, V Cholesterol Management in Coronary Artery Disease Percentage that received at least one prescription for HMG-CoA reductase inhibitor Completion Rate for Comprehensive Medication Review (CMR) Percentage that met eligibility criteria for medication therapy management and received a CMR Antipsychotic Use in Persons with Dementia Patients with dementia Accessed March 25, 2014 Where are the Measures Used? Medicare Part D Plan Ratings Star measures: medication adherence & safety Display measures: safety, adherence and MTM Accreditation programs URAC & CPPA National Business Coalition on Health (NBCH) evalue8 (health plan evaluation) P4P Programs Integrated Healthcare Association of California Inland Empire Health Plan PQA Patient Advisory Panel Introduction 7

8 THE PROVERBIAL STAR RATING Ratings are Everywhere! Quality over Quantity 8

9 What is a star rating? Quality measure of the pharmacy benefits manager (PBM) Rate One to Five stars It s a point system Rating is NOT dependent on PQA measure only 5 of the 14 are PQA/Pharmacy related Accessed March 25th, 2014 Sogol E, Galdo JA. Quality Ratings Impact Community Pharmacy: The CMS STAR Ratings. GPhA Journal. January Measure Name Weighting Category Weight Call Center Foreign Language Interpreter and TTY/TDD Available 2015 Star Rating Customer Service 1.5 Appeals Auto-Forward Customer Service 1.5 Appeals Upheld Customer Service 1.5 Complaints about the Drug Plan Member Complaints, Improvement 1.5 Members Choosing to Leave the Plan Member Complaints, Improvement 1.5 Drug Plan Quality Improvement Member Complaints, Improvement 5 Rating of Drug Plan Member Experience with Plan 1.5 Getting Needed Prescription Drugs Member Experience with Plan 1.5 MPF Price Accuracy Patient Safety and Drug Pricing 1 High Risk Medication Patient Safety and Drug Pricing 3 Diabetes Treatment Patient Safety and Drug Pricing 3 Medication Adherence for Oral Diabetes Patient Safety and Drug Pricing 3 Medication Adherence for Hypertension Patient Safety and Drug Pricing 3 Medication Adherence for Cholesterol Patient Safety and Drug Pricing 3 Accessed March 25th, Coverage/PrescriptionDrugCovGenIn/Downloads/2015_Star_Ratings_U er-call-slides_v2014_08_04.pdf. Accessed April 14, 2015 Pharmacy Specific Measures Measure Name High Risk Medication 3 Diabetes Treatment 3 Medication Adherence for Oral Diabetes Medication Adherence for Hypertension Medication Adherence for Cholesterol Weight 14 (was 18) total measures with different weighting 5 Claims Based measures = Pharmacy Account for over 50% of the total rating Accessed March 25th, 2014 Sogol E, Galdo JA. Quality Ratings Impact Community Pharmacy: The CMS STAR Ratings. GPhA Journal. January

10 Impact of Increased Medication Utilization The Congressional Budget Office estimates that a 1% increase in the number of prescriptions filled by beneficiaries would cause Medicare s spending on medical services to drop 0.2%. If a patient takes their medication as Increase certain pieces of the pie (e.g., drug utilization) and you ultimately decrease the bigger pieces and total spend If a patient takes their medication as prescribed, they don t end up in the hospital! Congressional Budget Office. Report Offsetting Effects of Prescription Drug Use on Medicare s Spending for Medical Services. November 29, Quality Bonus Payment Distribution Adapted from PQA Ambassador Progra THE MEASURES IN COMMUNITY PRACTICE 10

11 High Risk Medications Description Percentage of patients 65 years of age and older who received two or more prescriptions fills for a high-risk medication during the measurement period Definition Measurement Period Period of time over which the prescription medication fill pattern is assessed High-Risk Medication Select prescription drugs recommended to avoid in persons 65 years and older per the American Geriatric Society Beers Criteria Murphy E, Newsome R, Galdo JA. High Risk Medications in the Elderly: A Star M America s Pharmacist. May Accessed March 25, 2014 The Case of GG GG is an 85-year old Hispanic male, who resides at home with his family. The patient s son helps maintain GG s medications, and he is prescribed the following medications: Lisinopril 20mg po qday Metoprolol succinate 100 mg po qday Digoxin 250 mcg po qday Furosemide 20 mg po qday prn based on weight gain of 3-pounds in a day or 5-pounds over two days Zolpidem 10 mg po qhs for sleep Indomethacin 25 mg po TID for pain Atorvastatin 40 mg po qday Spironolactone 50 mg po qday Tiotroprium 18 mcg inhaled qday Diphenhydramine 25 mg po TID prn itching (OTC) Multivitamin po qday What are GG s Medical Conditions? Lisinopril; Metoprolol succinate; Digoxin; Furosemide; Zolpidem; Indomethacin; Atorvastatin; Spironolactone; Tiotroprium; Diphenhydramine; Multivitamin 11

12 What are GG s Medical Conditions? Lisinopril; Metoprolol succinate; Digoxin; Furosemide; Zolpidem; Indomethacin; Atorvastatin; Spironolactone; Tiotroprium; Diphenhydramine; Multivitamin Hypertension, Heart Failure, Chronic Obstructive Pulmonary Disease, Insomnia, Chronic Pain, Vitamin Deficiency, and potentially status-post Non-ST Elevated Acute Coronary Syndrome Star Rating Issues? Digoxin Reason: The maximum dose for digoxin is 125 mcg for geriatric patients Recommendation: Decrease digoxin to 125 mcg, monitor levels to 0.5 to 0.8 ng/ml per the DIG trial Zolpidem Reason: All non-benzodiazepine hypnotics are not recommended Recommendation: Non-pharmacological sleep hygiene Indomethacin Reason: Non-COX-selective NSAIDs should be avoided Recommendation: Acetaminophen, another NSAIDs would not be recommended as the patient is status-post NSTEACS and has a diagnosis of heart failure Diphenhydramine Reason: This is not a star rating red flag as the medication is OTC, however geriatric patients should not be on first-generation antihistamines due to the anticholinergic effects. Diabetes Treatment Description Patients who have received a medication for diabetes as well as any drug that could be used for the treatment of hypertension Definition Medication: Proxy for diagnosis of diabetes and hypertension Percentage of these diabetes-hypertension patients who receive an ACEI or ARB Accessed March 25th, 2014 Sogol E, Galdo JA. Quality Ratings Impact Community Pharmacy: The CMS STAR Ratings. GPhA Journal. January

13 Adherence Description Proportion of Days Covered is the PQArecommended metric for estimation of medication adherence for patients using chronic medications Definition Statins Renin angiotensin system antagonists Four classes of oral diabetes Biguanide Sulfonylurea Thiazolidinedione DPP-IV inhibitor Incretin mimetic Meglitinides Accessed March 25th, 2014 Sogol E, Galdo JA. Quality Ratings Impact Community Pharmacy: The CMS STAR Ratings. GPhA Journal. January What is Adherence? Proportion of Days Covered (PDC) (Gold Standard) Denominator = number of days between the first fill of the medication during the measurement period and the end of the measurement period Numerator = number of days covered by the prescription fills during the denominator period Overlapping days covered assumes that previous supply exhausted Medication Possession Ratio (MPR) Summation of the days supply of medication refills across an interval Numerator and denominator calculated in differing ways Time interval as the time between the first fill and last fill of a medication = Overestimate Adapted from PQA Ambassador Program Goals Change <74% >74% >79% >82% 2014 Diabetes PDC -- Five! 13

14 Goals Change <74% >74% >79% >82% 2015 Diabetes PDC >85% -- Five! Goals Change <74% >74% >79% >82% 2014 Diabetes PDC 77% PDC in 2014 is three stars -- Five! Goals Change <74% >74% >79% >82% 2015 Diabetes PDC >85% 77% PDC in 2015 is TWO stars -- Five! 14

15 Caveat: No primary literature exists to support these methods EMPOWERMENT OF THE PHARMACIST EQuIPP Electronic Quality Improvement Platform for Plans & Pharmacies Developed by Pharmacy Quality Solutions (PQS) and CECity Owned by PQA Accessed March 25th, 2015 Sogol E, Galdo JA. Quality Ratings Impact Community Pharmacy: The CMS STAR Ratings. GPhA Journal. January Newsome R, Murphy E, Galdo JA. The ABCs of Quality. GPhA Journal. February Performance Measures Accessed March 25th, 2015 Sogol E, Galdo JA. Quality Ratings Impact Community Pharmacy: The CMS STAR Ratings. GPhA Journal. January Newsome R, Murphy E, Galdo JA. The ABCs of Quality. GPhA Journal. February

16 Patient Outlier App available in Sept 2014 Adapted from PQA Ambassador Progra You Can Make a Difference Most Medicare Part D plans could move from 3 stars to 4 stars on each PDC measure if every pharmacy in its network helped just one more RASA patient, one more diabetes patient, and one more statin patient become highly adherent. David Nau, PhD, RPh, CPHQ, FAPhA President, Pharmacy Quality Solutions, Inc. Nau D. Medicare Star Ratings for Pharmacy Quality Alliance Quality Forum Lecture Series. Webinar aired live October 31, Star Rating of the PBM CMS PQA Community Pharmacy? PQS EQuIPP 16

17 What Pharmacies can do to Improve Results on Quality Measures! Adherence Programs Medication Synchronization Patient Intervention Packaging Behavioral Interviewing Pill Reminder Tools Medication Therapy Management Safety Alerts Targeting of Patients and Providers Adapted from PQA Ambassador Progra Empowerment of the Technician Adherence Programs Medication Synchronization Patient Intervention Packaging Behavioral Interviewing Pill Reminder Tools Medication Therapy Management Safety Alerts Targeting of Patients and Providers Half Full or Empty?? Better Patient Care, Increased Volume, Higher ROI, High Performance Networks, Alternative Revenue Sources Competition, Licking and Where Sticking, will Network you Exclusions be? 17

18 Department of Health and Human Services: Beyond 2015 Incentives to motivate higher-value care 85% of all Medicare fee-for-service payments tied to quality or value by 2016, and 90% by 2018 Increasing tying payment to value through alternative payment models 30% by 2016 and 50% by 2018 Alternative payment models include accountable care organizations and bundled-payment arrangements Changing the model of care delivered Health information technology reforms, eg transparency Leverage ACA established Patient-Centered Outcomes Research Institute (PCORI) to generate and disseminate data Burwell, S. Setting Value-Based Payment Goals HHS Efforts to Improve U.S. Health Care. N Engl J Med 372:10. March 2, April 6, 2015 METHODOLOGICAL CHANGES FOR CALENDAR YEAR 2016 Proposed Changes Eliminate Pre-determined Thresholds CMS found sponsors have more significant levels on improvement AKA must improve x percent is now gone New Measures MTM CMR Rate Assigned weight of 1, and continue to only be 1 LTC beneficiaries are included in the denominator Hospice at any time during the plan year are excluded 18

19 Proposed Changes, II Changes to measures Adherence and Diabetes Treatment Excluding ESRD patients Diabetes: Treatment of Hypertension PQA no longer endorses CMS will retire this measure in the CY2016 Medication Adherence Use actual death date as disenrollment New Measure! Opioids Measure 1 (Opioid High Dosage): The proportion (XX out of 1,000) of individuals without cancer receiving a daily dosage of opioids greater than 120mg morphine equivalent dose (MED) for 90 consecutive days or longer. Measure 2 (Multiple Prescribers and Multiple Pharmacies): The proportion (XX out of 1,000) of individuals without cancer receiving prescriptions for opioids from four (4) or more prescribers AND four (4) or more pharmacies. Measure 3 (Multi-Provider, High Dosage): The proportion (XX out of 1,000) of individuals without cancer receiving prescriptions for opioids greater than 120mg morphine equivalent dose (MED) for 90 consecutive days or longer, AND who received opioid prescriptions from four (4) or more prescribers AND four (4) or more pharmacies. PQA. Use of Opioids from Multiple Providers or at High Dosage in Persons Without Cancer. May Forecasting 2017 and Beyond Updates to the High Risk Medications Statin Therapy in a patient with diabetes Medication Synchronization Program acceptance and participation: Eligible patients who participate. Patient contact rate: % patients participating who were contacted with appointment call Med Sync Completeness: % patients enrolled with all chronic meds included in their sync Med Sync Continuation: % enrolled with chronic meds synced and still in sync after 6 months 19

20 Stakeholder Advisory Panel SAP A Hospital Admission for ADR Anticoagulants Adherence to Immunosuppressants SAP B MTM Patient Satisfaction Transition of Care in LTC Primary Medication Non-Adherence SAP C Hospital Utilization related to ADEs Concomitant Use of Opioids, Benzodiazepines, and Muscle Relaxants Gap in Therapy Glaucoma SAP D MTM: Specific Drug Problem Resolution Hepatitis C - Outcomes Future of Measures for Pharmacy Pharmacists are capable of impacting quality metrics and improving patient outcomes! Each pharmacy is being evaluated on how their patients are performing on quality measures. Health plans are utilizing preferred networks to get high quality results from their patients (often at a lower costs). Different philosophies from health plans and PBMs pertaining to performance on metrics: Pay-for-Performance (P4P)-additional payments or overall payments based on Star Measure Performance Sticks & Carrots -exclusion from network Adapted from PQA Ambassador Progra Take Home Points There is a two year lag on claims data to the CMS star ratings Perform now, stay in business in the future Pharmacies can account for 50% of a PBMs quality rating (aka, star rating ) Non-dispensing services, like medication synchronization, are the future of community pharmacy 20

21 Star Ratings John A. Galdo, Pharm.D., BCPS, CGP (Jake) Assistant Professor of Pharmacy Practice Community Practice Residency Director 21