Transcript Blood Pressure Meds - Indiana Pharmacists Alliance

The CMS Five-Star
Quality Rating System:
What It Means to You
and Your Pharmacy
Today’s Speaker
Rick McKaig
Director, Managed Care
AmerisourceBergen Drug Corporation
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Learning Objectives
At the end of this program, participants should be able to:
• Describe the Medicare Star Ratings Program
• Explain the 5 Medication Use Measures
• Understand the role of EQuIPP™
• Identify effective means for community pharmacies to improve their
individual performance on the medication use measures
• Acknowledge the short and long-term impacts of the Medicare Star
Ratings Program on Community Pharmacy
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Disclaimers
CMS
• Assigns Star Ratings to:
– Part C Health plans
– Part D Stand-alone plans
• CMS does not assign Star Ratings to pharmacies
• But by proxy, others do
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Pop “Star” Quiz
$317
Billion
5
2006
74%
P4P
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Pop “Star” Quiz
$317
Billion
5
2006
74%
P4P
A. CMS’ annual expenditures on health care for seniors
B. Estimate of economic losses associated with non-adherence
C. Annual economic spend on pharmaceutical products
D. Projected value of estimated savings as a result of the ACA
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Pop “Star” Quiz
$317
Billion
5
2006
74%
P4P
A. The enhanced dispensing fee for 5-Star pharmacies
B. The number of years before the 5-Star Rating system applies
to pharmacy
C. The number of stars in the CMS 5-Star Rating system
D. The number of current enrollees in Health Exchanges
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Pop “Star” Quiz
$317
Billion
5
2006
74%
P4P
A. The year the first Medicare Part-D prescriptions were filled
B. The year that pharmacy reimbursements first came under pressure
C. The year Medicare Part-D was enacted into law
D. The year Star Ratings started to be measured
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Pop “Star” Quiz
$317
Billion
5
2006
74%
P4P
A. The decline in pharmacy reimbursements since 2006
B. The bonus percentage for 5-Star health plans
C. The percent of Medicare beneficiaries enrolled in either a PDP or
MAPD plan
D. The 2014 inflationary growth rate of pharmaceuticals
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Pop “Star” Quiz
$317
Billion
5
2006
74%
P4P
A. Public Private Partnership for Pharmacy founded by CMS
B. An acronym for pay for performance
C. Independent pharmacy group that advocates for pharmacy
payment fairness
D. The group “People For Pharmacy”
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Bonus Question
Who was president when the surgeon general of the
US coined the oft-repeated phrase “Medications do
not work in patients who do not take them”
A. Jimmy Carter
B. Ronald Reagan
C. George H. Bush
D. Bill Clinton
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A basic understanding of Medicare
will help Star Ratings make sense
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The ABCD’s of Medicare
2010 Affordable Care Act
MA Bonuses for Star Performance
Part-A
Basic Hospital Insurance (1965)
Part-C
Medicare Advantage (1997)
Part-B
Option for Seniors
Replaces Part-A and Part-B
Basic Medical Insurance (1965)
Part-D (PDP)
Insurance for Drugs (2003)
59%
of beneficiaries
Part-D (MA-PD)
Insurance for Drugs (2003)
41%
of beneficiaries
CMS 2014 Statistics
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Independents should be happy that
Medicare has emerged as a major payer
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Growing Business
• 10,000 patients
age in daily
• Average use is
2.5 Rx/mo
• Retiree coverage
being replaced by
Medicare Plans
• 35,000 Low
Income Subsidy
(LIS) patients
under age 65
entering monthly
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Part-D Is Good for Independents
•
•
•
•
Plan - patients pick it!
Pharmacy—patients pick it!
No employer or labor union in the middle
Any willing provider regulations
Preferred Networks are a concern
• Chains accept lower reimbursement to drive foot traffic
• Today’s preferred networks are all about cost
• What if tomorrow’s networks could be based on quality, not cost?
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Your Pharmacy Can Be Ahead of the Game
Pharmacy performance
will determine P4P
2008
2009
CMS begins
collecting
data
CMS starts
reporting
Health Plan
Star Ratings
Oct 2013
2014
2015
2016
Health plans
turn focus
to Pharmacy
Networks
P4P
“Quality
Networks”
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Independents Are Positioned Well
NCPA study on patient’s level of connection with the pharmacist
89%
67%
36%
Independent Pharmacists
Chain Pharmacy
Mail Order
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You should care because
Star Ratings will impact reimbursements
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Adherence Is a National Problem
For every
100
prescriptions
written
50-70
Goes into a
pharmacy
46-66
come out of the
pharmacy
25-30
are taken
properly
15-20
are refilled as
prescribed
“Drugs don’t work in patients who don’t take them.”
— Former Surgeon General C. Everett Koop
Source: IMS
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Stars Are Consumer Facing!
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Here’s What CMS Publishes
Medicare Star Ratings
Excellent
Above Average
Average
Below Average
Poor
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Reimbursements May Look Like This
Medicare Part D Star Ratings
Excellent
Above Average
Average
Below Average
Poor
Plenty of details not known yet, but expect that 4-Star pharmacies
will be paid more than 3-Star pharmacies
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The five medication use measures
comprise 48.5% of a PDP’s overall score
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1. Use of High Risk Medications in the Elderly
The percent of your Medicare patients 65+ receiving two or more
prescription fills for a high-risk medicine
High Risk Meds
3%
Diabetes Treatment
87%
Oral Diabetes PDC
82%
Blood Pressure PDC
81%
Cholesterol PDC
76%
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2. Appropriate Treatment of Diabetes
The percent of your Medicare patients with meds for diabetes and
hypertension also receiving an ACE inhibitor, ARB, or direct renin
inhibitor med
High Risk Meds
3%
Diabetes Treatment
87%
Oral Diabetes PDC
82%
Blood Pressure PDC
81%
Cholesterol PDC
76%
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3. Adherence – Oral Diabetes Meds
The percent of your Medicare patients adherent with their oral
diabetes meds
High Risk Meds
3%
Diabetes Treatment
87%
Oral Diabetes PDC
82%
Blood Pressure PDC
81%
Cholesterol PDC
76%
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4. Adherence – Blood Pressure Meds
The percent of your Medicare patients adherent with their
blood pressure meds
High Risk Meds
3%
Diabetes Treatment
87%
Oral Diabetes PDC
82%
Blood Pressure PDC
81%
Cholesterol PDC
76%
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5. Adherence – Cholesterol Meds
The percent of your Medicare patients adherent with their
cholesterol meds
High Risk Meds
3%
Diabetes Treatment
87%
Oral Diabetes PDC
82%
Blood Pressure PDC
81%
Cholesterol PDC
76%
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Thresholds Are Tightly Grouped
Reaching even the 2-Star Level will require the attentiveness of your
pharmacists and technicians
3%
High Risk Meds
11%
87%
Diabetes Treatment
82%
82%
Oral Diabetes PDC
73%
81%
Blood Pressure PDC
73%
76%
Cholesterol PDC
70%
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A Typical Network of Independent Pharmacies
Stores that have reached 3, 4 or 5 Stars
High Risk Meds
61%
Diabetes Treatment
36%
Diabetes PDC
77%
Blood Pressure PDC
85%
Cholesterol PDC
88%
Source: EQuIPP™ May-2013 thru Oct-2013, based on 2014 thresholds
PDC is Proportion of Days Covered
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How you can find your
Star Ratings
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EQuIPP™ – A New Industry Tool
CMS
PDP
PBM
Healthplan
MTM
Neutral Entity
MTM
PBM
• Plans provide claims
• Currently at 26% of Medicare
beneficiaries
• Pharmacy Web App
Rx
Rx
Rx
Rx
Rx
Rx
Note: EQuIPP™ is a product offered by Pharmacy Quality Systems (PQS) which is a joint venture
between Pharmacy Quality Alliance (PQA) a non-profit entity and CE/City, a technology vendor.
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100% of Medicare Patients Measured
Health Plans
• Humana
• Coventry
• Wellcare
• HealthSpring / CIGNA
• Inland Empire Health Plan (CA)
• BCBS – Tennessee
• BCBS – North Carolina
• UPMC Health Plan (PA)
• Gateway Health Plan (PA)
26%
You have visibility to because
the plans subscribe to EQuIPP
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Supplemental Reports to Support Star
Star Ratings: Reducing High Risk Medication Use
Star Measurement
This Report
This measure calculates the percentage
of Medicare Part D beneficiaries 65 years or
older who received two or more
prescription fills for the same HRM drug
with a high risk of side effects in the elderly.
Includes Medicare Part D fills from last
week (Sunday through Saturday) for
patients 65 or older who received at least
one medication from the EQuIPP® list of
High Risk Medications.
Fill Date
Rx
Age
Fill
Days
NDC
Drug
BIN
Plan
3/21/14
123456
71
0
15
000378-5310-01
Zolpidem Tartrate 10 mg
156231
Silverscript
3/22/14
235689
68
1
30
00378-6410-01
Doxepin 100 mg
458921
Humana
3/23/14
568978
76
3
20
00185-0648-10
Diphenhydramine 25 mg
789456
Caremore
3/23/14
987654
81
2
30
00603-5167-32
Phenobarbital 64.8 mg
614575
Silverscript
Reminder: This report contains personal health information that falls within the definition
of “Protected Health Information” or “PHI” under federal law (HIPAA).
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The Value of an EQuIPP™ License
•
•
•
•
Health Plan Detail
Performance Over Time
State Peer Benchmarks
Multi-Store Owner Benefits
• Improvement Strategies
• CE Opportunities
• Frequently Asked Questions
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How can a pharmacy perform
well on Star Ratings?
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Workflow Must Change
Today’s Successful Pharmacy
Tomorrow’s Successful Pharmacy
Personalized Service
Speedy Rx Service
MTM’s treated as optional
MTM performance crucial
Patient initiates activities
Pharmacy schedules activities
Rx inflow controls workflow
Patient scheduling controls workflow
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MTMs Have New Importance
• Independent pharmacy
lags behind the chains
• Not just
“brown bag” reviews
• Multiple “TIPs” for
a single patient
can add up
• TIPs, TMRs, Gaps
– Require less time
– May already
be doing
Pharmacies must be enrolled
with both Mirixa and Outcomes
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MTM & TIP Opportunities
Healthplan reviews
patient records and
identifies opportunities
for interventions
Pharmacists reviews
opportunities and
counsels patient and
records activity
MTM = Medication Therapy
Management
CMR = Complete Medication
Review
TIP = Targeted Intervention
Program
Improves the health
of patients
United Healthcare (using
OutcomesMTM) and Caremark
(using Mirixa) have based their
initial Star improvement
strategies on assigning activities
to the patient’s pharmacy.
Not every MTM activity is a Complete Medication Review
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NCPA Simplify My Meds
Control Group
Med-Synch Patients
234
337
Days of therapy
Patients adherent
56%
Additional fills
patient/year
90%
+20
Med Synch
Proactively adjust timing of
multiple prescriptions
NCPA Tool Kit
Patient brochures, enrollment forms, physician
faxes, training, and more
Operational Practice
Frequently call patients to review status
NCPDP Codes to Synchronize Rx’s
SCC 47, SCC 48
Study from NCPA sheds new light on med synchronization programs. January 17, 2014.
Average enrolled patient was taking 5.9 synchronized medications.
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Commercial Adherence Programs
• Variety of approaches
– Turnkey programs
– Consulting
– Software
– Packaging
• May include training of your staff
• Most include patient materials
– Patient letters
– Point of dispense messaging
Complementary with synchronization of patient’s prescriptions
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Leverage Your Dispensing System
•
•
•
•
•
•
Enroll patients in Auto Fills
Use Refill Reminders (email, text, outbound calling)
Make refills easy to order (IVR, web, mobile)
Synchronization (reporting, calendars, drug/patient id)
MTM Interfaces
Compliance packaging interfaces
Complementary with synchronization of patient’s prescriptions
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Achieving strong ratings will require
changes in your practice,
here are a couple of success stories…
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Success Story: L&S Pharmacy Experience
MedHere Today Appointment model
• 300 patients enrolled
(10% of patients)
• 8,700 more fills for the
300 patients
• 29 more fills per patient per year
• $113,000 increase in annual
profit with existing patients
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Success Story
Med Synch Based Appointment Model
• Small chain based in Minnesota
• Synchronize all of a patient’s chronic
fill meds
• Patients are assigned a day of the
month to pick up meds
Study Measured Proportion of Patients Considered Adherent
Medication
Control Group
Study Group
ACEIs/ARBs (Blood Pressure)
40.8%
79.5%
Beta Blockers (Blood Pressure)
38.3%
71.8%
CCBs (Blood Pressure)
40.3%
68.9%
Diuretics (Blood Pressure)
37.0%
66.1%
Metformin (Diabetes)
40.2%
76.6%
Statins (Cholesterol)
37.4%
76.2%
STAR
Equivalent
Study conducted by Virginia Commonwealth School of Pharmacy
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YOU CAN DO IT TOO AND WE’RE HERE TO HELP YOU!
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Assessment Questions
1. The CMS Five-Star Quality Rating System are intended to help
beneficiaries compare MAPD plans and prescription drug plans
(PDP) on quality and service. True or False?
True
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Assessment Questions
2. Which is not one of the 5 key Star measures for pharmacy?
A. Members age 65 and older on medications with high risk side
effects
B. Members with diabetes using recommended blood pressure
medications
C. Taking insulin as directed
D. Taking blood pressure medication as directed
E. Taking cholesterol medication as directed
C. Taking insulin as directed
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Assessment Questions
3. A patient may have their high risk medication filled up to three times
before it counts against the pharmacy. True or False?
False
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Assessment Questions
4. EQUiPP currently measures what percentage of Medicare patients?
A. 100%
B. 54%
C. 26%
D. 72%
C. 26%
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Assessment Questions
5. Pharmacies must enroll in either Mirixa or Outcomes to capture all of
their available MTM cases. True or False?
False!!!!
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Questions
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