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Game-changer is emerging in community Rx
October 10th, 2011
It is almost six years since the beginning of Medicare Part D. But now, the development of a system to use quality-based payments for quality-based patient outcomes is coming closer to reality.
Imagine a Medicare Advantage Plan that includes drug benefits (MAPD) with 1 million members. Imagine a quality-based payment (QBP) system that rewards such plans for quality patient outcomes. Imagine the existence of measurable quality standards to include patient outcomes from medication therapy. And imagine the QBP system from the Centers for Medicare & Medicaid Services (CMS) becoming the de facto standard for health care delivery in the United States.
Well, imagine no more. This new system is dawning on us, and community pharmacy services are in the thick of it.
Next year begins the change. CMS has issued Medicare Plan (star) ratings for several years, but this month it will release new ratings with an expanded list of medication-related quality measures.
Of 17 total quality measures for Medicare Part D, five involve medication therapy. These include preventing the use of high-risk medications in the elderly and providing appropriate treatment of high blood pressure in patients with diabetes, as well as three measures related to medication adherence. These ratings will affect Medicare plan payments in 2012, in that plans with higher numbers of stars will get larger payments from CMS.
Community pharmacy practice, as we currently know it, will change. How pharmacists think about the work they do will change. How chain pharmacies are organized and managed will change.
From this point forward, measures of quality patient outcomes from medication therapy will include medication adherence rates for patients served, appropriate dosing for chronic medications, assurance of no high-risk interactions among and between multiple medications for the elderly, and high-risk drug/drug interactions for all patients.
These quality patient outcomes are essential to maximize quality-based payments. Pharmacies and pharmacy chains capable of driving improvements in quality-based outcomes will have a new seat at the table with managed care organizations seeking to maximize quality-based payments.
Pharmacy operators that can drive improvements in health outcomes will be rewarded.
Think back to the MAPD with 1 million patients. Think forward to a star rating system for quality-based outcomes. A five-star rating over a three-star rating from CMS for a managed care entity will yield a quality-based payment of an additional $15 to $16 per member per month above the base. The annualized calculation is simple. Think almost $200,000,000 to the MAPD annually.
The MAPD cannot achieve the five-star rating without active and effective participation from community pharmacies that create quality patient outcomes according to the criteria mentioned above. Think how this changes the way pharmacy is practiced. Think pharmacy at the negotiating table to achieve a piece of the quality-based payment pie.
Once in a great while, there comes a tectonic shift in an industry that is a true game-changer. Think back to the origin of pharmacy benefit managers. While few among us would consider it positive, would anyone deny the game changed over the years? Unfortunately, it was focused totally on cost reduction. That game is now in the rearview mirror. Its shortsightedness has been exposed for what it is.
Now think forward to the Pharmacy Quality Alliance (PQA) under the direction of pharmacist and industry veteran Laura Cranston, its executive director. Cranston and her staff at PQA are at the epicenter of this tectonic shift to include pharmacy performance in the achievement of quality-based payments for quality patient outcomes.
The origin of this dates to Jan. 1, 2006, which marked the beginning of the Medicare Prescription Drug Program, or Medicare Part D, under then President George W. Bush. Then CMS administrator, Dr. Mark McClelland was passionate about the government not merely paying for more medications but paying for greater value. Ways would have to be found to measure quality as well as cost. But there was no entity in place to identify measures of medication-use quality. The PQA was created to take on the challenge.
So what is the PQA and what is it about? It's a public-private partnership with stakeholders including health plans, PBMs, pharmacies, pharmaceutical manufacturers, patient advocacy groups and practitioner-based organizations. PQA's stated mission: "Improve the quality of medication use across health care settings through a collaborative process in which key stakeholders agree on a strategy for measuring and reporting performance information related to medications.”
Its list of some 70 members includes major Pharma players Pfizer, AstraZeneca, Bristol-Meyers Squibb, GlaxoSmithKline, Sanofi, Novartis, Merck and others. Express Scripts, Medco Health, Aetna, Humana and Med Impact are on board. The National Association of Chain Drug Stores is a founding member, and its president and chief executive officer, Steve Anderson, is on the board of directors. And while chain pharmacy organizations are currently minimally included, only with CVS Caremark and Walmart, one can hope and expect that this list will grow rapidly.
Robert Coopman is president of Robert Coopman Consultants, based in San Antonio. He can be contacted at email@example.com.