As pharmacists, we have two types of customers — the patient and the payer — and both want better value for their investment, expecting reduced healthcare costs and improved clinical outcomes. In order to stay competitive and provide the desired value, community pharmacies need to “know our numbers” when it comes to key quality measures.
According to the World Health Organization, the U.S. ranks in the mid-30s worldwide in healthcare quality. It spends 17% of GDP, or $1 for every $5 produced, on healthcare. The Affordable Care Act is primarily focused is on achieving higher quality with lower costs. Despite this emphasis on quality, current healthcare systems continue to be fragmented in an era where value-based medicine and care delivery is gaining more attention.
The Centers for Medicare & Medicaid Services (CMS) has stepped up and set standards for quality, safety, and care coordination for its Medicare Part D beneficiaries, and that has become the model for the rest of the healthcare ecosystem. CMS has incentivized plans and payers to deliver higher quality of care through the Medicare Star Rating System: a 5-star quality rating system of health plans designed to reward those that can achieve strong value-based performance metrics, ranging from customer service to patient outcomes. These ratings impact health plan federal subsidy payments and open enrollment periods.
How community pharmacy ‘Stays in the Game’
Pharmacists are recognized as an integral part of the healthcare delivery team and experts in managing medication-related problems. Medicare Star Ratings drive plan sponsors to incentivize pharmacies to interact with patients and perform care quality management, supporting community pharmacy’s continued expansion of its role providing clinical services. It also helps grow collaborative clinical and business relationships with other healthcare entities in the community.
Many CMS and commercial payers’ initiatives are now focused on pharmacy medication utilization, evidenced by an emerging number of quality-based financial and contractual network incentives. Additionally, more and more network contracts for commercial and Part D plans are incorporating value-based outcome goals / quality measure metrics as a condition for continued participation. Performance scorecard results incorporating these measures influence a pharmacy’s level of reimbursement and continued participation in the networks.
The quality performance measure categories in which community pharmacy can play a significant role include:
- Medication adherence
- Medication safety
- Medication therapy management (MTM)
The good news is that the growth of healthcare information technology reporting and enabling tools have provided the clinical and business intelligence, insight, and analytics to help target specific patient groups and medication “gap” opportunities. That, in turn, can help pharmacies pursue higher “scores” in many of these measures.
How do metrics impact business and practice?
Medication nonadherence is a $300 billion drain on the U.S. healthcare system. It is estimated that one-third of patients stop or miss taking their prescribed dose without telling their prescriber, and one-half of medications for chronic diseases are not taken as directed. Health plans and payers recognize that community pharmacists are experts when it comes to managing proper medication use and patient adherence. The industry has focused on five quality measures for which pharmacy can make the most impact:
- Treatment of hypertension in diabetic patients with a RAS antagonist
- RAS antagonist adherence in the treatment of chronic hypertension (non-diabetic patients)
- Statin adherence in treatment of hyperlipidemia
- Oral diabetic agent adherence in the treatment of diabetes
- High-risk medication use in the elderly
Quality measures playbook
Here are examples of a key quality areas that pharmacies can focus on improving:
Medication management
- Medication adherence
- MTM
- Medication reconciliation
- Medication synchronization
- Medications (transition of care and “gap care”)
Pharmacy-based disease state management
- Chronic diseases:
- Diabetes
- Hypertension
- Hypercholesterolemia
- COPD
- Asthma
- Outpatient pharmacist-based clinics:
- Diabetes
- Anticoagulation
Utilization management
- Discharge planning
- Formulary compliance
- Performing prior authorization to ensure the dispensing of costly medications are medically necessary
Realistic expectations and opportunities
Community pharmacy is still primarily a transaction-based business, and its compensation is still largely based on the product, not the service provided. Pharmacy also continues to struggle with investing in infrastructure and resources to develop and implement these quality-based care programs and realize an acceptable return on investment.
Yet, community pharmacies are now held accountable by PBMs to perform and deliver on the metrics for quality-based programs in the form of direct and indirect remuneration (DIR) fees. As a result, a pharmacy’s bottom line can be significantly impacted.
To stay in the game, community pharmacy has recognized the importance of seeking support and leveraging the resources of its wholesale drug distributor, GPO, PSAO, and other organizations in the evolution of the practice and business. Additionally, these organizations have been great platforms for sharing best practices that work.
Over the past several years, there are many success stories, and many more will come over the next few years as community pharmacy takes on more responsibility and demonstrates how it is able to “move the needle” on improving clinical outcomes while helping to curb growing healthcare costs.
David J. Fong, PharmD, is president of Dave Fong Rx Consulting, Inc. A former senior retail pharmacy executive for Fortune 100 and Fortune 500 companies, he is recognized as one of the U.S. and Canada’s business and professional healthcare leaders, leveraging his knowledge and experience working with pharmaceutical manufacturers, distributors, retailers, payers, and healthcare technology companies to bring value to the industry and the consumer.
