quality vs quantity: the next era of healthcare john a. galdo, pharm.d., bcps, cgp (jake) assistant...

Quality vs Quantity:The Next Era of

HealthcareJohn A. Galdo, Pharm.D., BCPS, CGP (Jake)Assistant Professor of Pharmacy PracticeCommunity Practice Residency Director

[email protected]

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

Disclosure

Describe the shift of healthcare from a quantity to quality system

Understand the 6* CMS Star Rating Pharmacy Measures

Discuss opportunities pharmacists have in the new healthcare system

Objectives

In 2011, how much did the US spend on healthcare?

1. $500 billion2. $1,000 billion3. $1,500 billion4. >$2,000 billion

Active Learning

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)

www.cms.gov Accessed online 10 September 2013.Top Therapeutic Classes by U.S. Spending. IMS data updated February 23, 2012. Available from http://www.imshealth.com/deployedfiles/ims/Global/Content/Corporate/Press%20Room/Top-Line%20Market%20Data%20&%20Trends/2011%20Top-line%20Market%20Data/Top_Therapy_Classes_by_Sales.pdf Accessed online 9 March 2013.

“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%

Healthcare in the US is Broken

Ho P, Bryson C, Rumsfield J. Medication Adherence Its Importance in Cardiovascular Outcomes. Circulation. 2009; 119: 3028-3035Forissier, T., Firlik, K. Estimated Annual Pharmaceutical Revenue Loss Due To Medication Non-Adherence, CAPGEMINI CONSULTING 2012

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

Quality in the Health-System

Friedberg MW, Landon B. Measuring quality in hospitals in the United States: Core process measures. In: Basow DS, ed. UpToDate. Waltham, MA: UpToDate. www.uptodate.com. Accessed March 25th, 2014.

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

Medicare Modernization Act of 2003


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

Why the fuss?


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

Measures of Quality of Healthcare

Friedberg MW, Landon B. Measuring quality in hospitals in the United States: Core process measures. In: Basow DS, ed. UpToDate. Waltham, MA: UpToDate. www.uptodate.com. Accessed March 25th, 2014.Donabedian A. Evaluating the quality of medical care. Milbank Q 1966; 44:166.

Current Health-System Measures Acute mycoardial 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. www.uptodate.com. Accessed March 25th, 2014. Updated March 2015.

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 2014. Pharmacy Quality Alliance Quality Forum Lecture Series. Webinar aired live October 31, 2013.

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

Pharmacy Quality Alliance

http://pqaalliance.org/about/default.asp Accessed March 25th, 2014

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*

PQA Measures

http://pqaalliance.org/measures/default.asp Accessed July 2, 2015

*Threshold must be 90%

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 Biguanides, Sulfonylurea, TZD, DPP-IV

PQA Measures, II


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 short-acting beta2 agonist over a 90-day period and no controller therapy

PQA Measures, III


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

Use of Benzodiazepine Sedative Hypnotic Medications in the Elderly◦ Percent of patients 65 years or older who received two or more

prescription fills for cumulative period of more than 90 days

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

PQA Measures, IV


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

PQA Measures, V


Primary Medication Non-adherence (PMN)◦ Percentage of prescriptions for chronic medications e-prescribed by a

prescriber and not obtained by the patient in the follow 30 days Not intended for use by PBM or health plans

Provision of MTM Services Post Hospital Discharge◦ Percentage of high risk patients that have been discharged from

hospital and that received MTM from a pharmacist within 7 days

Readmission of Patients Provided MTM Post Hospital Discharge◦ Percentage of patients that received MTM that are readmitted within

30 days

PQA Measures, VI


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

Where are the Measures Used?

PQA Patient Advisory Panel Introduction

The Proverbial Star Rating

Ratings are Everywhere!

Quality over Quantity

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

What is a star rating?

http://pqaalliance.org/measures/cms.asp Accessed March 25th, 2014Sogol E, Galdo JA. Quality Ratings Impact Community Pharmacy: The CMS STAR Ratings. GPhA Journal. January 2014.

Measure Name Weighting Category WeightCall Center – Foreign Language Interpreter and TTY/TDD Available

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

http://pqaalliance.org/measures/cms.asp Accessed March 25th, 2014http://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/Downloads/2015_Star_Ratings_User-Call-Slides_v2014_08_04.pdf. Accessed April 14, 2015

2015 Star Rating

Measure Name Weight

High Risk Medication 3

Diabetes Treatment 3

Medication Adherence for Oral Diabetes 3

Medication Adherence for Hypertension 3

Medication Adherence for Cholesterol 3

Pharmacy Specific Measures


• 14 (was 18) total measures with different weighting• 5 “Claims Based” measures = Pharmacy

• Account for over 50% of the total rating

If a patient takes their medication as

Impact of Increased Medication Utilization

Increase certain pieces of the pie (e.g., drug utilization) …

… and you ultimately decrease the bigger

pieces and total spend

Congressional Budget Office. Report Offsetting Effects of Prescription Drug Use on Medicare’s Spending for Medical Services. November 29, 2012. http://www.cbo.gov/sites/default/files/cbofiles/attachments/43741-MedicalOffsets-11-29-12.pdf.

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 prescribed, they don’t end up in the hospital!

Quality Bonus Payment Distribution

Adapted from PQA Ambassador Program

The Measures in Community Practice

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

High Risk Medications

Murphy E, Newsome R, Galdo JA. High Risk Medications in the Elderly: A Star Measure. America’s Pharmacist. May 2014.www.pqaalliance.org Accessed March 25, 2014

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

The Case of GG

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 myocardial infarction

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

What are GG’s Medical Conditions?

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.

Star Rating Issues?

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

Diabetes Treatment


Description◦ Proportion of Days Covered is the PQA-recommended 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

Adherence


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


Goals Change…

<74% >74% >79% >82%

-- Five!

2014 Diabetes PDC

Goals Change…

<74% >74% >79% >82%

-- Five!

2015 Diabetes PDC

>85%

Goals Change…

<74% >74% >79% >82%

-- Five!

2014 Diabetes PDC

77% PDC in 2014 is three stars

Goals Change…

<74% >74% >79% >82%

-- Five!

2015 Diabetes PDC

>85%

77% PDC in 2015 is TWO stars

Empowerment of the pharmacist

Caveat: No primary literature exists to support these methods

Electronic Quality Improvement Platform for Plans & Pharmacies

Developed by Pharmacy Quality Solutions (PQS) and CECity

Owned by PQA

EQuIPP

https://www.equipp.org/default.aspx Accessed March 25th, 2015Sogol E, Galdo JA. Quality Ratings Impact Community Pharmacy: The CMS STAR Ratings. GPhA Journal. January 2014.Newsome R, Murphy E, Galdo JA. The ABCs of Quality. GPhA Journal. February 2014.

Performance Measures

https://www.equipp.org/default.aspx Accessed March 25th, 2015Sogol E, Galdo JA. Quality Ratings Impact Community Pharmacy: The CMS STAR Ratings. GPhA Journal. January 2014.Newsome R, Murphy E, Galdo JA. The ABCs of Quality. GPhA Journal. February 2014.

Patient Outlier Appavailable in Sept 2014


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, FAPhAPresident, Pharmacy Quality Solutions, Inc.

Nau D. Medicare Star Ratings for 2014. Pharmacy Quality Alliance Quality Forum Lecture Series. Webinar aired live October 31, 2013.

Star Rating of the PBM

CMS PQA

PQS

EQuIPP

Community Pharmacy?

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


Adherence Programs◦Medication Synchronization◦ Patient Intervention◦ Packaging◦ Behavioral Interviewing◦ Pill Reminder Tools

Medication Therapy Management Safety Alerts Targeting of Patients and Providers

Empowerment of the Technician

Better Patient Care, Increased Volume, Higher ROI, High Performance Networks, Alternative Revenue Sources

Competition, Licking and Sticking, Network Exclusions

Half Full or Empty??

Where will you be?

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

Department of Health and Human Services: Beyond 2015

Burwell, S. Setting Value-Based Payment Goals – HHS Efforts to Improve U.S. Health Care. N Engl J Med 372:10. March 2, 2015.

Methodological Changes for Calendar Year 2016

April 6, 2015

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

Proposed Changes

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

Proposed Changes, II

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.

New Measure! Opioids…

PQA. Use of Opioids from Multiple Providers or at High Dosage in Persons Without Cancer. May 2015.

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

Forecasting 2017 and Beyond

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

Stakeholder Advisory Panel

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


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

Take Home Points

Quality vs Quantity:The Next Era of Healthcare

John A. Galdo, Pharm.D., BCPS, CGP (Jake)Assistant Professor of Pharmacy PracticeCommunity Practice Residency Director

[email protected]

quality vs quantity: the next era of healthcare john a. galdo, pharm.d., bcps, cgp (jake) assistant...

Documents

new healthcare system

quality system

pqa ambassador slide

measuring quality

quality of care

us healthcare system

shift of healthcare

medication adherence