Healthcare Reform and Value Based Purchasing: Opportunities for Pharmacist Involvement

Healthcare Reform and Value

Based Purchasing:

Opportunities for Pharmacist

Involvement

Jane S. Henry, MBA, RPh

Pharmacist Consultant

Adverse Drug Event Reduction Project Team February 16, 2013

Centers for Medicaid & Medicare Services

•

CMS Vision:

The right care for every person every time

•

CMS Aims:

Make care safe, timely, effective, efficient,

patient-centered and equitable

– Institute of Medicine, 2001 Six Aims for Healthcare

Better Outcomes

Status Quo Drift

Time

Current success with Population of Focus

Our Aim: SPREAD Improvement

Cycles

Where do we want to go?

Transformational Change

•

Widespread changes

•

Change in:

5

The Need for Transformational

Change. . .

•

1991 Harvard Medical Practice Study

•

1999 IOM report, To Err is Human

•

2001 IOM report, Crossing the Quality

Chasm

– Medical error/misuse

– Overuse

– Underuse

Our Health Care Macrosystem:

•  Falls short in ability to translate new knowledge

& technology into practice

•  Lacks even rudimentary clinical information

capabilities

•  Over-utilizes services with potential risks that outweigh potential benefits

•  Allows physician preference to rule over best

practices & evidence based medicine (EBM)

7

Our Health Care Macrosystem:

•

Is designed primarily to provide acute care

•

Chronic conditions are the leading cause

of illness, disability & death

– affect almost ½ of the US population

– account for the majority of health care

expenditures.

» Crossing the Quality Chasm

IOM

’

s Vision:

The purpose of Health Care

•

“

All health care organizations,

professional groups, and private and

public purchasers should adopt as their

explicit purpose to continually reduce the

burden of illness, injury, and disability, and

to improve the health and functioning of

the people of the United States.”

9

Fiscal Year 2009 and beyond...

Value Based Purchasing (VBP)

•  “Transform CMS from a passive payer of services to an active purchaser”

•  IPPS (Inpatient Prospective Payment System) -Hospitals Only

•  Public reporting and financial incentives for

better performance:

– Clinical quality (pt care processes and outcomes)

– Patient-centeredness (pt satisfaction)

– Efficiency (utilization and cost of services)

Current Public Reporting Activities

•  Physician Quality Data Reporting

(PQRI: Physician Quality Reporting Initiative)

•  Transparency Initiatives- Better Quality

11

Public Reporting: Hospital

hospitalcompare.hhs.gov

Mandated by 2003 Medicare Modernization Act, expanded in DRA Section 5001 (a) -RHQDAPU (Reporting Hospital Quality Data

for Annual Payment Update)

Hospitals must submit data on:

– Continues to expand: 42 Quality Measures

•  Medical Record Abstraction

•  Acute MI, Heart Failure, Pneumonia •  Surgical Care Improvement Project

– Abx selection and administration, VTE Prophylaxis Appropriate, hair removal prior to surgery

•  Outpatient procedures •  Hospital 30-day readmission

Public Reporting: Hospital cont.

hospitalcompare.hhs.gov

Hospitals must submit data on:

– HCAHPS Data (Hospital Consumers Assessment of

Hospital Providers & Systems)

•  Patient experience with healthcare and satisfaction •  Developed by Agency for Health Research and Quality

(AHRQ) •  27 Questions

– Mortality Data

•  AMI, HF, PNE

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Public Reporting: Other

•  Nursing Home

– medicare.gov/nhcompare

– MDS Data (Minimum Data Set)

•  Home Health

– medicare.gov/hhcompare

– OASIS Data (Outcome & Assessment Information Set)

Public Reporting: Physician

•  Legislative: Tax Relief and Health Care Act of

2006-signed 12/06

•

PQRI

– Originally a 5% decrease in Medicare reimbursement

for not reporting, now a 1.5% incentive for reporting

– Code based: G codes or CPT Category 2

Pharmacy Quality Alliance (PQA)

•

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.

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Pharmacy Quality Alliance

•

Identify claims-based measures that:

– Improve health care quality and patient safety

– Collect data in the least burdensome way

– Report meaningful information to consumers,

pharmacists, employers, health insurance plans and other healthcare decision makers

– Improve ability to make informed choices,

improve outcomes and stimulate the

PQA Medication Quality Measures

•

Proportion of Days Covered (PDC)

– The percentage of patients who met the PDC

threshold of 80 percent during the time period.

•  Beta-blocker (BB)

•  ACE Inhibitor, Angiotensin Receptor Blocker •  Statin

•  Biguanide •  Sulfonylurea •  Thiazolidinedione

•  DiPeptidyl Peptidase (DPP)-IV Inhibitor •  Diabetes

•  Anti-retroviral (this measure has a threshold of 90% for at least 2 medications)

17

PQA Medication Quality Measures

•

Diabetes Medication Dosing (DOS)

– The percentage of patients who were dispensed a dose higher than one

recommended for the following therapeutic categories of oral hypoglycemics:

•  biguanides, •  sulfonlyureas, •  thiazolidinediones,

PQA Medication Quality Measures

•

Medication Therapy for Persons with

Asthma

•

Suboptimal Control

– The percentage of patients with persistent asthma who were dispensed more than 3 canisters of a short-acting beta₂ agonist inhaler during the same 90-day period.

– Absence of Controller Therapy

19

PQA Medication Quality Measures

•

Use of High-Risk Medications in the

Elderly (HRM)

– The percentage of patients 65 years of age

and older who received two or more prescription fills for a high-risk medication during the measurement period.

PQA Medication Quality Measures

•

Completion Rate for Comprehensive

Medication Review

– The percentage of prescription drug plan members who met eligibility criteria for medication therapy management (MTM) services (multiple medications, multiple chronic diseases, multiple prescribers) and who received a comprehensive medication review (CMR) during the eligibility period.

21

PQA Medication Quality Measures

•

Antipsychotic Use in Persons with

Dementia

– The percentage of individuals (65 years and

older) with dementia who are receiving an antipsychotic medication without evidence of a psychotic disorder or related condition.

Comprehensive Medication Management –

Critical in Preventable Adverse Events

•  Office of Inspector General Report on Preventable Serious Adverse Events in Hospitalized Medicare patients1

–  Cited medication errors as the top preventable cause of serious adverse events

•  Avoidable Hospital Readmissions

–  Medication errors/ lack of reconciliation cited as a top cause of avoidable readmissions

•  Attention to medication management is becoming more critical for providers/hospitals with CMS and commercial carriers lack of willingness to pay for “avoidable

readmissions”

1_{oig.hhs.gov/oei/reports/oei-06-09-00090.pdf}

23

Drug Therapy Problems

    _{Number  of  DTP}  

Indica3on   Unnecessary  Drug  Therapy   4387   5%  

Needs  Addi3onal  Drug  Therapy   _25,898   30%  

Effec3veness   More  Effec3ve  Drug  Available   5,785   7%  

Dosage  Too  Low   _21,434   25%  

Safety  

Adverse  Drug  Reac3on   _8,860   10%  

Dosage  Too  High   _6,168   7%  

Compliance   Noncompliance   _1,342   16%  

    _Total   85,957      

Only 16% of all drug therapy problems were “Adherence” related

The Pharmacist

’

s Role

“As these newer models (ACO/PCMH) become more common, will the

pharmacist become a memberor will others provide the patients’ drug

therapy needs? The answer to this question will impact pharmacy’s

future significantly. I am concerned that too many pharmacists are spending too much energy holding onto the current dispensing practice model instead of investing time and money on establishing a new model.” “What advice would I give to those working on the incorporation of pharmacists into the PCMH and the ACO?”

“It would be to make sure you position pharmacists to take care of the patient.”

Fred Eckel, RPh, MS Professor – UNC School of Pharmacy Exec. Dir. NC Assoc. of Pharmacists

Pharmacy Times – The Patient-Centered Medical Home and ACOs...What Should Be the Pharmacist’s Role?

http://www.pharmacytimes.com/publications/issue/2011/May2011/The-Patient-Centered-Medical -Home-and-ACOsu2026-What-Should-Be-the-Pharmacistu2019s-Role

25

Current State of Pharmacy in U.S.

•  Workforce (Bureau of Labor Statistics): 275,000

pharmacists – 65% Dispensing

•  Use of Robotics

•  Pharmacy Technician Scope of Practice Increasing

•  Dispensing fees decreasing (ex. TX Medicaid)

Statutory Mission of the Quality

Improvement Organization (QIO)

Program

The statute authorizes the QIOs to work to improve services to Medicare Beneficiaries with a focus on:

–  Effectiveness

–  Efficiency

–  Economy

–  Quality

The QIOs will support and partner with CMS to achieve the aims of:

–  Better health

–  Better health for people and communities

–  Affordable care through lowering costs by improvement

Scope of the problem

•  More than 133 million Americans live with chronic illnesses1

•  91% of all prescriptions filled for a chronic condition2

•  1.5 million people are injured each year as a result of medication3

•  Uncoordinated care costs an estimated

$240 Billion/year 4

1. CDC National Center for Chronic Disease Prevention and Health Promotion: Chronic Disease Prevention http://www.cdc.gov/nccdphp/overview.htm 2. American Heart Association. Heart Disease and Stroke Statistics–2008 Update. Dallas, Texas: American Heart Association; 2008.http://www.americanheart.org 3. Institute of Medicine (IOM), To Err Is Human: Building a Safer Health System, Washington, DC: National Academy Press; 2000

Patient Safety and Clinical Pharmacy

Services Collaborative (PSPC)

WHAT: Quality Improvement Collaborative aimed at

improving health outcomes and patient safety for high-risk patients (Adapted IHI Breakthrough Series

Collaborative Model)

Improve the delivery system where there are gaps:

– Enhance care coordination among the providers and partners involved

– Fosters multidisciplinary, team based care approach

– Strengthens patient centered medical home

– Integrate medication management and other

services to minimize harm related to adverse drug events and maximize optimal health outcomes 29

Collaborative Goal

•  Reduce ADE’s in the population of focus (PoF); eligible Medicare beneficiaries having met one or more criteria for the high risk population through teamwork and processes that integrate clinical pharmacy services into patient care.

High Risk Population of Focus

•  Medicare, Medicare Advantage or Duel Eligible

Beneficiary

•  Five (5) or more chronic conditions and/or

•  Take eight (8) or more medications on a monthly

basis and/or

•  Are seeing 2 or more providers and/or

•  Take warfarin on a regular basis (> 3 months) and/

or

•  Take a hypoglycemic medication for diabetes

mellitus and/or

•  Take a short or long-acting antipsychotics

Patient Safety and Clinical Pharmacy

Services Collaborative (PSPC)

•  Mission: The PSPC is committed to saving and

enhancing thousands of lives a year by achieving optimal health outcomes and eliminating adverse drug events through increased clinical pharmacy services for the patients we serve.

•  Formation of care improvement teams with specific

involvement of clinical pharmacy services.

•  The PSPC focuses on high-risk patients (multiple medications, multiple providers)

•  Improve the delivery system gaps:

– Enhance care coordination among the providers

involved

– Integrate management of the medication process

PSPC Opportunity for impact

Key Attributes of the PSPC

•  Patient-Centered (Partnership for Patients)

•  Interdisciplinary Care Team

•  Cross-Organizational with Health Homes at the Center

•  Systematically Addresses Medication

Management, Safety and Risk -- Huge Issues for Ambulatory Care Patients

•  All Teach, All Learn

The transformational goal of the PSPC:

•  Integrate the healthcare delivery system, across multiple healthcare partners, to create a service delivery system for high-risk patients that will produce breakthroughs in the following three areas:

– 1) Improved patient health outcomes

– 2) Improved patient safety

– 3) Increase cost-effective clinical pharmacy services

Starting with the end in mind..

Data Monitoring, Tracking and Reporting

•  In the identified high risk population, track improvement in health status

– Number of adverse drug events (ADE) and potential

ADEs

– Number of ER visits, hospitalizations and/or hospital

readmissions associated with ADE

– Number of potentially inappropriate medications

prescribed.

– Patients on warfarin with INR drawn at least monthly

– Percent of patients with optimal INR

Staying focused…our PSPC aim

“Committed to saving and enhancing thousands of lives a year by achieving optimal health outcomes and eliminating adverse drug events through increase clinical pharmacy services for the patients we serve”

PSPC’s vision:

By 2015–3,000 communities have an integrated delivery system that assure optimal health outcomes and patient safety

Federal Health Care Service

(Indian Health Service, VA, DOD)

Health System Outcomes through Advanced Pharmacy Practice •  Surgeon General Report 2011

This material was prepared by the Kansas Foundation for Medical Care, Inc. (KFMC), the Medicare Quality Improvement Organization for Kansas, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. #10SOW-KS-ADE-13-01

Jane S. Henry, MBA, RPh

Kenneth Mishler, MBA, PharmD, RPh

The Kansas Foundation for Medical Care, Inc. 2947 SW Wanamaker Drive

Topeka, Kansas 66614

kmishler@kfmc.org jhenry@ksqio.sdps.org

1-800-432-0770