The Change in Our Stars: What’s Next for Pharmacy Quality Measures

Julie Kuhle, BS Pharm - VP Measure OperationsWoody Eisenberg MD - Sr. VP Performance Measurement and Strategic Alliances

Julie Kuhle, BS Pharm - VP Measure OperationsWoody Eisenberg MD - Sr. VP Performance Measurement and Strategic Alliances

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Learning Objectives

Describe changes in the Medicare Part D Star Rating Program

Explain the role of pharmacists in improving Star Rating Measures

Identify how the Enhanced MTM Model will differ from the current Part D MTM program

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What is the Pharmacy Quality Alliance?

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Established in 2006 as a public-private partnership through leadership of CMS

Now operates as an independent, nonprofit 501(c)3 corporation

Consensus-based, multi-stakeholder, transparent alliance with over 165 members and over 400 active representatives from these member organizations

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Key Activities of PQA

Develops quality medication performance measures for pharmacy services and drug plans

Demonstration projects using medication quality measures, focused on interventions and improving outcomes

Education for healthcare professionals on quality measures and performance improvement

Connecting pharmacy to healthcare quality initiatives

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Medicare Star Ratings

Annual ratings of Medicare plans that are made available on Medicare Plan Finder and CMS website; began in 2008

Ratings are displayed as 1 to 5 stars

Stars are calculated for each measure, as well as each domain, summary, and overall (applies to MA-PDs) level

Part C stars include 32 measures of quality, and Part D stars include 15 measures of quality

Two-year lag between “year of service” and reporting year for PQA measures in Star Ratings (e.g., 2014 drug claims for 2016 Ratings)

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Part D Stars

Medicare drug plans receive a summary rating on quality as well as four domain, and individual measure, scores (15 individual measures)

Five measures are from PQA (2016):– 2 measures of medication safety or MTM

• High risk medications in the elderly• CMR Completion Rate [new for 2016]

– 3 measures of medication adherence• Non-insulin diabetes medications• Cholesterol medication (statins)• Blood pressure (renin-angiotensin system antagonists)

Due to the higher weighting of clinically-relevant measures, the PQA measures account for 43% of Part D summary ratings for 2016

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Part D Weights

From CMS 2016 Star Ratings Technical Notes7

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Part D Improvement Measure

From CMS 2016 Star Ratings Technical Notes8

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*New* Star Ratings Measure for 2016Medication Therapy Management Program Completion Rate for Comprehensive Medication Reviews (CMRs)

Highlights:- PQA-endorsed measure - Measures the percentage of beneficiaries who met

eligibility criteria for the MTM program and who received a CMR with a written summary in the CMS standardized format.

- 2016 stars are based on 2014 measurement period- This measure is assigned a weight of “1”

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CMR Completion Rate

2016 Star Thresholds

2016 National Averages

MAPD: 30.9 % 2.3 starsPDP: 15.4 % 2.3 stars

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CMR Completion Rate

Stars1 2 3 4 5 Total

# contracts 85 215 99 42 16 458

65.7% 12.6%

For 4/5 star contracts, 10 of 58 were PDPs

MAPD and PDP Combined

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Improvement in Adherence Rates

Average across all contracts for each year

Part DMeasure

MA-PD PDP

2012 2013 2014 2015 2016 2012 2013 2014 2015 2016

PDC -Diabetes 73.0% 73.7% 75 % 77 % 77 % 74.4% 75.8% 77 % 79 % 80 %

PDC –RASA 72.2% 73.9% 76 % 78 % 79 % 74.3% 76.8% 78 % 81 % 82 %

PDC -Cholesterol 68.0% 69.0% 71 % 74 % 75 % 69.1% 71.0% 73 % 77 % 78 %

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PQA Measure Synopsis

Performance continues to improve, on average, across PQA measures for MA-PD and PDP contracts, but the rate of improvement is slowing

Medication adherence 4/5 star thresholds have been relaxed for MA-PDs but made more stringent for PDPs

PDPs continue to have better performance than MA-PDs on medication adherence, but worse performance on HRM

Stars for CMR completion rate are low this year (average: 2.3 stars) with nearly two-thirds of contracts receiving 1 or 2 stars

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Distribution of Overall Star Ratings

MA-PD

From CMS 2016 Star Ratings Fact SheetKey Points

• Number of contracts decreased by 26• Average star rating increased14

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Distribution of Overall Star Ratings

From CMS 2016 Star Ratings Fact SheetKey Points

• Number of contracts decreased by 2• Average star rating decreased

PDP

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High Performer Icon - 2016

From CMS 2016 Star Ratings Fact Sheet

MA-PD

PDP

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Part D Star Synopsis

MA-PD stars rose this year. Average is now 4 stars overall. Combination of relaxed thresholds for 4/5 stars in Part D along

with actual improvement on triple-weighted measures

PDP mean stars decreased from 3.7 stars (2015) to 3.4 stars (2016) PQA measures improved slightly but thresholds jumped

substantially

71% of MA-PD enrollees are in contracts with 4 stars or better; 32% of PDP enrollees are in contracts with 4 stars or better

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High Stakes for Part D Stars

Enrollment Implications

Quality Bonus Payments (MA-PD)

Poor and high performers identified by CMS Low-performer icon High-performer icon

Removal from Medicare for continued poor overall performance (< 3 stars for 3 years in a row)

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How are Health Plans and PBMs responding?

Formularies, clinical strategies, network contracts, marketing/promotions, aligning with star measures and QRS

More telephonic outreach to members and more targeted MTM activities

Contract strategies for pharmacy networks Pay for Performance (P4P) – pharmacies may be

eligible for bonus payment based on star performance

Preferred pharmacy network based partly on star performance of chain or stores

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Part D Display Measures

Display measures are not a part of the Star Ratings, but are used to provide benchmarks and feedback to plans

CMS also monitors display measures to assess plan performance; poor performance can lead to compliance actions by CMS

Part D Display measures (from PQA): Drug-Drug Interactions Excessive doses of oral diabetes medications Statin Use in Persons with Diabetes (New for 2016) HIV antiretroviral medication adherence (only in safety reports)

Display measure (NOT from PQA) Use of atypical antipsychotics in LTC residents

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Just Released: CMS Request for Comments

CMS released Request for Comments on proposed changes to the 2017 star ratingsPropose moving HRM measure from Stars to display in

2017 (2015 data)

Propose Statin Use in Persons with Diabetes as a display measure for 2017 and included in Star Ratings in 2018 (2016 data)

Propose reporting Opioid Overutilization measures on display page for 2018 (2016 data)

Propose reporting Antipsychotic Use in Dementia on display page for 2018 (2016 data)

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Statin Use in Persons with Diabetes Statin Use in Persons with Diabetes (age 40-75 years)

- PQA developed and endorsed in 2014- Based on ACC/AHA guidelines released in 2013- CMS started reporting rates to Part D plans in 2015- Denominator: Any person age 40-75 years with two or more prescription fills for any hypoglycemic medication

- Numerator: One fill of any statin medication in the measurement year

Pharmacist Opportunity

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Opioid Utilization Measures

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Opioid Utilization Measures –Reported at the health plan level (# per 1000 individuals)Excludes patients with cancer

Three rates:• High dose ( >120mg morphine equivalent dose) for 90 consecutive days or longer identifies the proportion of individuals that are receiving prescriptions for opioids at a high dose that could be inappropriate or could contribute to an adverse event.• Multiple prescribers and pharmacies (4 AND 4) identifies the proportion of individuals that are receiving opioid prescriptions from four (4) or more prescribers AND four (4) or more pharmacies, which may indicate uncoordinated care and/or doctor/pharmacy shopping.• High dose and multiple prescribers and pharmaciesThe measure may indicate misuse, abuse, or inappropriate and/or fragmented care.

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Antipsychotic Use in Persons with DementiaAntipsychotics should not be used in persons with dementia unless there are specific indications Denominator: Any person age 65 years with a diagnosis of dementia or two prescription claims for cholinesterase inhibitors and/or NMDA receptor antagonistsNumerator: One prescription fill AND greater than 30 days supply for any antipsychotic medications (exclude patients with schizophrenia, bipolar disorder, Huntington’s disease or Tourette’s)

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YOUR LOGO

Enhanced MTM Opportunities for Measurement

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CMS Part D Enhanced MTMModel for Stand-alone PDPsCMS will conduct the model test in: Virginia, Florida, Louisiana, Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota, Wyoming, and Arizona

Model Components

Regulatory flexibility for plans to identify those members most in need of and able to benefit from additional and more varied types of services tailored to the needs of the individual beneficiary

Risk stratification with respect to medication-related risk and offer different levels and types of MTM services

Supplemental benefits, items and services to the clinically-targeted enrollee population

MTM encounter data collection effort leveraging existing MTM-specific code sets for prescription drug data interoperability.

Prospective and performance-based payments to PDPs

Engage pharmacies more extensively in the MTM process PQA26

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MTM Services Delivered Through Pharmacies Sponsors and subcontracted MTM vendors may:

Increase engagement of pharmacies in the MTM process, and may further subcontract to conduct the MTM process- Engage pharmacies as subcontracted suppliers of assistive devices and appropriate-medication-use-related items or services including home delivery, prescription synchronization, or compliance packaging

- Place greater reliance on and compensation for clinical pharmacist screening of potential beneficiaries for MTM services, screening of medication regimens for drug therapy problems

- Allow prescribers to identify and refer at-risk individuals for MTM services, and order medication histories, pharmacist consultations and CMRs in advance of appointments.

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Enhanced MTM Monitoring and Quality MeasurementCMS will collect a standard minimum set of encounter data elements to compile performance indicators through its monitoring and evaluation contractors

Key principles in developing broad quality indicators (applied to all models) will include (1) clinical significance, and (2) a focus on process measures with a clear link to improved outcomes.

CMS also expects each plan sponsor to identify its own metrics for its own internal protocols and learning systems

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CMS Proposed Metrics

Percentage of patients who had medication reconciliation after a transition of care

Percentage of patients who had MTM services post discharge and were readmitted to hospital within 30 days

Prescriptions e -prescribed and not obtained by patient in following 30 days

Percentage of clinically significant drug events resolved

Proportion of targeted beneficiaries where PDP shares medication history to EHR

Cost per clinically significant intervention (versus the total prospective payment)

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Summary

The number of Part D contracts being rated has decreased over past several years; more consolidation expected in future

Quality continues to improve on PQA measures

Nearly two-thirds of contracts are performing below 3 stars on CMR completion rate

A growing number of prescription drug plans are implementing performance-based incentives for network pharmacies

More changes are proposed for 2018 Star Rating and display measures

Enhanced MTM Model provides substantial opportunity for pharmacists to work collaboratively with PDPs

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Contact info:Woody Eisenbergweisenberg@PQAalliance.org

Julie Kuhlejkuhle@PQAalliance.org

Office: 703-690-1987

www.PQAalliance.org

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Questions?