The CMS Five-Star Quality Rating System: What It Means to You and Your Pharmacy.

The CMS Five-Star Quality Rating System:What It Means to You and Your Pharmacy

2

Today’s Speaker

Rick McKaigDirector, Managed Care

AmerisourceBergen Drug Corporation

3

Learning Objectives

At the end of this program, participants should be able to:

• Describe the Medicare Star Ratings Program

• Explain the 5 Medication Use Measures

• Understand the role of EQuIPP™

• Identify effective means for community pharmacies to improve their individual performance on the medication use measures

• Acknowledge the short and long-term impacts of the Medicare Star Ratings Program on Community Pharmacy

4

Disclaimers

CMS

• Assigns Star Ratings to:

– Part C Health plans

– Part D Stand-alone plans

• CMS does not assign Star Ratings to pharmacies

• But by proxy, others do

5

Pop “Star” Quiz

$317 Billion 5 2006 74% P4P

6

Pop “Star” Quiz

$317 Billion 5 2006 74% P4P

A. CMS’ annual expenditures on health care for seniors

B. Estimate of economic losses associated with non-adherence

C. Annual economic spend on pharmaceutical products

D. Projected value of estimated savings as a result of the ACA

7

Pop “Star” Quiz

$317 Billion 5 2006 74% P4P

A. The enhanced dispensing fee for 5-Star pharmacies

B. The number of years before the 5-Star Rating system applies to pharmacy

C. The number of stars in the CMS 5-Star Rating system

D. The number of current enrollees in Health Exchanges

8

Pop “Star” Quiz

$317 Billion 5 2006 74% P4P

A. The year the first Medicare Part-D prescriptions were filled

B. The year that pharmacy reimbursements first came under pressure

C. The year Medicare Part-D was enacted into law

D. The year Star Ratings started to be measured

9

Pop “Star” Quiz

$317 Billion 5 2006 74% P4P

A. The decline in pharmacy reimbursements since 2006

B. The bonus percentage for 5-Star health plans

C. The percent of Medicare beneficiaries enrolled in either a PDP or MAPD plan

D. The 2014 inflationary growth rate of pharmaceuticals

10

Pop “Star” Quiz

$317 Billion 5 2006 74% P4P

A. Public Private Partnership for Pharmacy founded by CMS

B. An acronym for pay for performance

C. Independent pharmacy group that advocates for pharmacy payment fairness

D. The group “People For Pharmacy”

11

Bonus Question

Who was president when the surgeon general of the US coined the oft-repeated phrase “Medications do not work in patients who do not take them”

A. Jimmy Carter

B. Ronald Reagan

C. George H. Bush

D. Bill Clinton

12

A basic understanding of Medicare will help Star Ratings make sense

13

The ABCD’s of Medicare

CMS 2014 Statistics

Part-ABasic Hospital Insurance (1965)

Part-BBasic Medical Insurance (1965)

Part-CMedicare Advantage (1997)

Option for SeniorsReplaces Part-A and Part-B

Part-D (MA-PD)Insurance for Drugs (2003)

Part-D (PDP)Insurance for Drugs (2003)

41% of beneficiaries

2010 Affordable Care Act MA Bonuses for Star Performance

59% of beneficiaries

14

Independents should be happy that Medicare has emerged as a major payer

15

Growing Business

• 10,000 patients age in daily

• Average use is 2.5 Rx/mo

• Retiree coverage being replaced by Medicare Plans

• 35,000 Low Income Subsidy (LIS) patients under age 65 entering monthly

16

Part-D Is Good for Independents

• Plan - patients pick it!

• Pharmacy—patients pick it!

• No employer or labor union in the middle

• Any willing provider regulations

Preferred Networks are a concern

• Chains accept lower reimbursement to drive foot traffic

• Today’s preferred networks are all about cost

• What if tomorrow’s networks could be based on quality, not cost?

17

Pharmacy performance will determine P4P

2008CMS begins

collecting data

2009CMS starts reporting

Health Plan Star Ratings

Oct 2013 2014Health plansturn focus

to Pharmacy Networks

2015P4P

2016“Quality

Networks”

Your Pharmacy Can Be Ahead of the Game

18

Independents Are Positioned Well

NCPA study on patient’s level of connection with the pharmacist

Independent Pharmacists Chain Pharmacy Mail Order

89%

67%

36%

19

You should care because Star Ratings will impact reimbursements

20

Adherence Is a National Problem

Source: IMS

For every

100prescriptions

written

15-20are refilled as

prescribed

25-30are taken properly

46-66come out of the

pharmacy

50-70Goes into apharmacy

“Drugs don’t work in patients who don’t take them.” — Former Surgeon General C. Everett Koop

21

Stars Are Consumer Facing!

22

Here’s What CMS Publishes

Medicare Star Ratings

Excellent

Above Average

Average

Below Average

Poor

23

Reimbursements May Look Like This

Medicare Part D Star Ratings

Excellent

Above Average

Average

Below Average

Poor

Plenty of details not known yet, but expect that 4-Star pharmacies will be paid more than 3-Star pharmacies

24

The five medication use measures comprise 48.5% of a PDP’s overall score

25

1. Use of High Risk Medications in the Elderly

The percent of your Medicare patients 65+ receiving two or more prescription fills for a high-risk medicine

Cholesterol PDC

Blood Pressure PDC

Oral Diabetes PDC

Diabetes Treatment

High Risk Meds 3%

87%

82%

81%

76%

26

2. Appropriate Treatment of Diabetes

The percent of your Medicare patients with meds for diabetes and hypertension also receiving an ACE inhibitor, ARB, or direct renin inhibitor med

Cholesterol PDC

Blood Pressure PDC

Oral Diabetes PDC

Diabetes Treatment

High Risk Meds 3%

87%

82%

81%

76%

27

3. Adherence – Oral Diabetes Meds

The percent of your Medicare patients adherent with their oral diabetes meds

Cholesterol PDC

Blood Pressure PDC

Oral Diabetes PDC

Diabetes Treatment

High Risk Meds 3%

87%

82%

81%

76%

28

4. Adherence – Blood Pressure Meds

The percent of your Medicare patients adherent with their blood pressure meds

Cholesterol PDC

Blood Pressure PDC

Oral Diabetes PDC

Diabetes Treatment

High Risk Meds 3%

87%

82%

81%

76%

29

5. Adherence – Cholesterol Meds

The percent of your Medicare patients adherent with theircholesterol meds

Cholesterol PDC

Blood Pressure PDC

Oral Diabetes PDC

Diabetes Treatment

High Risk Meds 3%

87%

82%

81%

76%

30

Thresholds Are Tightly Grouped

Reaching even the 2-Star Level will require the attentiveness of your pharmacists and technicians

Cholesterol PDC

Blood Pressure PDC

Oral Diabetes PDC

Diabetes Treatment

High Risk Meds 3%

87%

82%

81%

76%

11%

82%

73%

73%

70%

31

A Typical Network of Independent Pharmacies

Source: EQuIPP™ May-2013 thru Oct-2013, based on 2014 thresholdsPDC is Proportion of Days Covered

Cholesterol PDC

Blood Pressure PDC

Diabetes PDC

Diabetes Treatment

High Risk Meds 61%

36%

77%

85%

88%

Stores that have reached 3, 4 or 5 Stars

32

How you can find your Star Ratings

33

EQuIPP™ – A New Industry Tool

Note: EQuIPP™ is a product offered by Pharmacy Quality Systems (PQS) which is a joint venture between Pharmacy Quality Alliance (PQA) a non-profit entity and CE/City, a technology vendor.

CMS

PDP Healthplan

PBM MTM MTM PBM

Rx Rx Rx Rx Rx Rx

Neutral Entity

• Plans provide claims

• Currently at 26% of Medicare beneficiaries

• Pharmacy Web App

34

You have visibility to because the plans subscribe to EQuIPP

100% of Medicare Patients Measured

Health Plans

• Humana

• Coventry

• Wellcare

• HealthSpring / CIGNA

• Inland Empire Health Plan (CA)

• BCBS – Tennessee

• BCBS – North Carolina

• UPMC Health Plan (PA)

• Gateway Health Plan (PA)

26%

35

Supplemental Reports to Support Star

Reminder: This report contains personal health information that falls within the definitionof “Protected Health Information” or “PHI” under federal law (HIPAA).

Star Ratings: Reducing High Risk Medication Use

Fill Date Rx Age Fill Days NDC Drug BIN Plan

3/21/14 123456 71 0 15 000378-5310-01 Zolpidem Tartrate 10 mg 156231 Silverscript

3/22/14 235689 68 1 30 00378-6410-01 Doxepin 100 mg 458921 Humana

3/23/14 568978 76 3 20 00185-0648-10 Diphenhydramine 25 mg 789456 Caremore

3/23/14 987654 81 2 30 00603-5167-32 Phenobarbital 64.8 mg 614575 Silverscript

Star Measurement This Report

Includes Medicare Part D fills from last week (Sunday through Saturday) for patients 65 or older who received at least one medication from the EQuIPP® list of High Risk Medications.

This measure calculates the percentage of Medicare Part D beneficiaries 65 years or older who received two or moreprescription fills for the same HRM drug with a high risk of side effects in the elderly.

36

The Value of an EQuIPP™ License

• Health Plan Detail

• Performance Over Time

• State Peer Benchmarks

• Multi-Store Owner Benefits

• Improvement Strategies

• CE Opportunities

• Frequently Asked Questions

37

How can a pharmacy perform well on Star Ratings?

38

Rx inflow controls workflow Patient scheduling controls workflow

Patient initiates activities Pharmacy schedules activities

MTM performance crucialMTM’s treated as optional

Workflow Must Change

Tomorrow’s Successful PharmacyToday’s Successful Pharmacy

Personalized Service

Speedy Rx Service

39

MTMs Have New Importance

• Independent pharmacy lags behind the chains

• Not just “brown bag” reviews

• Multiple “TIPs” for a single patient can add up

• TIPs, TMRs, Gaps

– Require less time

– May already be doing

Pharmacies must be enrolled with both Mirixa and Outcomes

40

Healthplan reviews patient records and

identifies opportunitiesfor interventions

MTM & TIP Opportunities

Not every MTM activity is a Complete Medication Review

Improves the healthof patients

United Healthcare (using OutcomesMTM) and Caremark (using Mirixa) have based their initial Star improvement strategies on assigning activities to the patient’s pharmacy.

Pharmacists reviews opportunities and

counsels patient and records activity

MTM = Medication Therapy Management

CMR = Complete Medication Review

TIP = Targeted Intervention Program

41

NCPA Simplify My Meds

Med SynchProactively adjust timing of multiple prescriptions

Operational PracticeFrequently call patients to review status

Study from NCPA sheds new light on med synchronization programs. January 17, 2014. Average enrolled patient was taking 5.9 synchronized medications.

NCPA Tool KitPatient brochures, enrollment forms, physician faxes, training, and more

NCPDP Codes to Synchronize Rx’sSCC 47, SCC 48

Control Group Med-Synch Patients

Days of therapy

Patients adherent

Additional fillspatient/year

337

56% 90%

+20

234

42

Commercial Adherence Programs

• Variety of approaches

– Turnkey programs

– Consulting

– Software

– Packaging

• May include training of your staff

• Most include patient materials

– Patient letters

– Point of dispense messaging

Complementary with synchronization of patient’s prescriptions

43

Leverage Your Dispensing System

• Enroll patients in Auto Fills

• Use Refill Reminders (email, text, outbound calling)

• Make refills easy to order (IVR, web, mobile)

• Synchronization (reporting, calendars, drug/patient id)

• MTM Interfaces

• Compliance packaging interfaces

Complementary with synchronization of patient’s prescriptions

44

Achieving strong ratings will require changes in your practice,

here are a couple of success stories…

45

Success Story: L&S Pharmacy Experience

• 300 patients enrolled (10% of patients)

• 8,700 more fills for the 300 patients

• 29 more fills per patient per year

• $113,000 increase in annual profit with existing patients

MedHere Today Appointment model

46

Success Story

Study conducted by Virginia Commonwealth School of Pharmacy

Medication Control Group Study GroupSTAR

Equivalent

ACEIs/ARBs (Blood Pressure) 40.8% 79.5%

Beta Blockers (Blood Pressure) 38.3% 71.8%

CCBs (Blood Pressure) 40.3% 68.9%

Diuretics (Blood Pressure) 37.0% 66.1%

Metformin (Diabetes) 40.2% 76.6%

Statins (Cholesterol) 37.4% 76.2%

Study Measured Proportion of Patients Considered Adherent

Med Synch Based Appointment Model

• Small chain based in Minnesota

• Synchronize all of a patient’s chronic fill meds

• Patients are assigned a day of the month to pick up meds

47

YOU CAN DO IT TOO AND WE’RE HERE TO HELP YOU!

Assessment Questions

1. The CMS Five-Star Quality Rating System are intended to help beneficiaries compare MAPD plans and prescription drug plans (PDP) on quality and service. True or False?

True

48

Assessment Questions

2. Which is not one of the 5 key Star measures for pharmacy?

A. Members age 65 and older on medications with high risk side effects

B. Members with diabetes using recommended blood pressure medications

C. Taking insulin as directed

D. Taking blood pressure medication as directed

E. Taking cholesterol medication as directed

C. Taking insulin as directed

49

Assessment Questions

3. A patient may have their high risk medication filled up to three times before it counts against the pharmacy. True or False?

False

50

Assessment Questions

4. EQUiPP currently measures what percentage of Medicare patients?

A. 100%

B. 54%

C. 26%

D. 72%

C. 26%

51

Assessment Questions

5. Pharmacies must enroll in either Mirixa or Outcomes to capture all of their available MTM cases. True or False?

False!!!!

52

53

Questions