ORLANDO, Fla. — The Centers for Medicare and Medicaid Services’ Five-Star Quality Rating System already is impacting how pharmacies think about their patients and their medication adherence programs, noted Samuel Stolpe, director of quality strategies for the Pharmacy Quality Alliance, during a Lunch and Learn session Monday at McKesson ideaShare called “When the Stars Align: Prepare Your Pharmacy For Success.” According to Stolpe, it’s going to become a bigger influencer going forward, especially as the industry develops a pharmacy Star metric that will have a public element and certain health plans experiment with pay-for-performance models to incentivize higher Star ratings among pharmacies.
PQA is currently in the process of working on Pharmacy Quality Ratings, thanks to a grant from the Community Pharmacy Foundation. “Right now, hospitals, physicians, nursing home facilities, they’re all getting rated,” he said. But pharmacies aren’t. “We’re very focused on making sure that this is going to be fair. Right now, it doesn’t have a public facing element. We’re figuring out ways of doing it in a beta test.”
As for pay-for-performance models, the Inland Empire Health Plan (IEHP), serving 836,000 residents of Riverside and San Bernardino counties in California, now offers incentives to all qualified IEHP practitioners for providing preventive, diagnostic and treatment services to IEHP members. “They have a measure set, of which the five PQA measures are embedded, as well as a generics substitution rate measure,” Stolpe said. “If a pharmacy performs at a three Star level or higher, they will get a bonus,” he said. Those pharmacies performing at a five Star level may be getting a very substantial bonus depending upon the number of beneficiaries they’re serving.
Today, the Star rating system influences the formation of pharmacy networks and, to an extent, which Medicare Part D plans a participant will choose. Tomorrow, the Star Rating System can empower pharmacies to approach pharmacy benefit managers and health plans with a defined “here’s what we can do for you.” “It’s one thing for a health plan to approach you and say here’s a list of reasons why we don’t think you’re performing well,” Stolpe said. It’s a totally different story if you show up to them with your own report card and say, ‘Here are the things that matter to you and here’s how I’m knocking it out of the park for you, maybe we should talk about that,’” he said.
"There’s some real low-hanging fruit for health plans that need your help.”“There’s some real low-hanging fruit for health plans that need your help,” Stolpe added. Approximately 38% of Medicare Part D contracts for 2014 are at four Stars or higher. That means that 62% aren’t at that level yet. “Those are areas where we can really go out and make a difference. Identifying those plans that are struggling and helping them to perform better.”
The Pharmacy Quality Alliance, with more than 155 members, is focused on improving the quality of medication management and use across healthcare settings with the goal of improving patients’ health. “We’re a measurements developer, and we have a very specific niche,” Stolpe said. “We’re focused on safe and appropriate medication management.”
PQA measurements account for 50% of Star ratings, Stolpe said. “These measures are very highly susceptible to pharmacist intervention. Health plans and PBMs are getting better at figuring out how to leverage their pharmacy networks to help improve their performance on these Star ratings.”
The Star ratings are slated for change in 2016, Stolpe noted, to include medication therapy management measures, and the changes are something that pharmacies should be looking to influence today. “There’s a two-year lag on data that informs the measurements,” he explained. “So for 2014 Stars, we’re using 2012 data.”