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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
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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
• Transformational Change in healthcare
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Better Outcomes
Status Quo Drift
Time Current success with Population of Focus
Our Aim: SPREAD
Improvement Cycles
Where do we want to go?
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Transformational Change • Widespread changes • Change in:
– Institutional culture – Work processes – Clinical care – Use of information technology
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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
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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) » Crossing the Quality Chasm
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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
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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.”
– Crossing the Quality Chasm, (p. 39)
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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)
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Current Public Reporting Activities
• Hospital Quality Data Public Reporting • Physician Quality Data Reporting (PQRI: Physician Quality Reporting Initiative) • Transparency Initiatives- Better Quality
Information for Medicare Beneficiaries (BQI)
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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
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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 • 30 day mortality across continuum
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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)
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Public Reporting: Physician • Legislative: Tax Relief and Health Care Act of
2006-signed 12/06 • PQRI (Physician Quality Reporting Initiative)
– 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 – 216 National Quality Forum endorsed measures
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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 development of NEW PAYMENT MODELS.
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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)
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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, • DPP-IV
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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
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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.
• Beers’ List Medication
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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.
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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.
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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”
1oig.hhs.gov/oei/reports/oei-06-09-00090.pdf
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Drug Therapy Problems
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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
Pharmacists utilized the Assurance IT electronic therapeutic record system and training through Medication Management System, Inc.- www.medsmanagement.com
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The Pharmacist’s Role “As these newer models (ACO/PCMH) become more common, will the pharmacist become a member or 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
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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) …...So, a question to ponder is:
What will the pharmacist’s role be going forward?
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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 4. Owens, MK “The Health Care imperative: Lowering Costs and Improving Outcomes”, The Institute of Medicine, 2010
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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
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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.
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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.
• Started in 2008, now enrolling PSPC 5.0.
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• 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 • Align with national efforts – Partnership for
Patients
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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 – Diabetics with HgA1c less than 9.0
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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)
• Improving Patient and Health System Outcomes through Advanced Pharmacy Practice
• Surgeon General Report 2011
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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
1-800-432-0770
For More Information Contact
