AMCP: Improving Quality Measures Through Pharmacy Pay-for-Performance Programs

As health care shifts to value-driven payment, health plans are not immune. Annual Medicare Star Ratings measure performance of Medicare Advantage and pre­scription drug plans, and the re­sults—posted on the Medicare Plan Finder and Centers for Medicare & Medicaid Services websites—can impact enrollment as well as qual­ity bonus payments. In fact, poor overall performance of less than 3 stars on the 5-star scale for 3 years in a row results in a low-performing flag next to the plan on the Medicare Plan Finder tool and a subsequent inability for a consumer to enroll in it using the Plan Finder website.

To improve performance on quality measures, health plans are reaching out and incen­tivizing partners, including community pharmacy networks. David Baker, PharmD, vice president of managed care, Pharmacy Quality Solutions, Inc., and Bhavesh Modi, RPh, assistant vice president, Health­first, spoke about pharmacy pay-for-performance programs at AMCP Nexus.

SHARED FOCUS: PERFORMANCE

Pharmacies, along with health plan members and physicians, are health plans’ partners in improving quality care.

Health plans/pharmacy benefit managers that are successful at holding all partners accountable will perform the best. To engage pharmacies in quality improvement efforts, health plans can share perfor­mance data with them. Performance reports allow pharmacies to get a handle on and prioritize improve­ment efforts. Together, the pharmacy and health plan can track outcomes of quality interventions such as medication synchronization or appointment-based models, and get a handle on how they are doing.

Performance data is essential for pay-for-per­formance programs. For such programs to work, open communication between the health plan and participating pharmacies is crucial, as is early agreement on metrics, the presenters explained. Consistent exposure to metrics and performance, too, are key for maintenance.

PAY-FOR-PERFORMANCE CONSIDERATIONS

In developing and implementing a pharmacy pay-for-performance program, a health plan will need to consider many components. First is the scope of the program. Will the venture be a pilot project or will it be a broad network program? Other considerations that will need to be decided include overall goals and measures to support performance, how those goals and measures will be weighed to gauge success, and which pharmacies to include in the program (such as chain and/or independent pharmacies).

Health plans will also need to figure how often to assess performance: every 3, 6, or 12 months, or will there be a year-to-date analysis?

In setting performance thresholds, health plans should aim to drive both performance and improvement, according to the presenters. Performance threshold designs can include multiple thresholds or focus on a single threshold.

 Improvement threshold designs can factor in improvement from baseline to recognize how pharmacies progress over time.—Jolynn Tumolo