Presentation - Alabama Pharmacy Association

6/27/2016
Healthcare Trends and Changes –
Creating Connectedness and Leveraging Medication
Synchronization to Influence Patient Behavior
and Drive Adherence
Alabama Pharmacy Association Annual Convention
June 13, 2016
OBJECTIVES
List current healthcare trends that are influencing change within pharmacy practice.
Evaluate value-based payment models and quality measures and how they impact
community pharmacy practice
Assess the power of creating a relationship between the pharmacist and patient
through timely, relevant communications
Understand how appointment based medication synchronization is changing not only
patient behavior, but the way community pharmacies are practicing
Examine evidence that demonstrates how community pharmacy is impacting adherence
and Star ratings through the implementation of these solutions
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HEALTHCARE TREND #1
FEE FOR SERVICE REIMBURSEMENTS
Fee-for-service (FFS)
reimbursements are subject to
downward pressure from the public
payer and the continuation of
narrowing networks
Troy Trygstad, Making Your Case: Integrating Pharmacists Into New Care Delivery Models, APhA 2016 presentation
MCKINSLEY & CO
ANALYSIS
BROAD NETWORKS
NARROW NETWORKS
ULTRA-NARROW
NETWORKS
http://medicaleconomics.modernmedicine.com/medical‐economics/content/tags/aca/narrow‐networks‐obamacares‐broken‐promise‐and‐how‐doctors‐and‐pat?page=full
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NARROW NETWORK
BATTLEGROUND STATES
MAINE
MISSISSIPPI
WASHINGTON
PENNSYLVANIA
NEW HAMPSHIRE
SOUTH DAKOTA
CONNETICUT
http://medicaleconomics.modernmedicine.com/medical‐economics/content/tags/aca/narrow‐networks‐obamacares‐broken‐promise‐and‐how‐doctors‐and‐pat?page=full
HEALTHCARE TREND #2
PROVIDERS AND PAYERS
Providers are becoming payers, but payers are losing their appetite
to become providers, therefore everyone consolidates.
Troy Trygstad, Making Your Case: Integrating Pharmacists Into New Care Delivery Models, APhA 2016 presentation
• Health systems – 1 IN 5 will become payers by 2018:
• 34% of health systems own health plans
• 21% plan on launching a health insurance plan by 2018
• Tuffs – Minuteman Health
• Piedmont Healthcare and WellStar Health System (Atlanta) - MA
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Consolidation
PAYERS BY 2018
Examples:
• Humana – Medicare Advantage – owned 22 medical centers at the end of
2014 (Florida) staff by PCP and some specialists of which 10,600 PCP
“ownership” relationships in 2014 compared to 8,400 in 2013
• UnitedHealth Optum unit that handles medical operations has direct
relationship with 17,000 physicians (owns or helps with contracting)
• Anthem purchased CareMore – physician based medical group
• Optum absorbed Monarch HealthCare – large physician practice in
California
• Highmark (BSBC) bought West Penn Allegheny Health System in Pittsburg,
creating a hospital, physician and health plan network
HEALTHCARE TREND #3
CONSUMERISM
Consumerism will play an increasing role in how we are paid for
pharmacy services because health savings accounts have
significantly grown.
The consumer will become more in control of how they spend their
own dollars on health care.




As a result, control shifts from the health plan to the consumer.
Consumer choice will be driven by high quality, low cost.
35.3% under age 65 enrolled in HDHP (employer based), half HSA
53.7% under age 65 in HDHP (exchanges)
Troy Trygstad, Making Your Case: Integrating Pharmacists Into New Care Delivery Models, APhA 2016 presentation
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HEALTHCARE TREND #4
Pharma entering into the risk, reward, and outcomes
• ACOs will increasingly look for risk sharing to become part of standard
contracting agreements with manufacturers in the near future.
• According to input from 100 accountable care organizations, “8% of Medicare
ACOs and 4% of Commercial ACOs already have active risk-sharing programs
with manufacturers. The risk-sharing models vary across ACOs, but the message
is clear in that the organizations expect manufacturers to have a stake in patient
outcomes.” (Kelly, 2014)
• Health care payers and pharmaceutical manufacturers agree to link coverage
and reimbursement levels to a drug’s effectiveness and/or how frequently it is
utilized.
Troy Trygstad, Making Your Case: Integrating Pharmacists Into New Care Delivery Models, APhA 2016 presentation
HEALTHCARE TREND #5
Increasing Pressure on PBMs to Evolve beyond Drug Cost
Part D Enhanced Medication Therapy Management (“MTM”) Model
demonstration
o
o
o
o
Medication risk based – risk stratify patients
Expansion of services
MTM encounter data – MTM-specific code set – ONC
Prospective funding for enhanced benefits/services that could include
pharmacy or beneficiary incentives - PMPM
Bonus performance payment (via increased premium subsidy)
o Achieve 2% reduction in expected FFS expenditures
o Request Part A & B claims and ACO alignment
o $2 PM increase in gov subsidy to plan premium – lower premium
Troy Trygstad, Making Your Case: Integrating Pharmacists Into New Care Delivery Models, APhA 2016 presentation
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6/27/2016
HEALTHCARE TREND #6
NEW PAYMENT MODELS
New payment models are growing
rapidly, both in diversity and volume
Troy Trygstad, Making Your Case: Integrating Pharmacists Into New Care Delivery Models, APhA 2016 presentation
Health Reform is here…
“First, is that 30% of all Medicare provider payments will move to alternative payment models in 2016 that are tied to how well providers care for their patients and will get to 50% by 2018.”
“The second goal would be to tie all Medicare fee‐for‐service (FFS) payments to quality and value, achieving at least 85% in 2016 and 90% in 2018.” Sylvia Mathews Burwell, HHS Secretary 6
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ALTERNATE PAYMENT MODELS
Target percentage of Medicare FFS payments linked to quality and alternative payment models in 2016 and 2018
All Medicare FFS (categories 1‐4)
FFS linked to quality
Alternative payment models (categories 3,4)
100%
100%
90%
85%
50%
30%
2016
2018
ALTERNATE PAYMENT MODELS
Examples:
1. Accountable Care Organizations
‐ MSSP, Next Gen
2. Patient Centered Medical Home
3. Bundled Payments
4. Integrated care demonstrations for Medicaid/Medicare enrollees (i.e. MLS regs)
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QUALITY FOCUS
with Medicare Access & CHIP Reauthorization Act - MACRA (2015)
Paying physicians – the “old” way
- Medicare Physician Fee Schedule (MPFS)
- Sustainable growth rate (SGR) formula
- Ensure that Medicare increases did no exceed growth in GDP
‐Resulted in frequent “doc fixes” by Congress
New method: Merit-based Incentive Payment (MIPS)
- Consolidates the current Medicare FFS incentive
programs into one system under MACRA
- Adds a new clinical practice improvement measure
Reference: Sam Stolpe, PharmD, Quality Metrics and Value‐based Payments, NASPA 2016
MERIT-BASED (MIPS)
INCENTIVE PAYMENTS
Physician given a publicity report score of 1-100
- Quality measures (PQRS)
- Efficiency measures/Resource use (Value-based Modifier)
- Meaningful use of electronic health rescores (MU)
- Clinical practice improvement activities
Physician performance rewarded or penalized
- Thresholds established based on mean performance composites
- Providers scoring below threshold subject to payment reductions
- -4% in 2018, -5% in 2020, -7% in 2021, -9% in 2022
- Providers scoring above threshold receive bonuses (funded by penalties)
- +12% in 2019, +15% in 2020, +21% in 2021, +27% in 2022
- $500M bonus pool for “best of best”
Providers in alternative models may opt out
Reference: Sam Stolpe, PharmD, Quality Metrics and Value‐based Payments, NASPA 2016
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MEDICARE INCENTIVES
QUALITY BONUS PAYMENTS
The Star Rating now affects payment to Medicare Advantage plans in which
higher-rated plans get higher payment
Quality Bonus Payments (QBPs) are being awarded on a sliding scale
according to the Star Ratings
2016 payments will be based on 2015 ratings which are based on 2013 and
2014 data
QBP opportunity for many large MA-PDs exceed $100 million
Sam Stolpe, PharmD, Quality Metrics and Value‐based Payments,, NASPA 2016
STAR RATINGS
MEDICARE C & D
Annual ratings of Medicare plans that are made available on
Medicare Plan Finder and CMS website
• Ratings are displayed as 1 to 5 Stars
• Stars are calculated for each measure, as well as each domain, summary and overall
• Part C Stars include 32 measures of quality and Part D include 15 measures of quality
Two –year lag between “year of service” and reporting year for
Star ratings
• 2014 drug claims are used for 2016 Star Ratings
• 2016 Star Ratings were released in October 2015 to inform beneficiaries who were
enrolling for 2016
Sam Stolpe, PharmD, Quality Metrics and Value‐based Payments,, NASPA 2016
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MEDICARE MA-PD AND PDPS
HIGH STAKES FOR PART C/D STARS
Enrollment Implications
•
•
•
•
Quality Bonus Payment (MA-PD)
Poor performers identified by CMS
Low-performing icon
One-star difference – new beneficiaries: 10%, changing beneficiaries: 5%
Worst Performers for Part D
• Several Medicare contracts received a “low performer icon” which means that they
have consistently been below 3 stars
• Over 100 contracts had 2 Star or lower on all PQA adherence measures
Removal from Medicare for continued poor overall performance (<3 Stars for
3 years in a row)
Sam Stolpe, PharmD, Quality Metrics and Value‐based Payments,, NASPA 2016
STAR RATINGS
PART C
Medicare drug plans receive an overall rating on quality assurance domain
scores (32 measures total in 2016)
Pharmacists can affect Part C measures in several ways:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
C03 Annual Flu Vaccine
C05 Improving or Maintaining Mental Health C12 Osteoporosis Management in Women who had a C17 Rheumatoid Arthritis Management C14 Diabetes Care , C15 Diabetes Care x3
C16 Controlling Blood Pressure Chronic Management Services x3
C04 Improving or Maintaining Physical Health, C06 Monitoring Physical Activity, C07 Adult BMI Assessment – provide BMI/Biometric screenings
C11 Care for Older Adults – Pain Assessment Pain management and opioid use
C09 Care for Older Adults – Medication Review, C10 Care for Older Adults – Functional Status Assessment C18 Reducing the Risk of C19 Plan All‐
Cause Readmissions Transitional Care Services
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STAR RATINGS
PART D
Medicare drug plans receive an overall rating on quality assurance domain
scores (15 measures total in 2016)
Domain on safety contains 5 measures:
1. D11 High Risk Medication X3
2. D12 Medication Adherence for Diabetes X3
3. D13 Medication Adherence for Hypertension (RAS antagonists) X3
4. D14 Medication Adherence for Cholesterol (Statins) X3
5. D15 MTM Program Completion Rate for CMR X1
*Part D Display Measure ‐ Statin Use in Person with Diabetes Due to the higher weighting of clinically relevant measures, the PQA
medications use measures account for 43% of Part D Star ratings for 2016
National Report Card on Medication Adherence
identified the six key predictors of medication adherence
01
02
03
04
05
06
Patients’ personal connection with a pharmacist or pharmacy staff
How easy it is for them to afford their medications
The level of continuity they have in their health care
How important patients feel it is to take their medication exactly as prescribed
How well informed they feel about their health
The extent to which their medication causes unpleasant side effects
NCPA. (2013). Medication Adherence in America A National Report Card . Washington, D.C.: Langer Research Associates.
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NON-ADHERENCE
HOW DO WE ADDRESS THESE REASONS
DRIVE PATIENT RELATIONSHIP
HELP THEM REMEMBER
NCPA. (2013). Medication Adherence in America A National Report Card . Washington, D.C.: Langer Research Associates.
PHARMACY
CONNECTEDNESS
Patients who obtain their medication by mail are significantly less likely
than others to feel that someone at their prescription provider knows
them pretty well
Connectedness peaks among those who use an independent
neighborhood pharmacy
36%
MAIL
ORDER
67%
CHAIN
PHARM
89%
NEIGHBOR
PHARM
NCPA. (2013). Medication Adherence in America A National Report Card . Washington, D.C.: Langer Research Associates.
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AUTOMATED, DIGITAL
COMMUNICATIONS
Voice of the Pharmacist
Relevant Messaging
Record messages to be sent to patients,
helping providers deliver timely
information with a personal feel without
hiring any additional staff.
Easily deliver messages which are
important and relevant to the patient:
Clinical Refill Reminders, Birthday, Will
Call Bin, Special Events etc.
HAPPY
BIRTHDAY
NEW PATIENT
WELCOME
WILL CALL BIN
MANAGEMENT
QUARTERLY
EVENTS
Pharmacy Loyalty Results
High Touch
Utilize behavior analytics, selective
segmentation and market-tested
campaigns to improve adherence and
loyalty.
ON-DEMAND
CAMPAIGNS
CLINICAL REFILL
REMINDERS
CRAFTING A
COMMUNICATION
Conduct needs analysis
Patient
“Pre-Condition”
Communication
Patient
“Post-Condition”
Write the message
Beta-test the message
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ATTENTION SPANS
ARE SHRINKING
12 sec
8 sec
2000
2013
Data: Grove Microlearning Infographic
PLAIN LANGUAGE
How can we communicate with
patients clearly and concisely?
Use short sentences
Use the active voice
Use everyday words
CDC Resource: Everyday Words for
Public Communication
Assessment
Chronic
Individuals
More effective
test
life-long
you
works better
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WRITING THE
MESSAGE
Key Take Away
0 sec
20%
35%
35%
10%
35 sec
Contact Information
Establish Voice of Authority
Use Short Sentences
Personal
Closing
Use the Active Voice
Use Everyday Words
HERE ARE THE
OUTCOMES
Clinical Refill Reminder calls
have cut days late by 50%.
Will Call Bin Management
campaigns have seen a
30% reduction in return-to-stock.
Flu Campaigns have increased
immunizations by up to
500% year-over-year.
New patients who receive a
Welcome Call are 22% more
likely to bring their next fill
to that pharmacy.
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APPOINTMENT BASED
MED SYNC
More than synchronizing patient’s
medications so they come due on the
same day of the month
Changing the way pharmacies are
practicing – from reactive to proactive
engagement with their patients
Should become the standard of care
for pharmacies in the future
APPOINTMENT-BASED
MEDICATION SYNCHRONIZATION
Why Med Sync?
Adherence
Schedule an appointment with patient
Opportunity for additional patient interventions
Adherence Star Measures
Diabetes, Hypertension and Cholesterol for targeted patient populations
Today 6,000+ Pharmacies are Performing Med Sync
4.5M Medicare patients out of 132k total patients are synched
Identify
Recruit
Conduct
Sustain
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THE IMPACT OF
MED SYNC
Med Sync patients were over
2.5 times more likely
to be adherent to medications.
Patients who received ABMS services were
79% more likely to continue their
prescription drug regimen.
79%
OUTCOMS
RESULTS TELL THE STORY
JUST THE
FACTS
One 1,000+ member PSAO increased its overall Star Ratings from 3.1 to 4.1 in the first year of working with PW
One 80+ store pilot group using PW proved patients were 2.5 times more adherent than the control group of patients using the same pharmacy 32%
INCREASE
2.5
TIMES
One 30+ store pilot group increased its overall Star Ratings from 3.9 to 4.1 in just the first 4 months of working with PW
One 500+ member GPO showed an increase of 2.7 Million fills year over year while working with PW
4%
IN 4 MONTHS
2.7
MILLION
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Additional Services Centered around the
APPOINTMENT
Disease State
Management
Immunizations
Comprensive
Medication
Review, Med
Rec, TOC
Clinical
Tests,
Biometrics
COMPREHENSIVE PHARMACY CARE MANAGEMENT
DIR – DIRECT & INDIRECT
RENUMERATION
COMMON TYPES OF PHARMACY RATES AND CONCESSIONS CAPTURED AS *DIR
Performance Metrics
o Refill Rates/Extended Supply Rates
o Generic Dispensing Rates
o Preferred Dispensing Rates (preferred brands compared to non‐preferred brands)
o Audit Performance/Error Rates
o Qualitative Measures, often in comparison to other pharmacies participation in network
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VALUE-BASED PAYMENT MODELS
FOR COMMUNITY PHARMACISTS
SCAN/Express Scripts
Inland Empire Health Plan
HealthFirst
QUESTIONS?
Mindy Smith, BSPharm, RPh
Vice President Pharmacy Practice Innovation PrescribeWellness
m: (703) 927-2288
[email protected]
prescribewellness.com
9701 Jeronimo, Suite 300, Irvine, CA 92618
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