Challenges and Changes. Improvement of Medication Use. The Role of Private-Sector Accreditation with New Health Insurance Marketplaces

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1 URAC Spring 2013 Volume 6 Issue 2 AMCP Quality Management News and Information for Pharmacy About URAC About AMCP The Affordability of Pharmacy Benefits: Challenges and Changes By Terri S. Moore, PhD, RPh, MBA, Senior Manager, Product Development, URAC Janice Anderson, RPh, Director, Pharmacy Programs, URAC The Affordable Care Act (ACA) is challenging all stakeholders, including pharmacists, to do more with less. While many of the ACA s provisions are targeted at the individual and small-group insurance [more on page 2] The Affordability of Pharmacy Benefits EQuIPP: Building Bridges for Quality The Role of Private-Sector Accreditation The Growing Focus on Medication Use Sponsored by: EQuIPP: Building Bridges for Quality Improvement of Medication Use By David Nau, PhD, RPh, CPHQ Senior Director, Quality Initiatives, PQA Mark Conklin, PharmD, MS Director, Quality Innovations, PQA The Pharmacy Quality Alliance (PQA), in collaboration with technology partner CECity, has launched the EQuIPP Initiative as a means to deliver valid, consistent performance information to those stakeholders The Role of Private-Sector Accreditation with New Health Insurance Marketplaces [more on page 3] By William R. Vandervennet, Jr., FACHE, MHSA, BSN, URAC Chief Operating Officer This October, millions of individuals are expected to begin enrolling in health plans offered through new health insurance marketplaces. Earlier this year, the Obama Administration released a series of rules governing the [more on page 6] Readership Questionnaire URAC and AMCP want to better understand how our readers are using the newsletter and what we can do to improve it. Please help us by completing a brief questionnaire. Click or visit 1

2 The Affordability of Pharmacy Benefits: Challenges and Changes [CONTINUED FROM PAGE 1] markets, broader changes affecting the entire system are on the horizon. Access to affordable coverage, including prescription drugs, is a vexing problem that will require a sustained commitment by consumers, clinicians, payers, and policymakers. Against this backdrop, private-sector accreditation will be an important component to stretching scarce health-care dollars and maximizing value. The greatest challenge facing pharmacists and the entire system is how to make coverage more affordable. In the pharmacy arena, pharmacists, health plans, PBMs and employers have all made great strides in recent years in driving down the cost of traditional, oral solid medications. Working together, pharmacists and payers have expanded access to lower-cost generic drugs, moved to preferred pharmacy networks, and expanded mail-service pharmacy options for maintenance medications. Improved efforts at medication adherence have also contributed to better outcomes and overall lower medical costs. At a more targeted level, the pharmacy benefit for health plans offered through new state health insurance marketplaces, or exchanges, could prove problematic. Federal rules finalized earlier this year require plans to cover at least one drug per class or the same number of drugs per class as the state s essential-health benefit benchmark plan, whichever is greater. States may select among several benchmark plan options, including (1) the largest health plan by enrollment in any of the three largest small-group insurance products; (2) any of the largest three state employee health benefit plan options by enrollment; (3) any of the largest three national Federal Employees Health Benefits Program (FEHBP) plan options by aggregate enrollment; or (4) the coverage plan with the largest insured commercial, non-medicaid enrollment offered by a health maintenance organization (HMO) operating in the state. In the interest of affordability, this structure bears close watching in the years ahead. Health plans and employers fear that the design of the pharmacy benefit offered on exchange plans could undermine the ability to keep coverage affordable. While pharmacists and payers have made progress on traditional pharmaceuticals, the cost of complex, injectable-biologic drugs present new challenges and opportunities to consumers, pharmacists, and payers. The good news is that these breakthrough medicines are transforming patient care and allowing individuals to lead fuller and more productive lives. For individuals living with rheumatoid arthritis, multiple sclerosis, and cancer, these drugs are known to be life changing and a testament to the bio-pharmaceutical industry. The downside is that many of these drugs are incredibly expensive and require an additional level of expertise for shipping and administering. While comprising a very small rate of overall utilization, the rate of growth in the cost of biologic drugs is unsustainable. Worse still, one of the most important tools available elsewhere to pharmacists and payers access to lower-cost generic drugs is not available for biologics. URAC has pioneered privatesector accreditation for a wide-range of pharmacy topics including pharmacy benefit management, drug therapy management, mail-service pharmacy, workers compensation pharmacy benefit management, and specialty pharmacy. By promoting rigorous standards related to customer service, pharmacy operations, and patientcentered medication management, URAC accreditation has raised the bar on quality and challenged pharmacists, health plans, PBMs, and other pharmacy organizations to do better. In the coming months, URAC will take accreditation to the next level with the unveiling of a unique data analytics tool. This proprietary tool which will not be offered by any other accreditor will help pharmacists and plans to pinpoint gaps in care and identify corrective action. Traditionally, privatesector accreditation has focused on processes what percentage of patients have received mammograms or cholesterol screenings or enrolled in smoking cessation programs, or received their prescription in a timely manner but it has not provided meaningful or actionable data. URAC s new data analytics tool is geared toward the changing times and will help provide a platform from which pharmacists and payers can more accurately assess which parts of their care programs need improvement. URAC will talk much more about this new data analytics tool in the months ahead. 2

3 EQuIPP: Building Bridges for Quality Improvement of Medication Use [CONTINUED FROM PAGE 1] interested in measuring and improving the quality of medication use. EQuIPP helps to foster an environment where health plans and PBMs can connect with their pharmacy network to move the needle towards better medication use across their memberships. AMCP and URAC are members of PQA. The EQuIPP Initiative grew out of a PQAcoordinated demonstration project in Pennsylvania involving Highmark BCBS and Rite Aid Corporation. The successful demonstration was followed by a beta phase in 2012 to test the platform with a broader group of health plans and community pharmacy organizations operating in Pennsylvania, Florida, and Alabama. Positive user engagement and a growing interest from organizations outside of the beta-phase locations have led to the national rollout of EQuIPP. Gathering Performance Information Management EQuIPP addresses both the growing focus on medication use in health care, as well as the need to measure performance quality of a key but historically underutilized member of the health care team: the community pharmacy. A basic tenet of all quality improvement models is that quality must be measured. Additionally, all members of a health care team, including community and retail pharmacy, should understand how the team s performance is being measured and be involved in formulating strategies for improvement of quality. If community pharmacies are to be a meaningfullyengaged member of the health care quality improve- [more on page 4] The Growing Focus on Medication Use Increased attention is being paid to the use of medications in promoting a value-driven health care system. This was spurred by the Medicare Part D Plan Ratings but will also be important for the health care exchanges (or marketplaces) that are being established nationwide. Within the Medicare Part D Star Ratings program, medication-use measures comprise only 5 of the 18 measures associated with a plan sponsor s overall Star Rating, but given their significant weight (3 times other measures), they represent nearly half of a plan sponsor s Part D summary rating. The Quality Bonus Payment system for Medicare Advantage drug plans (MA-PDs) is based on the combination of Part C and Part D measures; thus, MA-PDs have significant financial reasons to pay attention to medication use. When it comes to improving medication use, especially medication adherence, health plans are confronted with the need to develop a rather complex strategy that can ensure access to and the delivery of high quality services, and encourage members to adopt and maintain healthy behaviors. Case management programs, health coaching, direct member outreach, more recently via mobile apps and other technologies, and physician provider initiatives have long been part of a health plan s intervention skill set and will likely continue to be part of future strategies. Community Pharmacies Are Underutilized Partner Community/Retail pharmacies, however, have been an underutilized partner for initiatives to improve the quality of medication use. Although medication therapy management (MTM) programs have included community pharmacies, the Medicare Star Ratings encourages plans to drive improvements in medication use beyond their MTM-eligible members. Since community pharmacies generally have frequent interaction with a health plan s members, especially those members with chronic illnesses, they offer a unique opportunity for engagement of patients and monitoring of appropriate medication use. Based on PQA s demonstration project experiences, it appears that community pharmacies can be especially helpful for lower-intensity, longitudinal interventions that are effective for managing day-to-day medication use. 3

4 EQuIPP: Building Bridges for Quality Improvement of Medication Use [CONTINUED FROM PAGE 3] ment team, they must be aware of how quality is being measured and understand their potential effect on quality. Until now, most pharmacies had limited ability to measure quality of medication use for their patients. EQuIPP offers an efficient platform for measuring quality of medication use and for making this information available to pharmacies. It supports the valid and consistent collection, aggregation, and distribution of performance information for quality measures related to medication use, which allows plans and pharmacies to collaborate towards common objectives. The EQuIPP platform currently supports the 5 medication-use quality measures that are part of the Medicare Part D Star Ratings program as well as one measure from the Part D Display Measure set (Drug-Drug Interactions). All of these measures were developed, and are maintained by, the Pharmacy Quality Alliance. Many of these measures are also included in URAC s accreditation measure sets for health plans and its Pharmacy Quality Management suite of accreditation programs. Future measures may be added to EQuIPP as programs adopt new medication-use measures. Participation in EQuIPP is open to all health plans, PBMs and pharmacies that are interested in collaboration for improvement of medication use. [more on page 5] About AMCP The Academy of Managed Care Pharmacy (AMCP) is a national professional association of pharmacists, health care practitioners and others who develop and provide clinical, educational and business management services on behalf of more than 200 million Americans covered by a managed pharmacy benefit. AMCP members are committed to a simple goal: providing the best available pharmaceutical care for all patients. Some of the tasks AMCP s more than 6,000 members perform include: Monitoring the safety and clinical effectiveness of new medications on the market; Alerting patients to potentially dangerous drug interactions when a patient is taking two or more medications prescribed by different providers; Designing and carrying out medication therapy management programs to ensure patients are taking medications that give them the best benefit to keep them healthy; and Creating incentives to control patients out-ofpocket costs, including through lower copayments on generic drugs and certain preferred brands. These practices, and more, aim to ensure that all patients can receive the medications they need to improve their health while at the same time keeping health care costs under control. AMCP serves its members in many ways. Throughout the year, AMCP provides conferences, online learning access, peer-reviewed literature through its Journal of Managed Care Pharmacy, and leadership development seminars. Each is designed with the goal of advancing professional knowledge, improving the design and delivery of pharmacy benefits, and ultimately, patient satisfaction and health outcomes. The focus of the Academy has been to create scientifically designed methodologies for making medical choices as intelligently as current knowledge will allow, supported by evidence-based clinical studies. Some of the Academy s most successful products to date are AMCP s Format for Formulary Submissions and the AMCP Framework for Quality Drug Therapy. The Format is a standardized methodology for assessing drugs scientifically, based on the value they provide. Widely adopted by numerous health plans, governmental agencies such as the Department of Defense and leading pharmacy benefit management companies, the Format has become a de facto industry standard. Managed care organizations employing the Format cover approximately half of all pharmacy care beneficiaries. The AMCP Framework for Quality Drug Therapy was developed over a period of years with the input and review of over 100 stakeholders, including both providers and users of care. It is essentially a reliable, adaptable and scalable methodology for applying quality improvement initiatives to patient care focused on the patient, not the process. These and all other AMCP publications, including the Journal, can be found on the AMCP website, 4

5 EQuIPP: Building Bridges for Quality Improvement of Medication Use [CONTINUED FROM PAGE 4] Each health plan and PBM that participates in EQuIPP gets full visibility into their pharmacy network s performance across key quality measures and a distribution channel for the communication of that information to pharmacies, and also receives benchmarks for their performance across relevant lines of business (commercial, Medicare, and Medicaid) at both national and state levels. Since the plans and PBMs provide data on a monthly basis, the quality report dashboards are regularly updated to provide near real-time assessment of quality. Pharmacies Can Compare Performance to National Averages The community pharmacy participants receive easy access to quality report dashboards that allow them to understand how their pharmacy is performing on each quality measure and to also compare their performance to star-rating thresholds as well as state and national averages for all pharmacies. They also have access to web-based educational programs and toolkits to support them in implementation of quality improvement programs. The EQuIPP team also offers workshops and other training programs to assist pharmacies in adapting to the new environment of quality transparency and value-driven health care. Quality is best improved through collaborative efforts of all stakeholders with support of reliable and efficient performance information systems. EQuIPP provides the common language for quality improvement of the medication-use system. Health plans, PBMs and pharmacies all have a shared interest in quality since all can benefit from improved quality of medication use. EQuIPP should make it easier for collaborations to occur across all of these stakeholders. EQuIPP is delivered through Pharmacy Quality Solutions, a joint venture of PQA and CECity. For more information about EQuIPP, please send an to info@equipp.org or visit About URAC URAC is an independent, non-profit organization whose mission is to promote continuous improvement in the quality and efficiency of health care management through the processes of accreditation and education. To support this goal, our Board of Directors represents the full spectrum of stakeholders interested in our health care system, including consumers, employers, health care providers, health insurers, purchasers, workers compensation carriers and regulators. Incorporated in 1990, URAC pioneered utilization management accreditation by creating a nationally recognized set of standards to ensure accountability in managed care determinations of medical necessity. As the health care industry evolves, URAC continues to address emerging issues: we now offer 28 accreditation and certification programs across the health care spectrum. Many states have found URAC accreditation standards helpful in ensuring that managed care plans and other health care organizations meet quality benchmarks. 47 states and the District of Columbia currently reference one or more URAC accreditation programs in their statutes, regulations, agency publications or contracts, making URAC the most recognized national managed care accreditation body at the state level. Five federal agencies recognize URAC accreditation. The Centers for Medicare & Medicaid Services (CMS) recognize URAC Health Plan Accreditation for the Medicare Advantage Program; CMS Center for Medicaid State Operations recognizes the comparability of URAC Health Plan Standards with federal Medicaid Managed Care Regulations; the Office of Personnel Management (OPM) recognizes all URAC accreditation programs under the Federal Employee Health Benefits Program; TRICARE/ Military Health System recognizes URAC Health Network, Disease Management, Health Utilization Management and Case Management Accreditations; the Department of Veterans Affairs recognizes URAC Health Call Center Accreditation; and the Department of Labor recognizes URAC Independent Review Organization Accreditation. Additionally, URAC s Health Plan Accreditation has been recognized by the Department of Health and Human Services to accredit Qualified Health Plan issuers seeking to participate on Health Insurance Exchanges in all 50 states and the District of Columbia, and OPM will accept URAC Health Plan Accreditation for issuers participating on Multi-State Exchanges. 5

6 The Role of Private-Sector Accreditation with New Health Insurance Marketplaces [CONTINUED FROM PAGE 1] design of health plans on exchange markets, including private-sector accreditation. Significantly, private-sector accreditation will be mandatory for health plans offered on marketplaces. Private-sector accreditation focuses on access and quality issues that matter most to patients, including timely access to services, high quality of care, and consumer protections when interacting with health plans. At URAC, one of the nation s largest accrediting bodies, the process for developing accreditation standards and quality measures is very inclusive, with active input from a broad range of stakeholders, including consumers, physicians, hospitals, labor unions, pharmacists, nurses, employers, and the National Association of Insurance Commissioners. This consensus-oriented approach to standards-setting is a model for quality improvement and will serve consumers well as they consider enrollment in an exchange plan. Well-established, private-sector accreditation programs with meaningful quality measures help foster continuous quality improvement by health plans and are an important complement to rigorous state and federal regulation of health plans. In the private sector, many large employers use private-sector accreditation of health plans as a condition of contracting. Non-proprietary, publicly available, and widely accepted quality measures are also critical to achieving system-wide improvements, including measures used for individuals enrolled in exchange plans. Yet, measurement alone paints an incomplete picture. Private-sector accrediting bodies must change with the times and that means also being able to provide health plans and exchanges with sophisticated data-analytic tools that help measure and improve care quality and patient satisfaction. Measurement alone is insufficient the data should also help pinpoint gaps in care and how best to take corrective action. This ability to continuously track and improve performance is a foundational goal of health care reform and one that must be embraced. Private-sector accreditation is not the proverbial silver bullet to generating greater value in health care no one thing is but it can and should play an important role. This fall, millions of individuals will begin enrolling in marketplace plans that have been subject to the same strict government review and accreditation standards as commercial health plans. Health care is changing and URAC is keeping pace with the changing times. This fall, millions of individuals will begin enrolling in marketplace plans that have been subject to the same strict government review and accreditation standards as commercial health plans. Health care is changing and URAC is keeping pace with the changing times. 6

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