Pharmacists Can Help Care Teams Meet Quality Measures

editorial

quality measures

Pharmacists Can Help Care Teams Meet Quality Measures

Loren Bonner, Senior Editor

As the U.S. health care system moves toward value-based payment and delivery models, clinical measures continue to be developed to assess whether patients are meeting certain specified care goals and outcomes. “To achieve value, these models focus both on measuring the quality of care delivered using specific quality measures and on reducing unnecessary costs of care,” said Anne Burns, RPh, vice president of professional affairs at APhA. Pharmacists’ medication expertise can positively affect metrics focused on conditions treated by medications, as well as metrics for wellness and prevention, according to Burns.

CMS ratings

Health insurance plans have used certain quality measures—many revolving around medication use— to connect community pharmacists to pay for performance, value-based contracts, and more. Quality measures in CMS’s star rating program set the foundation. The program began when provisions in the Affordable Care Act called for quality bonus payments within the Medicare Advantage program to be awarded on the basis of how well health plans execute on a set of performance measures. For years, community pharmacists have been acutely aware of this program. Increasingly, they are being asked to improve the metrics or risk being eliminated from the plan. “Pharmacists are much more keenly aware of what’s inside the star ratings program because the measures are being used in value-based networks, and pharmacists are being held accountable for them,” said Laura Cranston, BSPharm, CEO of the Pharmacy Quality Alliance (PQA). The nonprofit got its start developing measures for the Medicare Part D prescription drug program, and many of those measures are being used in Medicare, Medicaid, state-based, and private-sector value-based programs. “We have started work on pharmacy-level measures, which evaluate performance of the pharmacy holistically—across all payer types,” said Cranston.

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Reprinted with permission from the Provider Status column in the September 2018 issue of Pharmacy Today (www.pharmacytoday.org). For more information about ways for pharmacists and student pharmacists to follow and influence the profession’s efforts to achieve provider status, access the provider status recognition section of APhA’s website (www.pharmacist.com/ providerstatusrecognition) and APhA’s Pharmacists Provide Care website (PharmacistsProvideCare.com). Copyright © 2018, American Pharmacists Association. All rights reserved. Right now, she explained, health plans are only concerned about their select Medicare patients at a particular pharmacy. PQA wants to develop the metrics for the whole pharmacy, taking into account patients with Medicaid, commercial insurance, and those who are uninsured. “There are lots of different opportunities to use a measure like this [for the whole pharmacy] in the valuebased landscape,” said Cranston. Some of those opportunities could even provide room for pharmacists to work with other providers to improve patient outcomes.

Team-based care

Pharmacists should be informed about quality measures affecting physicians across the country because it creates an opportunity to work more closely on a patient’s care team. Beginning in 2017, CMS implemented the Quality Payment Program (QPP), authorized through the Medicare Access and Children’s Health Insurance Program (CHIP) Reauthorization Act (MACRA). Essentially, QPP represents new opportunities for pharmacists to help physicians meet quality measures. MACRA changed the fee-for-service formula Medicare uses to pay eligible clinicians in Part B. Under MACRA, physicians and other eligible clinicians choose one of two quality payment pathways: the MeritBased Incentive Payment System (MIPS) or an APM (Advanced Payment Model).

According to CMS, roughly 600,000 Medicare Part B–eligible clinicians are subject to MIPS in 2018, and only under certain conditions will clinicians be exempted from the program. MIPS can also serve as a stepping stone for providers and organizations to move into an APM. For pharmacists, there is opportunity to enter into partnerships with physicians to help them meet certain quality measures. Many of the roughly 300 measures in the quality category for MIPS can be affected by pharmacists. Two measures specifically mention pharmacists. They are medication reconciliation after discharge in the quality category, and population management of medications in the clinical improvement category. “Value-based models use a team-based approach to care, where health care practitioners, working in a coordinated manner, deliver care and are held accountable for quality metrics and costs of care,” said Burns. “To be valued and included in these models, pharmacists need to understand quality measures, how a pharmacist can impact them, and have the skills to contribute to team-based care.” 

Value-based models use a team-based approach to care, where health care practitioners, working in a coordinated manner, deliver care and are held accountable for quality metrics and costs of care. To be valued and included in these models, pharmacists need to understand quality measures, how a pharmacist can impact them, and have the skills to contribute to team-based care. — Anne Burns, RPh

Vice President of Professional Affairs at APhA