Latest news and updates about the Medicare and pharmacy industries.

Quality Metrics for Drug Plans Are Impacting Pharmacies’ Bottom Line—Here’s How to Turn That Around

Posted on in Industry Updates by Amplicare Team

Few people would choose a one-star hotel room over a five-star luxury suite. The same goes for health insurance plans, with one difference. There’s lot more at stake here than a lousy night’s sleep—for the patients, plans, and the pharmacies that support them. 

Created by the Centers for Medicare and Medicaid Services (CMS) in 2007, the Star Rating System is designed to incentivize Medicare Advantage and Part D plans to provide higher quality care. The rating also informs patients how well a plan performs, generating more transparency in the healthcare marketplace. High-performing plans enjoy rewards, like bonus payments and greater marketing opportunities. Plans that perform poorly, however, can experience serious penalties. This includes removal from Medicare, if they dip below a three-star rating for three consecutive years. 

With so much on the line, plan providers are always looking for ways to boost their star rating. And many of their initiatives will significantly impact your pharmacy’s bottom line—for better or for worse. It’s estimated that pharmacies with between 150-300 Medicare patients have as much as $75,000 at stake each year1 from these incentive programs, whether they realize they’re being evaluated or not. 

To stay competitive, it’s vital that you know which ratings systems the plans you work with are being evaluated by, which systems they’re evaluating you by, and what you can do to improve quality. 

Performance measures and you 

Medicare drug plans are rated on a number of different categories, including customer service and member complaints. But the measures that directly impact pharmacies involve medication adherence, medication safety, and medication therapy management (MTM).  

Since clinically-relevant measures are weighted more heavily, measures relating to medication use accounted for 42% of all Part D summary ratings in 2017 2. It’s no wonder that plans are keen to incentivize pharmacies that help them boost these metrics.  

The perks of being paid by performance 

Whether you realize it or not, at least one of the plans that pays you is almost certainly using a quality-based incentive program already. These initiatives can put more money in your pocket, or take it away. They can help you gain access to preferred networks, or bar you from entry. They may even lower the direct and indirect remuneration (DIR) fees you pay, or cause them to skyrocket. 

Through greater reimbursement gains and the potential for pay-for-performance (P4P) bonus payments, your pharmacy stands to make a lot of money from these programs. This is money you can use to upgrade infrastructure, bring in more staff, and make other improvements that further enhance patient care. 

But to do that, you first need to know what to look for.  

Moving toward a culture of quality

To thrive in this quality-based environment, pharmacies need to go above and beyond for patients. That means performing diligent care quality management to improve patient safety. This can include analyzing data to spot patients at risk of infection or adverse drug events. It can also involve interacting with patients regularly to check they know how to take their medication correctly—and that the drugs are working. 

Medication nonadherence is a $300 billion drain on the U.S. healthcare system every year 3, so it’s no surprise that CMS’s Star Rating System places a great deal of emphasis on the proportion of days covered (PDC) metric. Specifically, CMS evaluates PDC among patients taking non-insulin diabetes medications, statins, and renin-angiotensin system (RAS) antagonists.  

With an estimated one in three patients stopping or missing 4 their prescribed dose without informing their prescriber, adherence is a core area that pharmacies can focus on.

The first step is identifying high-priority patients with plans that operate on a P4P program. This will typically include patients with diabetes, chronic hypertension, and hyperlipidemia (high cholesterol), and those taking high-risk medications. These target groups not only represent the biggest clinical opportunity for your pharmacy, but can also experience dramatically improved health outcomes and lower rehospitalization rates as a result of greater adherence. 

Intervene, improve, and earn incentives  

There are numerous simple interventions you can implement today to improve patient care, earn incentives, and potentially save lives. 

Focus on building relationships with your patients to establish trust. The better you know your patients, the more likely it is that you’ll be able to spot a non-adherence risk, like a newly-diagnosed diabetic who isn’t certain how their medication works. This will allow you to proactively step in to offer guidance and support before it becomes a problem. You might also provide educational pamphlets and handouts for patients to take away. 

Talking to patients can go a long way. Don’t be afraid to ask them during each visit if they have any questions or concerns about their prescriptions, and ensure all your staff know to do the same. You can also strengthen your relationship with the patients’ prescribing doctor, reaching out to them directly with a personalized fax to let them know which statins are covered by a patient’s plan. 

Medication synchronization is another intuitive step that can significantly boost adherence by removing barriers to prescription refills. Getting to the pharmacy can be more difficult for some patients than others, especially if they’re elderly or unwell. By arranging for all their prescriptions to be refilled simultaneously at a convenient time each month, you can ensure a patient only has to make one trip to get the live-saving medications they need. Many dispensing softwares have medication syncing capabilities built-in, so this can be an easy step to implement. 

And if a patient does miss a refill, call them. If you don’t have the manpower to make individual calls, set up your system to make automated calls with a friendly reminder. It could make all the difference. 

Boost adherence. Drive quality. Save lives.  

While CMS doesn’t rate pharmacies directly, its clinical performance metrics for plans still play a vital role in the way pharmacies are paid and rewarded. Keep abreast of new metrics (expect changes as soon as September) to continue driving quality in the areas that matter most. 

At Amplicare, we can help your pharmacy stay on top in this competitive performance-based landscape. With our Amplicare Impact tool, patient opportunities are directly integrated into your daily workflow, so you can take immediate steps to boost their adherence—and their outcomes. You care about your patients’ health, and so do we. Let’s work together to improve their care.

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