By: Amber Ray
Do pharmacy quality measures actually measure pharmacy quality?
There are two fundamental problems with the US healthcare system: cost and quality. It is well-known that the US spends more than any other country on healthcare. However, less well known is that the US also has worse healthcare quality, roughly defined as the extent to which healthcare services achieve healthcare goals and match with current guidelines. It’s as if the US is paying for a diamond but getting a cubic zirconium instead.
Historically, healthcare providers have been paid on a fee-for-service basis, that is they get paid for providing a service, regardless of the quality of care provided. This creates a perverse incentive wherein providers are rewarded for delivering more units of service, regardless of need or quality; part of the current spending problem has been blamed on fee-for-service. To incentivize the delivery of high-quality care, health care payers have begun paying providers based in part on quality measures. If appropriately designed, these performance-based payment models create systems wherein providers and organizations delivering the highest quality care are rewarded, and those failing to do so are incentivized to improve.
The use of performance-based payment models is common in the US healthcare system, and received a substantial boost from the 2010 passage of the Affordable Care Act. Pharmacy benefits managers lagged behind other payers in implementing performance-based payments, but that has changed in recent years. For example, in 2018, more than half of all Medicare Part D plans used quality measures to adjust pharmacy payments or fees.
If well-designed, performance-based payment models can strengthen pharmacies providing the highest quality services. However, if these models are poorly designed, pharmacies serving vulnerable patients could receive reduced payments simply because of the nature of their patients or other factors outside of their control. Little research has evaluated best practices to design and implement quality measurement systems that support effective performance-based pharmacy payment models.
Dr. Ben Urick, Research Assistant Professor at the UNC Eshelman school of Pharmacy, has explored best practices for creating performance-based pharmacy payment models through his dissertation work as well as through the lens of pharmacies participating in the North Carolina community pharmacy enhanced services network (NC CPESN®). The NC CPESN is clinically-integrated network of pharmacies delivering a variety of enhanced services that was formed in 2014 as part of a large federally-funded research project.
In this blog, we discuss four of Dr.Urick’s recently published papers that address the lack of rigorous exploration of pharmacy value measurement.
Forming the basis for much of his work, this study developed and tested a conceptual model of pharmacy value. The purpose of this work was to explore and strengthen the conceptual foundation for measurement of pharmacy value.
Through four key principles, this paper built a framework to assess community pharmacy value and produced an example of a composite pharmacy performance measure. The key principles included; 1) theory-based quality and spending measures, 2) scoring which accounts for measure reliability, 3) full risk-adjustment, and 4) a value matrix to identify high and low value pharmacies.
The authors demonstrated that it is possible to stratify pharmacies into high, typical and low value categories using an evidence-based methodology, and contended that by using the framework described, payers might see a closer reflection between quality performance and performance-based payments.
In this paper, the authors reported on the creation of a pharmacy alternative payment model (APM) as a part of the NC CPESN and provided the first ever description of the design and implementation of performance measures for a group of enhanced services pharmacies. Moreover, the study highlighted the resources needed to effectively do so.
This study investigated the plausibility of measuring quality based on medication adherence, hospitalizations, ED visits, and total cost of medical care – a unique feature since all previous performance-based measure systems relied on surrogate outcomes such as adherence alone.
Using a mix of different types of measures, this program was successful in measuring pharmacy quality, stratifying pharmacies based on outcomes, and demonstrating that global outcome measurement is possible. This work provides an example of a composite performance measurement system that can be used to support alternative pharmacy payment models and demonstrates the importance of risk-adjusting based on pharmacy populations to ensure accurate quality measurements.
In this paper, Renfro, Urick et al. sought to understand the community pharmacy characteristics that might impact performance on quality measures specific to medication management.
The performance outcomes evaluated included the same set of performance measures included in the APM evaluation.
The authors found that there were five characteristics that were significantly associated with three performance measures, but none were associate with four or more. Pharmacist work hours allocated to non-dispensing activities, home visits, and offering smoking cessation programs were positively associate with performance. This suggests that there are activities that pharmacists do that may impact performance measures, but it was surprising that no characteristics were broadly associated with performance.
However, investigators also found that certain characteristics, like the development of a care plan, use of automated dispensing, offering medication synchronization, and offering disease state management programs were correlated negatively with pharmacy performance.
One explanation, the authors offered, was that the pharmacies offering these additional services may have been attracting a sicker population. These questions were addressed in the next paper.
This final study questions whether performance-based payment models punish pharmacies providing services to the neediest patients. Quality measures used by Part D plan sponsors do not account for improvement of patients over time and are not risk-adjusted to account for variations in patient severity. If pharmacies offering enhanced services are more likely to attract sicker patients, failure to adjust measures systematically disadvantages these pharmacies.
Using prescription filling patterns, Urick assigned non-elderly Medicaid enrollees to either an enhanced pharmacy participating in the NC CPESN or a control pharmacy and explored the potential for pharmacies participating in an enhanced services network to attract sicker patients based on health status, demographics and health resource use.
Authors found that pharmacies that participated in the enhanced services network tended to serve patients who spend more healthcare dollars, had more hospital admissions and more ED visits. They also found that these patients were older, used more medications and had worse health status at baseline, and were more likely to reside in a rural area.
These results suggest that enhanced services pharmacists may be serving sicker populations and may be disadvantaged in performance-based payment models. This is a serious concern, and calls for adjustment in the measure sets currently used to evaluate pharmacy performance.
According to Urick, risk-adjusted models that explore the extent to which controlling for known socioeconomic factors influence performance is the logical next step in improving pharmacy performance-based models. Additionally, more testing is needed to determine the reliability, validity and comparative superiority of various measures derived from the work outlined.
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