Value Driven Systems

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As the US Healthcare system continues to evolve into a value driven marketplace, pharmacists are challenged with a changing environment and a steep learning curve. Quality performance measures may begin to affect preferred network opportunities as well as be the onus for the creation of Pay for Performance (P4P), Quality Incentive Bonus, or Pay for Value programs (similar programs tying payment to quality that go by many different names). According to Allied Health News, P4P Programs in healthcare is an effort to increase the quality of medical care in the U.S. while at the same time reigning in the often staggering costs(1). P4P programs have been in existence since at least the early 1990s, however as the Affordable Care Act continues to roll out, these programs are growing across the entire health care system.


What does that mean to the profession of pharmacy as a whole?

Today health plans are beginning to offer incentives, separate and different from reimbursement, to pharmacies for high quality services. Across the nation, regional and national payers are creating varied programs. The specifics of each program may differ in regard to eligibility and payment (Table 1), however the basic quality metrics appear to be the same. Many rely on the medication quality measures created by the Pharmacy Quality Alliance (PQA) and adopted by CMS. Currently there are two specific areas measured related to medication use; these are patient safety and medication adherence. Many health plans are partnering with Pharmacy Quality Solutions (PQS) to gauge a pharmacy’s performance using EQuIPP (Electronic Quality Improvement Platform for Plans and Pharmacies); the process allows PQS to act as a neutral intermediary between health plans and pharmacies. Pharmacists may consider this as an opportunity to focus on improving patient outcomes while gaining financial incentives that can be used to improve technology, infrastructure and clinical services, all aspects of the pharmacy business as a whole.

Possible Designs of P4P Programs

  • Pharmacies evaluated on Medication-Use measures

o All or some from the CMS Star Ratings program

o May include additional measures that are in consideration by CMS or from other quality-related groups

  • Pharmacies receive bonus payments on a designated schedule based on performance and/or performance improvement

o 6 months

o 12 months

  • Some models will be “pay to play” wherein pharmacies forgo traditional reimbursement associated with medication dispensing. High performing pharmacies may receive bonus payments for good clinical performance.
  • Pharmacy eligibility and /or bonus based upon the number of patients for each measure in addition to attainment of goals.
  • Some goals are fixed, others based on relative performance

o Dollars go to top performers

Current P4P programs and EQuIPP

Three specific Pay for Performance Programs are currently in existence and are utilizing the EQuIPP platform. Table 2 outlines these programs and where to seek additional information for each program.

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P4P Programs using EQuIPP

Inland Empire Health Plan (IEHP)

Caremark-SilverScript Network Performance Program

Launched in 2014 based on:

  • Star measures (PDC adherence* and Diabetes Treatment; Hypertension Measure)
  • Combination of payment for gap closures delivered through Mirixa and bonus on reaching performance goals
  • Information available on the Caremark - Silverscript website
  • 866-488-4708

Healthfirst of NY

Program launched October 2014 based on:

  • Star measures (PDC adherence*)
  • Combination of payment for program commitment and for reaching performance goals
  • Information available on HealthFirst
  • ??

*PDC – Proportion of Days covered is an adherence calculation method

What I should ask about P4P programs?

  • Is there a clear timeframe for evaluation and payments?
  • Are there clear goals/thresholds for success?
  • How will the program be communicating to you and your pharmacies?
  • What performance measures will be included?
  • How will you prepare your pharmacies and all pharmacy staff for success?
    • Do they have all the tools/training right now?