Quality key to value-driven health care
Health care has begun to emphasize quality in addition to cost as a means to provide what is known as value-driven health care. Of particular interest is the increased recognition of the value of the pharmacist’s role as a member of the healthcare team. Pharmacists are medication experts and have demonstrated success in improving the quality of medication use, especially as it relates to such key quality metrics as high-risk medications, or HRM, in the elderly; adherence as measured by the proportion of days covered; and the movement of patients with diabetes to the appropriate hypertension medication.
The Centers for Medicare and Medicaid Services, or CMS, established a five-star quality rating system a few years ago to educate consumers. The Patient Protection and Affordable Care Act ties reimbursement rates to performance as measured by the star rating system. Updated CMS star measures or ratings are available to all Medicare members prior to open enrollment. There are added incentives to attract patients to higher quality plans. For example, five-star plans can offer enrollment to patients year round, not just during open enrollment. To learn more quality measures, the following websites are recommended for review:
- CMS.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/Downloads/2014-Draft-Tech-Notes.pdf; and
There are numerous ways in which the profession has defined the quality of medication use, and pharmacy is key in the metrics designed for medication use. The star-measures specifically related to medication management and use will demonstrate how pharmacists can impact the overall rating through patient-centered care.
The star-measures looks at three specific areas — diabetes, cardiovascular, and cholesterol — relative to adherence measures. While there have been numerous methods designed to measure adherence in the past — such as medication possession ration, or MPR — the current measurement used is the proportion of days covered, or PDC. MPR has sometimes been criticized as overestimating the true rate of medication adherence. There are variations in the calculation of the PDC; however, PDC is considered to be more consistently defined than the MPR, according to the Pharmacy Quality Association. The calculation to achieve PDC is based on the fill dates and days supply for each fill of a prescription; however, it is not a simple summation of the days supply.
Health plans, PBMs and CMS are using the PDC calculation in determining the adherence rates of patients, as well as how patients from various pharmacies are managing their medications. Many payers have been tracking adherence of their beneficiaries for years, but recently began specifically looking at individual pharmacies to determine who is providing higher patient-centric quality care.
In addition to adherence, medication safety is focus for measuring quality in pharmacy. Use of HRMs is a key area of review for CMS. HRM is the percentage of patients older than 65 years who received two or more prescription fills for a high-risk medication during the measurement period — typically a 12-month period. The CMS star ratings for a plan to meet the HRM quality goal in 2013 was 5% or lower. This means that only 5% of patients should be on the medications that are considered high-risk. CMS has changed this metric for 2014 to 3%, which is the single-largest change seen in one metric. This is seen as an important measure to improve outcomes in elderly patients. Pharmacists are the gatekeepers to preventing the use of HRM in elderly patients. This medication safety metric does not prohibit a patient from taking some of the medications on the list, but instead reviews the usage over time. Table 1 provides a list of HRMs currently screened for this quality metric. Most pharmacists are familiar with the “Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.” The Beers Criteria now is maintained by the American Geriatrics Society, whereas the HRM list, and corresponding NDC code list, is maintained by PQA and includes only the subset of Beers medications that can be tracked reliably by prescription drug claims data.
Another medication safety metric provides pharmacists with opportunities to assist patients with diabetes to the appropriate ACE/ARB for hypertension. This metric underscores the appropriate medication selection to minimize harm to organs in patients with diabetes.
Of interest is the complexity of the two medication safety metrics. Both of these metrics rely heavily on pharmacists working with patients and prescribers. Unlike with adherence, where a pharmacist can help a patient become more adherent to therapy, these metrics cannot be impacted by just one individual. There is now, more than ever, a need for appropriate communication between all of the patient’s healthcare providers. HRM is a challenging measure, as the approach to improve this specific metric will require a multidisciplinary approach for pharmacists, patient, physicians and other prescribers.
In addition to the current CMS metrics, there are a number of display measures that have been developed by PQA and are being tackled. These include drug-drug interactions; excessive doses of oral diabetes medications; comprehensive medication review, or CMR; completion rate; and HIV antiretroviral medication adherence (only in safety reports). Additional metrics that are being used by some plans include asthma metrics for overuse of SABAs or under-use of maintenance medications.
To address a number of the metrics there has been a move toward partnerships for quality with plans, or PBMs, and community pharmacy. It is becoming more apparent that community pharmacy will be asked to assist plans and PBMs in moving toward obtaining a higher star rating. This is demonstrated in a number of developments. A health plan in Southern California is offering a pay for performance, or P4P, program for community pharmacies that have patients who are beneficiaries of the plan. The plan has in place specific metrics — CMS five star, asthma and others — that the pharmacies can reach and receive a payment every six months. These quality bonus payments are a way for the plan to provide additional reimbursement to those pharmacies that provide the highest level of patient-centric care, and who are tracking their progress on the metrics. This specific plan is partnering with Pharmacy Quality Solutions, or PQS, to use the Electronic Quality Improvement Platform for Plans and Pharmacies, or EQuIPP.
Globally, PQS tracks quality metrics for specific plans. Pharmacies may engage with PQS to access the EQuIPP platform, which shows them specifically where they stand on each of the quality metrics relative to the goals of a given plan (or CMS five-star goals), whether that is for adherence rates, medication safety initiatives or other metrics. The EQuIPP platform allows pharmacists to “Know Your Numbers” — how well performance is recorded relative to quality metrics.
Plans also are reviewing the current preferred network processes that they use. While historically cost has been a driving factor in the preferred networks, moving forward plans are looking to move to a quality and cost system. Plans are looking to those pharmacies that can drive them to a five-star status — the highest rating possible. Pharmacies that can provide five-star services to plan beneficiaries will be looked upon more favorably than those that provide lower star ratings
What impact do the quality metrics have on patient-centered care? Pharmacists are now being looked upon to apply clinical training across the board in community settings to drive quality. While this may not be happening in each and every practice, we are seeing the beginnings of a movement across the profession and specifically in community settings. Pharmacists are in a position to engage patients not only on the quality metrics to adherence and medication safety, but also transition of care, MTM services and other clinical-based disease state programs. All of these efforts to improve the patients’ medication-use quality result in better disease state management, adherence rates and patient understanding.
Enlisting patients in the drive to improve Rx
Nowhere is the need to engage more effectively with patients more apparent than in the area of medication adherence.
“Over 50% of patients with chronic conditions stop taking their medications,” said Diane Gilworth, a geriatric nurse practitioner and chief clinical officer for Dovetail Health. “So we have to find a way to help patients take better care of themselves.”
The health system’s dismal record for effectiveness in getting patients to adhere to their drug regimens prompted GlaxoSmithKline to overhaul its approach to encouraging adherence and to create a new business unit, called the Patient Engagement Group.
“We were doing things like refill reminders and text messages. We’re really good at patient education, at pushing leaflets and alerts to patients. But with all those rational solutions, we were completely missing the irrational behavioral part of nonadherence,” said Christy Brown, a pharmacist who directs patient engagement efforts at GSK as head of insights and innovation.
“How do we get people more engaged and more active in their health? … That in turn will lead to better adherence,” she said.
In response, GSK shifted its marketing focus “from a very product-focused, information-based, one-way conversation to a more behavioral-based approach … and giving providers some tools,” Brown said.
“We have to get into patients’ homes and understand, on a very granular, detailed level, what those behavioral characteristics are that are driving patients not to take their medications,” she said. “If we can reduce the readmission rate and lower total medical expense, then people will understand there’s a value here. And they’ll be willing to pay for longitudinal care.”
That shift, Gilworth added, “is a very big change because we used to think of things in very tight financial time frames. We have to extend that now, probably beyond the 30-day readmission incentives.”
That broader, more holistic, longer-term focus on health and outcomes, she said, is already beginning to occur among accountable care organizations. “ACOs are beginning to … understand that we have to take care of people over the long run, and that behavior, particularly in chronic disease, waxes and wanes,” Gilworth said. “How do you stay engaged when you’re trying to figure out how to eat?”
Engaging patients: Health care’s new ‘holy grail’
It has been called “the blockbuster drug of the century,” the holy grail of health care and the next great frontier in the search for a more responsive and cost-effective healthcare system. But is it a truly achievable goal, and will it really transform the way health care is delivered in the United States?
We’re talking about the health system’s vast, but still halting, movement to engage and empower patients. The ability and willingness of patients to engage more fully in their own health care and disease prevention is the lynchpin of the health system’s gradual but inexorable embrace of patient-centered care, and advocates say it will transform the relationship between patients and their clinicians — and, along with it, the way health care is delivered in America.
“Patient engagement is at the forefront of today’s health reform debate to the extent that it has even been called the next blockbuster drug,” said Wendy Everett, president of NEHI, the nonprofit health policy and advocacy group formerly known as the New England Health Initiative. “And as the system begins to focus on improving value and controlling costs — and as providers are increasingly held accountable for patient outcomes — how patients are engaged, empowered and activated will all play a critical role.”
Kristin Carman, a VP at the American Institutes for Research, describes the engagement process as “patients, families, their representatives and health professionals working in active partnership at various levels across the healthcare system to improve health and health care.”
Writing for Medical Home News, Sara Guastello, a director with the influential health consultancy organization Planetree, defines patient-centered care as “care delivered in a way that incorporates the patient’s perspective, is organized around his or her experiences and values, and is responsive to needs that may change over time.”
“For the vast potential of patient-centered care as a crucial lynchpin for healthcare quality to be realized, we must invite patients in to be a part of the discussion … and to be a part of developing the solutions for achieving that aim,” Guastello said.
“Patients with the skills and confidence to be actively engaged in their health care,” Guastello said in a conference earlier this year, are less likely to require an emergency room visit or hospital stay; “more likely to adhere to treatment plans;” more likely to adopt healthy behaviors and achieve better health outcomes; and less costly to insurers and health plan payers. That makes patient-centered care and a full regard by health providers for the patient experience “nothing less than a quality and business imperative,” according to Planetree.
How much progress has the nation’s health provider community made in adopting the new, more patient-centric and patient-engaged model of care? Not nearly enough, say many providers.
Among them is physician Robert Mandel, CEO of Health Dialog, a provider of health management services. “I don’t think we’re very far along on rewiring [the healthcare system],” he noted. “Traditionally, the health system has taken [patients’ sense of] control away. It’s been a very lopsided relationship that’s created this sense of helplessness among patients.”
The healthcare industry, Mandel noted at an Oct. 3 conference on patient engagement hosted by NEHI in Boston, “needs to think of itself in a much broader way. It’s really about individual well-being and how we as clinicians contribute to people’s well-being in the most effective way possible.”
“This is a continuous dialogue for your entire life, about how you optimize your well-being based on a whole host of things — your environment, your genetics, your behaviors,” Mandel added. “It’s not just about self-management of a condition. It’s about how you manage your health throughout your life, and how we [as clinicians] support that.”
In one respect, the demand by patients to share more completely in their own healthcare decisions could be seen as just the latest stage on which the Baby Boom, Gen X and Gen Y generations are acting out their lifelong determination to exert their influence and individuality. But the rise of the engaged and more informed patient is also gaining traction among health providers at all levels. Among the reasons:
- It works. According to studies, patients who are encouraged to participate fully in their own treatment plans by empathetic doctors, nurses and pharmacists show demonstrable improvements in outcomes;
- Patients who become true partners in their own health — including adopting healthier behaviors and researching their own conditions and treatments — can help ease the practice loads on time-pressured, overbooked primary-care physicians; and
- Patients effectively enlisted in their own care are more likely to adhere to their medication andtreatment regimens.
Fueling the drive to engage patients as partners is the urgent need to curb the nation’s runaway health costs. Citing federal statistics, Planetree’s Guastello reports that 24.7% of Medicare patients are readmitted to hospitals within 30 days of discharge, costing taxpayers an extra $17 billion annually. And with health reform gradually shifting hospital reimbursements to penalize those with excessive readmission rates and reward providers for measurable improvements in patient outcomes, the need for a paradigm change in health delivery has only increased.
Indeed, increasing transparency about the true cost of care will help drive patients to become more engaged in their treatment, experts say. “At the very least, it stops the conversation and focuses on how important is this test, and what are we going to do with the results?” Diane Gilworth, a geriatric nurse practitioner and director of clinical care at Dovetail Health, said.
“It’s going to engage a new kind of conversation when we begin to infuse costs,” she added. Health practitioners, she said, have “always been worried about having that conversation, because we don’t want to be in a situation where cost influences our choices. But the reality is we have to … begin to have that conversation.”
“We’re not going to solve health care’s problems unless we fundamentally restructure the way we see patients,” Gilworth said. “We need more time to have trusting, vulnerable, trust-based relationships so things don’t fall through the cracks, and that’s going to take an entire change in the way we pay for health care.”
According to the National eHealth Collaborative, the overarching goal is to develop “more efficient and effective models of care that treat patients as partners instead of just customers.” To that end, the collaborative devoted nearly a year to developing a Patient Engagement Framework — based on input from more than 150 experts in health care, technology and human behavior — “to guide healthcare organizations in developing and strengthening their patient engagement strategies through the use of e-health tools and resources.”
“It provides a basic framework” for patients and providers, beginning with “informing, navigating the system, finding a provider, etc.,” said Kate Berry, CEO of the National e-Health Collaborative. The framework addresses the whole continuum of care between clinicians and empowered, informed patients, including such issues as developing a wellness plan, shared decision-making, care experience surveys, electronic health records and integration of patient records with clinical trials and insurance claims data.
“This is not how the system works today. So it’s a huge cultural change, both for … patients, and for providers as well,” Berry said at NEHI’s Oct. 3 conference. She added, “you can’t do any of that without health information technology as an enabler.”
Addressing the NEHI gathering, Harvey Fineberg, president of the Institute of Medicine, recalled the nature of the doctor-patient relationship a half-century ago. The “authoritarian physician,” he noted, was “direct, certain, unwilling to compromise and uninterested in others’ opinions.”
“We’ve all encountered these physicians,” he said. “But … if you are truly patient-centered in your relations to the patients’ needs, it’s not about you deciding and choosing. It’s about understanding and learning from each patient, at each stage of illness, exactly what that patient needs at that moment, and being prepared to … meet the patient where the patient needs to be met.”
That involves learning new ways to communicate on the part of both patients and providers. And it means clinicians and other caregivers must understand that “for the vast majority of people out there, their lives do not revolve around their health,” noted Alexandra Drane, founder and chairperson of health consultancy Eliza Corp. “They’re not sitting around waiting to get lectured.”
Feinberg said the Institute of Medicine is working to shift the paradigm toward empowered patients. “Like NEHI, we have tried to increase the focus on patient engagement and what it really means to be patient-centered. Figuring out what it means to realize patient-centeredness in care has been a continuing task over [the] last dozen years,” he said.
Increasingly, pharmacy leaders also are focusing on patient empowerment. “This is an area … on state pharmacy associations’ radar,” said Rebecca Snead, EVP and CEO of the National Alliance of State Pharmacy Associations.
Peggy Funk, interim executive director of the Maryland Pharmacists Association, said: “MPhA has been working closely with the Script Your Future Coalition that is focused on this issue. We’ve already hosted a few events … with the goal of strengthening a patient’s own motivation and commitment to change.”
Among the goals, Funk said, are helping pharmacists and nurses improve medication adherence, empathy and patient communications through motivational interviewing education.
Also working in collaboration with other health advocates to boost patient-centered approaches is the Connecticut Pharmacists Association, which co-sponsored a conference in September, titled: “Better Health: Everyone’s Responsibility.” Association EVP Margherita Giuliano said, “we are part of a coalition called CT Partners for Better Health. The coalition will be continuing this focus going forward.”
“It’s very important,” said Laura Cranston, executive director of the Pharmacy Quality Alliance. “Patient-centered care is about meeting the patient where they are at a given point in time. It’s not treating every patient exactly the same.”
“What our system is being challenged to do across every segment of pharmacy, and of health care, is to say, ‘Where is the voice of the patient in the work that you’re doing, and how can you make the voice of the patient relevant so they understand what we’re trying to measure and why?’” she said.
To that end, Cranston told DSN Collaborative Care, “the healthcare system as a whole is asking, ‘What is the patient’s experience with their pharmacy provider, their dental provider, their primary-care provider?’ And they’re all saying they need to be able to measure the patient’s experience. So as we head into 2014, one of our challenges is … [that] the healthcare system needs more patient-reported outcomes measures.”
What’s more, “low health literacy impacts a patient’s ability to engage in the healthcare system,” noted Thomas Buckley, assistant clinical professor at the University of Connecticut School of Pharmacy. Addressing the CPhA conference in September, Buckley cited a study published in the Journal of the American Medical Association that found that 33% of Americans were unable to read basic healthcare materials, 26% were unable to understand information on an appointment slip, and 60% did not understand standard informed consent.
Overcoming that gap is one of many steps that can lead to a new, more fruitful partnership between patients and their physicians, pharmacists and nurses, said Christine Bechtel, planning chair of the National Partnership for Women and Families.
“It’s essential that the culture of the system change, and that starts with more communication,” she said. “We need to start talking with patients, instead of to them or about them.”
Patients need to be part of that culture shift from the outset, said Susan Sheridan, director of patient engagement for the recently established Patient-Centered Outcomes Research Institute created as part of the Patient Protection and Affordable Care Act. “To get good care, we need good information and good policies, and that can come from good research that’s patient-centered, with patients helping design more relevant research and information,” she said.
To that end, PCORI will launch a new training program in the fall to design guidelines for researching patient-centered outcomes. The group is inviting scientists, patients, clinicians and other stakeholders “to really understand what that research science is,” Sheridan said.