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PBMI – 2016 Excellence Award
Submitted by:
Inland Empire Health Plan (IEHP)
10801 Sixth Street, Suite #120
Rancho Cucamonga, CA 91730
Program/Pilot/Product Description:
Background/History
Inland Empire Health Plan (IEHP) is a not-for-profit health plan primarily serving the metropolitan areas
of San Bernardino and Riverside counties located in southern California. To date, IEHP offers both
Medicaid (Medi-Cal) and Medicare health plans with approximately 1 million total covered lives.
Historically, IEHP struggled to achieve quality performance goals for both Medicare and Medicaid lines
of business in Part D medication-related performance goals associated with the CMS Five Star Quality
Rating System. The 2014 Medicare Star Ratings for one of IEHP’s contracts (H5640) that was eligible for
scoring is listed below in Table 1:
Table 1
Measure Name
High Risk Medication Use in the Elderly
Medication Adherence: Diabetes
Medication Adherence: Hypertension
Medication Adherence: Cholesterol
2014 Star Rating
2
2
1
1
Across both Medicare and Medicaid members, the performance for key medication use quality
measures was lacking and tremendous opportunities exist in closing medication related care gaps.
Most Medicare Health Plans elect to adopt internal programs to boost their Star Ratings, however,
health plan-run programs may be short-lived and the interventions are not customized to patients’
conditions. A long term initiative was created to optimize pharmacy quality care using the Pharmacy
Provider Network.
Historically, network pharmacies have not been leveraged or engaged as a partner with health plans to
improve performance despite the high encounter rate with members and unique positioning to help
improve performance on medication-related quality measures. With this recognition, IEHP sought to
foster a more collaborative relationship with the pharmacy network to improve quality on measures
related to medication use.
In 2014, IEHP elected to change the reimbursement methodology for community pharmacies which
resulted in a net budgeted surplus for the plan. In order to creatively engage and leverage network
pharmacies to help improve overall performance, the savings realized by IEHP after changing the
reimbursement methodology were used to create a bonus pool for a retail pharmacy engagement
program (i.e. Pay-For-Performance (P4P)) with performance incentives. The focus of the P4P program
was to improve performance within prescription-based quality measures such as those associated with
adherence and patient safety.
Program Overview
In order to engage network pharmacies serving a considerable number of IEHP members in their local
communities a focused program eligibility was defined. The program limited participation only to those
pharmacies in the immediate service area of San Bernardino and Riverside counties who were also
processing a minimum threshold of 500 claims for IEHP members over a 6 month period.
At the commencement of the Pharmacy P4P Program in October 2013, around 500 pharmacies met the
eligibility criteria of which over 200 were independent pharmacies and the remaining being pharmacies
comprised of retail chains and/or mass merchants.
These participating pharmacies were then scored on a total of 7 weighted measures which were areas of
significant opportunity for IEHP. The measures were scored using a point system for achieving certain
levels of performance, with clinical measures receiving a higher weighting. The initial measures in the
Pharmacy P4P Program included: Proportion of Days Covered for Diabetes, Hypertension, and
Cholesterol, Asthma-Absence of Controller Therapy, Use of High-Risk Medications in the Elderly,
Diabetes-Appropriate Treatment of Hypertension, and generic dispensing rate.
With the plan demographics containing a large Medicaid population with unique needs, the asthma
measure was included in the program due the need for improvement and ability for pharmacies to help
increase quality in the disease state. The non-clinical measure associated with the program is the
generic dispensing rate (GDR) which carries less weight in the overall performance evaluation.
The plan recognized that sharing updated pharmacy-level performance data was a key element to help
network pharmacies track their current performance, especially as it related to individual program goals
established by IEHP. As a result, the plan partnered with Pharmacy Quality Solutions, Inc. by hosting
performance data on clinical measures within the EQuIPP™ dashboard, which made performance data
available to pharmacies and IEHP. The dashboard was updated on a monthly basis and represented a
rolling 6-month measurement period in order for pharmacies to accurately track measure performance
trends and observe the impact of various clinical programs or patient interventions.
Specific measure performance listed in the EQuIPP dashboard was used to determine an overall
performance score for each participating pharmacy. The overall performance score was determined by
the number of points obtained for each measure by hitting two possible performance thresholds. The
first threshold represented a target corresponding with a previous CMS 3-Star MAPD threshold, where
applicable. Pharmacies that achieved this threshold received one half-point for each measure. The
second threshold represented a bonus threshold corresponding with a previous CMS 5 Star threshold
where pharmacies would receive one full point. Therefore, high performing pharmacies are awarded a
greater number of overall points and a higher percent of the total performance bonus disbursed at the
end of each 6 month measurement period. The plan then applied the overall performance score to an
incentive calculation that was dependent on the prescription claim volume processed by the pharmacy
during the measurement period to generate a performance bonus for the pharmacy.
The plan determined that disbursing performance incentives after each 6 month measurement period
would be most effective for maintaining pharmacy engagement and for ensuring program transparency
by having incentive payments tied to the corresponding measurement periods displayed within EQuIPP.
With program commencement in October 2013, the first measurement period corresponded to October
2013 through March 2014 where the plan held multiple pharmacy stakeholder committee meetings
between IEHP and participating pharmacy organizations. The purpose of the stakeholder meetings was
to bolster pharmacy engagement with a comprehensive understanding of the program as well as discuss
available resources for performance improvement. To date, the program completed 4 measurement
periods where improvement has been observed (as noted in the Achieved Outcomes section) and has
also evolved into a second phase (as noted in the Lessons Learned section).
Achieved Outcomes (e.g., improved health outcomes, realized savings):
As formerly stated, IEHP had considerably low performance across several of the medication-related
quality measures and corresponding disease states. However, some of the most visible performance
scores specific to Medicare are those publicly reported in the CMS 5 Star Quality Rating System, and as a
result, much attention was paid to performance improvement across the three adherence measures
mentioned above.
At baseline, ahead of the October 2013 launch, performance for each of the adherence measures is
listed below in Table 2.
Table 2
Measure Name
Medication Adherence: Diabetes
Medication Adherence: Hypertension
Medication Adherence: Cholesterol
Baseline Performance Score (PDC)
Among P4P Eligible Pharmacies
74.47%
74.04%
71.80%
Overall low performance trends from baseline were maintained throughout the first 6 month
measurement period as displayed in Chart 1. The first performance period ended in March 2014 with
the subsequent performance incentives being disbursed in August 2014. Once the first bonus
disbursement was applied, communications were sent to participating pharmacies indicating the
amount of bonus money not obtained when compared to pharmacies performing in the top 20%;
therefore, all participating pharmacies were made aware of the bonus money “left on the table” with
their current performance. Furthermore, pharmacies also gained insight on the bonus amount of their
top performing pharmacy peers which quickly demonstrated the value and urgency to become more
engaged in the P4P program and improve performance.
As a result, performance during the following two months improved sharply as indicated by the blue
arrow listed in Chart 1. Within 6-month rolling measurement periods there were performance increases
that ranged from 12-16% from baseline across all three adherence measures which has been relatively
sustained throughout the program to date.
As a means to indirectly measure the level of engagement among P4P pharmacies with store level
access to the EQuIPP dashboard, IEHP also measured the number of pharmacies that were regularly
tracking performance four months prior and four months after disbursement. As listed in Chart 2,
pharmacies were typically accessing performance rates within EQuIPP 3-3.5 times per month. Prior to
the first performance incentive payment, 40% of stores with store-level access were regularly
monitoring their performance. However, once the payment was disbursed followed by the
communication listed above, almost 80% of applicable stores were then accessing their performance
information 3-3.5 times per month.
Chart 1
Chart 2
Due to contract consolidation and migrating member populations from an existing contract to a new
MAPD contract, it becomes difficult to directly compare the 2014 Star Ratings to the 2016 ratings with
the newest contract being too new for determining star scores. Therefore, determining performance for
the plan’s Medicare population can be surmised by averaging the 2014 (2016 Stars) performance across
both contracts as listed in Table 3.
Table 3
H5640
H5355
Average Score
Diabetes PDC
2014
71.00%
77.00%
74.00%
RASA PDC
2014
70.00%
76.00%
73.00%
Statin PDC
2014
65.00%
76.00%
70.50%
HRM
2014
9.00%
5.00%
7.00%
Extrapolating the average score between both MAPD contracts and comparing the score against the
2016 cutpoints results in the expected Star scores listed below in Table 4.
Table 4
H5640
H5355 (if able to be rated)
Average (based on average score)
Diabetes PDC
2016 Stars
3
NA (4 Stars)
3
RASA PDC
2016 Stars
2
NA (3 Stars)
3
Statin PDC
2016 Stars
2
NA (4 Stars)
3
HRM
2016 Stars
3
NA (5 Stars)
4
Ultimately, by comparing the expected 2014 average (2016 Stars) between the plan’s two MAPD
contracts and the 2012 performance (2014 Stars) of contract H5640, the plan has observed a significant
performance improvement. Table 5 lists the comparative Star Ratings from 2014 to 2016.
Table 5
Measure Name
High Risk Medication Use in the Elderly
Medication Adherence: Diabetes
Medication Adherence: Hypertension
Medication Adherence: Cholesterol
2014 Star Rating
2
2
1
1
2016 Star Rating
4
3
3
3
Change
+2
+1
+2
+2
Lessons Learned:
 Leveraging the pharmacy network to help improve medication-use quality is an effective
resource especially when combined with incentives related to performance.
 Sharing performance information with pharmacies helps pharmacy team members to
understand improvement opportunities.
 Partner with Pharmacies (Corporate office for Chains or PSAOs for independents) to maximize
performance and foster relationships.
 Hosting stakeholder meetings with pharmacy partners is key to a successful program as lessons
and best practices can be shared amongst participants to help drive success for the overall
program.
 Transparency with performance and program details are crucial to developing a strong
relationship with network providers.
 Setting percentile-based performance thresholds may be a better method to drive continuous
performance rather than static cutpoints.
o Note: Phase II of the IEHP Pharmacy P4P Program will involve additional measures such
as an additional Asthma treatment measure along with Statin Use in Persons with
Diabetes. Program thresholds have been updated to reflect current percentile-based
performance which will be updated on a yearly basis.