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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.