Making It Stick: New Strategies for Medication Adherence
Alexandra Tungol Lin, PharmD
Clinical Manager ‐ Health Outcomes & Pharmacy Care Management Blue Cross Blue Shield of Michigan
Objectives
• Describe the impact of the Quality Rating System (QRS) on payers
• Define the Proportion of Days Covered (PDC) measure
• Identify how QRS represents opportunities for pharmacists in the retail and ambulatory care settings
• Recognize strategies to improve medication adherence
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What is the Quality Rating System (QRS)?
A system that rates Qualified Health Plans (QHPs) based on relative quality and price
Think the Commercial version of Medicare Part D Stars
Centers for Medicare & Medicaid Services. Health Insurance Marketplace Quality Initiatives. Available at: https://www.cms.gov/Medicare/Quality‐Initiatives‐Patient‐Assessment‐Instruments/QualityInitiativesGenInfo/Health‐Insurance‐
Marketplace‐Quality‐Initiatives.html. Accessed September 10, 2015.
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Purpose of QRS
• Inform consumers regarding the quality of healthcare services and enrollee experience with useful and comparable information
• Facilitate regulatory oversight of QHPs offered
• Allow issuers to improve performance through self evaluation
Centers for Medicare & Medicaid Services. Overview of 2015 QRS Requirements for QHP Issuers. Available at: https://www.cms.gov/Medicare/Quality‐Initiatives‐Patient‐Assessment‐Instruments/QualityInitiativesGenInfo/Downloads/Issue‐
Brief‐4‐QRS‐Requirements‐for‐Issuers.pdf. Accessed September 10, 2015.
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QRS Scores on HealthCare.gov
• 2015 was the beta test year for QRS
• Ratings information will be publically displayed beginning fall 2016
•Health Insurance Marketplace. Available at: https://www.healthcare.gov/. Accessed January 4, 2016.
•Centers for Medicare & Medicaid Services. Quality Rating System Measure Technical Specifications. Available at: https://www.cms.gov/Medicare/Quality‐Initiatives‐Patient‐Assessment‐Instruments/QualityInitiativesGenInfo/Downloads/2015‐QRS‐Measure‐
Technical‐Specifications.pdf. Accessed September 10, 2015.
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QRS Measure Set
• Evidence based recommendations supported by NCQA, PQA and AHRQ
• Consists of 43 measures, 12 of which are survey measures collected as part of the QHP Enrollee Survey
NCQA=National Committee for Quality Assurance; PQA=Pharmacy Quality Alliance; AHRQ=Agency for Healthcare Research and Quality
Centers for Medicare & Medicaid Services. Quality Rating System Measure Technical Specifications. Available at: https://www.cms.gov/Medicare/Quality‐Initiatives‐Patient‐Assessment‐Instruments/QualityInitiativesGenInfo/Downloads/2015‐
QRS‐Measure‐Technical‐Specifications.pdf. Accessed September 10, 2015.
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QRS Measures Implemented in 2015
Access to Care*
Access to Information*
Annual Dental Visit
Flu Shots for Adults Ages 18‐64*
Follow‐Up After Hospitalization for Mental Illness (7‐Day Follow‐
Up)
Initiation and Engagement of Alcohol and Other Drug Dependence Treatment
Annual Monitoring for Patients on Persistent Medications Plan Administration*
Appropriate Testing for Children With Pharyngitis
Prenatal and Postpartum Care Appropriate Treatment for Children With Upper Respiratory Infection
Proportion of Days Covered Care Coordination
Rating of All Health Care*
Cervical Cancer Screening
Rating of Health Plan*
Chlamydia Screening in Women
Rating of Personal Doctor*
Comprehensive Diabetes Care: Eye Exam (Retinal) Performed
Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Control (<8.0%)
Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Testing
Comprehensive Diabetes Care: Medical Attention for Nephropathy
Controlling High Blood Pressure
Cultural Competence*
Rating of Specialist*
Relative Resource Use for People with Diabetes (Inpatient Facility)
Use of Imaging Studies for Low Back Pain
Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents Well‐Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life
Asterisk (*) – Collected as part of QHP Enrollee Survey Centers for Medicare & Medicaid Services. Quality Rating System Measure Technical Specifications. Available at: https://www.cms.gov/Medicare/Quality‐Initiatives‐Patient‐Assessment‐Instruments/QualityInitiativesGenInfo/Downloads/2015‐QRS‐
Measure‐Technical‐Specifications.pdf. Accessed September 10, 2015.
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QRS Measures Implemented in 2016 and 2017
Adult BMI Assessment
Antidepressant Medication Management
Aspirin Use and Discussion*
Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
Breast Cancer Screening
Childhood Immunization Status (Combination 3)
Colorectal Cancer Screening
Follow‐Up Care for Children Prescribed ADHD Medication
HPV Vaccination for Female Adolescents
Immunizations for Adolescents (Combination 1)
Medical Assistance With Smoking and Tobacco Use Cessation*
Medication Management for People With Asthma (75% of Treatment Period)
Plan All‐Cause Readmissions
Well‐Child Visits in the First 15 Months of Life (6 or More Visits)
Asterisk (*) – Collected as part of QHP Enrollee Survey Centers for Medicare & Medicaid Services. Quality Rating System Measure Technical Specifications. Available at: https://www.cms.gov/Medicare/Quality‐Initiatives‐Patient‐Assessment‐Instruments/QualityInitiativesGenInfo/Downloads/2015‐QRS‐
Measure‐Technical‐Specifications.pdf. Accessed September 10, 2015.
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Health Plan’s Dilemma
Marketplace QRS
Medicare Stars
NCQA Accreditation
Alignment of Quality Efforts
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Crosswalk of Quality Measures
Pharmacy Related QRS Measure
NCQAa Stars
Annual Monitoring for Patients on Persistent Medications


Appropriate Testing for Children With Pharyngitis


Appropriate Treatment for Children With Upper Respiratory Infection


Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Control (<8.0%)

b
Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Testing


Controlling High Blood Pressure


Proportion of Days Covered (diabetes, RAS antagonists, statins)


Antidepressant Medication Management


Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis


Follow‐Up Care for Children Prescribed ADHD Medication
Medication Management for People With Asthma (75% of Treatment Period)



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aHEDIS
measure required for NCQA Accreditation of Commercial Health Plans; bStars evaluates for HbA1c poor control (>9.0%)
•Centers for Medicare & Medicaid Services. Quality Rating System Measure Technical Specifications. Available at: https://www.cms.gov/Medicare/Quality‐
Initiatives‐Patient‐Assessment‐Instruments/QualityInitiativesGenInfo/Downloads/2016‐QRS‐Measure‐Technical‐Specifications.pdf . Accessed January 8, 2016. 10
•Centers for Medicare & Medicaid Services. Medicare 2016 Part C & D Star Rating Technical Notes.
Multi‐Pronged Strategy to Address Quality Measures
Patients
Prescribers
Network Pharmacies
• Adherence Patient Outreach Call Program
• Health Fairs
• Pharmacy Benefit Quick Guide • Pharmacy Website & Mobile Apps
• Prescriber Reports & Dashboards (patient level adherence rates)
• Physician Incentive Programs
• Pharmacy Reports & Dashboards (patient level adherence rates)
• Pay for Performance
Data
Data
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Proportion of Days Covered (PDC)
• Definition: The number of days that a patient is covered by prescription claims for the same medication or within equivalent therapeutic category, divided by the number of days in treatment period
# Days Covered
# Days of Treatment Period
• Treatment period: Period of time beginning on the earliest prescription dispensing date (prior to September 30th) of that year and ending with last day in the year or date of death or disenrollment. Treatment period must be at least 90 days long
Centers for Medicare & Medicaid Services. Quality Rating System Measure Technical Specifications. Available at: https://www.cms.gov/Medicare/Quality‐Initiatives‐Patient‐Assessment‐Instruments/QualityInitiativesGenInfo/Downloads/2016‐
QRS‐Measure‐Technical‐Specifications.pdf . Accessed January 8, 2016.
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PDC Threshold
• A patient is considered adherent if PDC > 80% (level which the potential clinical benefit of cardiovascular and diabetes medications is achieved)
 For example, a patient is on a statin medication and gets 30‐day fills. If the patient is late for a refill or fails to receive or refill the medication, the PDC is lowered
• Patients targeted by this measure have at least two prescriptions filled for the following drug classes: diabetes (all classes excluding insulin), RASA, statins
Centers for Medicare & Medicaid Services. Quality Rating System Measure Technical Specifications. Available at: https://www.cms.gov/Medicare/Quality‐Initiatives‐Patient‐Assessment‐Instruments/QualityInitiativesGenInfo/Downloads/2016‐
QRS‐Measure‐Technical‐Specifications.pdf. Accessed January 8, 2016.
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Drug Classes
Diabetes
•Biguanides
•Dipeptidyl peptidase IV inhibitors (DPP4)
•Incretin Mimetic Agents
•Meglitinides
• Sodium glucose co‐
transporter 2 inhibitors (SGLT2)
•Sulfonylureas
•Thiazolidinediones
•Combination products
Renin Angiotensin
System Antagonists (RASA)
• Angiotensin converting
enzyme inhibitors (ACEs)
• Angiotensin II receptor blockers (ARBs)
• Direct renin inhibitor
• Combination products
Lipid Lowering Agents
• Statins
• Combination products
Centers for Medicare & Medicaid Services. Quality Rating System Measure Technical Specifications. Available at: https://www.cms.gov/Medicare/Quality‐Initiatives‐Patient‐Assessment‐Instruments/QualityInitiativesGenInfo/Downloads/2016‐
QRS‐Measure‐Technical‐Specifications.pdf. Accessed January 8, 2016.
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Adherence Strategies & Clinical Pearls Adherence Estimator
1. “I am convinced of the importance of my prescription medication”
2. “I worry that my prescription medication will do more harm than good to me”
3. “I feel financially burdened by my out‐of‐pocket expenses for my prescription medication”
Disagree completely
Disagree mostly
Disagree somewhat
Agree somewhat
Agree mostly
Agree completely
•Merck. Adherence Estimator. Available at: http://www.adherenceestimator.com/. Accessed January 8, 2016. •McHorney CA. The Adherence Estimator: a brief, proximal screener for patient propensity to adhere to prescription medications
for chronic disease. Curr Med Res Opin. 2009 Jan;25(1):215‐38.
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Medication Synchronization/
Appointment Based Model (ABM)
• Definition: The pharmacist coordinates the refill of a patient’s medications so he/she can pick them up on a single day each month
• Resources
– Pharmacy Locator: • http://www.aphafoundation.org/map
– Implementation guide & resources:
• http://www.aphafoundation.org/appointment‐based‐model
– PQA Medication Synchronization Educational Series:
• http://pqaalliance.org/resources/other.asp
APhA Foundation. Pharmacy’s Appointment Based Model (ABM). Available at: http://www.aphafoundation.org/
appointment‐based‐model. Accessed January 8, 2016. 17
Adherence Tips & Tricks
• Setting reminders through an alarm clock or phone
• Pillboxes
• Store medications in the same place and incorporate as part of your daily routine
• Keep an up to date list of medications
• Mobile apps
– MyMedSchedule (free): www.mymedschedule.com
– MyMeds ($9.99/year): http://about.my‐meds.com
Dayer L, Heldenbrand S, Anderson P, Gubbins PO, Martin BC. Smartphone medication adherence apps: potential benefits to patients and providers. J Am Pharm Assoc (2003). 2013 Mar‐Apr;53(2):172‐81. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/
PMC3919626/. Accessed January 8, 2016. 18
Adherence Tips & Tricks (contd)
• Community Pharmacy
– 90 day fills
– Automatic refills
– Refill reminders
• Patients that are traveling should plan ahead regarding refills
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Pick Up Lines
“gaps in refill history”
“Your doctor and I can work together to help you”
“Everyone forgets to take their medicine from time to time. When was the last time you forgot to take any of your medicine?” Agency for Healthcare Research and Quality. AHRQ Health Literacy Universal Precautions Toolkit. Tool 16: Help Patients Remember How and When to Take Their Medicines. Available at: http://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality‐patient‐
safety/quality‐resources/tools/literacy‐toolkit/healthlittoolkit2.pdf. Accessed January 7, 2016. 20
Case Example:
Addressing Statin Muscle Aches
• Patients may address by
– Taking their statin on an alternate dosing schedule (e.g., every other day)
– Tablet splitting
• Pharmacists may address by considering
–
–
–
–
–
Alternative statin
Drug‐drug interactions
Statin dose decrease
If exercising may be causing the pain
Vitamin D supplements
Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to ReduceAtherosclerotic
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Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014 Jun 24;129(25 Suppl 2):S1‐45. Available at: http://circ.ahajournals.org/content/129/25_suppl_2/S1.long. Accessed January 8, 2016. Follow Up
• After talking with the patient, summarize in writing what was discussed and send to patient
• Patient educational flyers
• Track outcomes
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Publicly Available Resources
Script Your Future
National Consumers League. Script Your Future. Available at: http://www.scriptyourfuture.org/tools/. Accessed January 8, 2016. 24
FDA
U.S. Food and Drug Administration. Medication Adherence (October 2015). Available at: http://www.fda.gov/Drugs/ResourcesForYou/
HealthProfessionals/ucm470165.htm. Accessed January 8, 2016.
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Adult Meducation
American Society on Aging and American Society of Consultant Pharmacists Foundation. Adult Meducation: Improving Adherence in Older Adults. Available at: http://www.adultmeducation.com/. Accessed January 8, 2016.
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American College of Preventive Medicine
American College of Preventive Medicine. Medication Adherence Time Tool Launch Page. Available at: http://www.acpm.org/?Adherence. Accessed January 8, 2016. 27
“Cash” Claims
Make it “Count”: If there is no claim, it did not happen…
Recall the definition of PDC: The number of days that a patient is covered by prescription claims for the same medication or within equivalent therapeutic category, divided by the number of days in treatment period
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Generic Drug Discount Programs
• Launched in 2006 • Offered by various pharmacies
• Select generics available for as low as $4 for 30 day supply, $10 for 90 day supply or free
• Membership vs. Non‐Membership programs
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Submitting Claims: Why it Matters to the Patient
• Lowest available prices for drugs
• Review of each drug claim for several safety factors
– Drug interactions
– Inappropriate dosages
– Duplicate medications • Care management programs: Patients are targeted based on their pharmacy and medical claims history • Transactions that count: Transactions apply toward patients’ deductibles and out‐of‐pocket maximums
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Submitting Claims: Why it Matters to You as the Pharmacist
• Pay for Performance • Performance based pharmacy networks
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What You Can Do
• Use the NCPDP field 426‐DQ (U&C Charge)
when submitting claims for discounted medications offered by your pharmacy
• Educate and train pharmacy staff to properly submit claims through the insurance, including discounted and free medications
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Conclusions
• QRS evaluates Marketplace plans similar to how the Star Ratings evaluate Medicare plans
• Pharmacists can have a major role in improving medication adherence and other quality measures for QRS, Stars and HEDIS
• The Proportion of Days Covered (PDC) measure evaluates medication adherence based on pharmacy claims data
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