Equipped
for Adherenc
EQuIPP supports quality improvement
strategies for community pharmacies
and the payer community
By Mark Conklin, PharmD, MS
36
america’s
Pharmacist | June 2012
www.americaspharmacist.net
e
Today’s health care system is
photography: iStockphoto
trending toward value-based purchasing arrangements.
Increasingly, provider compensation will not be tied
solely to a set fee per service, but rather to the value of the
health outcome, plus an incentive payment for providers
who can demonstrate improvements in patient care. One
of the strongest drivers for this change is the Centers
for Medicare & Medicaid Services (CMS), which added
medication adherence to its plan ratings program (also
known as star ratings) in 2012. Medicare Part D plans
are rated on a scale of one to five stars, and that rank is
now based, in part, on medication adherence. Medicare
beneficiaries are able and encouraged to count a plan's
stars when considering which to choose. Additionally,
CMS has tied Medicare Advantage plans’ medication
adherence rates to its quality bonus payments, leading
to tremendous financial incentives to plans to improve
medication adherence and other quality metrics.
However, health plans alone cannot easily make the
types of patient behavior changes to improve medication
adherence rates or resolve other medication-related issues
included in the star-based quality rating program. That’s
where pharmacists come in.
Pharmacists have long been the care provider with the
expertise and accessibility necessary to influence positive
changes in patients’ medication use. Until recently, the
traditional fee-for-service financial arrangements drove
most, if not all, payment for pharmacy services. That
system did not foster an environment where health care
www.americaspharmacist.net
www.americaspharmacist.net
of improvement. Pharmacists can then use EQuIPP to
help coordinate and inform their quality improvement
efforts, allowing them to deliver high-quality care locally
while understanding how their care affects the greater
health system in which they operate. The coordination of
improvement efforts may be the most critical and useful
feature of the EQuIPP platform. Performance measurement
information is only as meaningful as it is actionable.
Early Exposure
38
america’s
Pharmacist | June 2012
Why Don’t They Take It?
Medication non-adherence costs the U.S. health care
system $290 billion in avoidable medical spending per
year, according to 2009 research by the New England
Healthcare Institute. With so much money at stake and
a broad consensus from CMS and others that improving
medication adherence is important and necessary, there
remains a stunning lack of broad-based improvement in
adherence rates. Why?
To begin, studies have shown that the decision to take
a medication as directed is a complex, individual process
deeply rooted in each patient’s values and health beliefs.
It’s usually deep in the psychological weeds, and not in the
medical literature, that you will find the right lever to pull
to affect a change in medication-taking behavior.
Complex behavioral processes such as medication
www.americaspharmacist.net
photography: Jack Hollingsworth
providers, including pharmacists, were able to be engaged
in large-scale continuous quality improvement efforts
outside of those that directly affected the accurate and
timely dispensing of medications.
To help change that dynamic, a group of pharmacy
stakeholders, including NCPA, formed the Pharmacy
Quality Alliance in 2006. PQA engages in the development
and implementation of performance measures with the
goal of improving medication management and use across
health care settings. Earlier this year, PQA launched the
EQuIPP (Electronic Quality Improvement Platform for
Plans and Pharmacies) Initiative in collaboration with its
technology partner CECity.
The EQuIPP Initiative was developed on the belief
that the landscape for the delivery of pharmacy services
is changing. Pharmacists and pharmacy organizations
will need a means to assess the quality of their care using
standard quality metrics, benchmark their performance
against their peers, and have a way to coordinate their
improvement strategies. While improving the quality of
care can be a daunting task, the resources to answer the
question, “Where do I start?” and incentives to do so are
right around the corner.
The EQuIPP web-based platform provides an
environment that marries systematic, population-based
quality improvement efforts with the local nature of care
delivery. Pharmacists can use performance information
displayed in the EQuIPP dashboards to benchmark their
current performance against peers and identify areas
The EQuIPP Initiative will be in its beta phase throughout
2012. Pharmacies and health plans in Pennsylvania,
Florida, and Alabama are being recruited to receive an
early experience with the EQuIPP platform. Within those
states, as many as 50 independent community pharmacies
are eligible to participate. They and health plans will be
provided access to the platform and asked to provide
feedback on the user interface, the strategic resources
provided, and on the overall ability of the model to deliver
value for their respective organizations. Beginning in 2013,
the initiative will expand nationally in a phased approach.
Additional details will become available as new states gain
accessibility to EQuIPP.
PQA is working with the respective state pharmacy
associations to coordinate the engagement of independent
community pharmacy owners. Those interested should
watch for communications from their state associations on
the beta phase, or they can also visit www.equipp.org for
additional information.
adherence tend to require intricate interventions, which
often are difficult to coordinate and are resource-intensive.
That can be due to the need for extensive communication
among the intervention team, the complex details associated
with the patient experience, or the need to encounter a large
number of participants to bring about a small change in
the overall rate. Additionally, the reasons for medication
adherence decisions vary from patient to patient and even
from one medication to another for the same patient.
Research has outlined three self-reported potential
drivers of adherence: perceived concerns about medications,
perceived need for medications, and perceived affordability
of medications. However, within these areas, the source of
the ultimate decision may vary significantly from patient
to patient and even medication to medication, making it
very difficult to devise an intervention that can be applied
broadly across populations.
How is a pharmacist to know if the reason a patient
does not want to take their ACE inhibitor is that they
are not concerned about their condition because they
otherwise feel healthy; they don’t want to take it because
they feel worse while on it; or that they are struggling with
a new diagnosis and do not want to comes to terms with
a declining health status? All are possible explanations for
a patient’s non-adherence, but each requires a different,
and very personal, approach, which makes broad-based
improvement efforts tricky to coordinate.
To further complicate the issue, the reason associated
with a patient’s non-adherence to their ACE inhibitor
may be quite different than their reason for not adhering
to their statin. Thus, it is possible that a successful
behavior change for a patient for one medication does
not necessarily mean that they have adopted an “adherent
personality.” Conversely, just because a patient does not
adhere to one medication doesn’t necessarily mean he/she
will not adhere to all of his/her medications.
and thoughtful in its approach as to align with how you or
your organization conduct business. Successful strategies
have consisted of an explicitly structured process by which
pharmacists can identify who is, or who will be, nonadherent; an effective communication strategy with the
patient to understand what his/her particular decision
is based on; and a relationship with the patient that
encourages him/her not only to get the next prescription
filled on time, but the next one and the one after that. A
number of resources, patient education tools, screening
mechanisms, and outreach efforts are likely to be involved
in the best of strategies.
The EQuIPP Initiative was developed not only to
provide performance information to pharmacists and
pharmacies, but to support them in their development
and execution of quality improvement strategies. The
EQuIPP platform is able to centrally coordinate all of the
patient education tools, training modules, screening, and
other interventional tactics that a pharmacy may use when
seeking to execute a medication adherence or other quality
strategy. Complex intervention strategies will require a
well-coordinated effort so that pharmacists are supported
by a variety of resources within a cohesive interventional
framework to deliver the local, individually focused care
that is necessary to effect patient behavior change. EQuIPP’s
performance dashboards further complement pharmacists’
interventional strategy by allowing them to see and
understand how their individually focused efforts impact
the greater health care system in which they practice.
For more information about the EQuIPP Initiative,
visit www.EQuIPP.org. For more general information
about performance measurement and the pharmacy
quality agenda, visit www.PQAalliance.org.
Mark Conklin, PharmD, MS, is the director of quality innovations
at the Pharmacy Quality Alliance (PQA), a non-profit organization
Developing a Strategy
formed in 2006 by a group of pharmacy stakeholders including
Given the dynamic and complex nature of medicationtaking behavior, it is safe to say that pharmacists don’t
need an adherence intervention so much as they need an
adherence strategy. Since the development of an entire
strategy can be overwhelming, its progress may be stunted
from the start by a difficulty in understanding where to
begin. A good strategy is often intensively studied prior
to implementation (so that it can fit with your workflow)
NCPA, which serves on its board. He can be reached at mconklin
www.americaspharmacist.net
@PQAalliance.org.
Editor’s Note: Editor’s Note: For more information about
Medicare’s star ratings, be sure to read PQA’s article
in the December 2011 issue of America’s Pharmacist
and/or view NCPA’s online tutorial about the star ratings program at www.pharmacistelink.com/starpower.
June 2012 | america’s Pharmacist
39