Why Performance Measures Matter to Your Pharmacy
Both of your customers — the patient and the payer — want better value for their investment through reduced total healthcare cost and improved outcomes.
This desire is being driven by the tremendous mismatch of healthcare expenditures compared to healthcare quality in the U.S. The United States spends more than any other country in the world on healthcare. In fact, 17% of the GDP, or nearly $1 out of every $5 dollars produced, is spent on healthcare. Yet according to the World Health Organization, the United States ranks in the mid-30s worldwide in healthcare quality. The huge gap between investment in healthcare and quality of outcomes is leading many experts to look for ways to improve the quality of each dollar spent and to create tangible changes in how health systems are incentivized. This impacts every aspect of the healthcare system, including your pharmacy.1
THE MEDICARE STAR RATINGS SYSTEM
Star ratings are a 5-star quality rating system of health plans designed by CMS to help patients compare and choose Medicare plans. These ratings impact health plan reimbursement and open enrollment periods, and higher ratings are better. The ratings are used to review many aspects of plans and benefits provided to patients, ranging from customer service to patient outcomes. The quality measures most relevant to community pharmacies are the five measures related to medication use and medication adherence. Each of these quality measures directly affects patients’ quality of care and health outcomes.2
The five measures are:3
|
Core Measure #1 |
The treatment of hypertension in diabetic patients with a renin angiotensin system (RAS) antagonist |
|---|---|
|
Core Measures #2, #3, #4 |
Medication adherence for three chronic disease states:
|
|
Core Measure #5 |
The rate of high-risk medication use in the elderly |
MEDICATION THERAPY MANAGEMENT
Medication therapy management, or MTM, is one tool pharmacists can use to improve upon the pharmacy quality measures. When used within this guide it refers to medication therapy management in a general sense and not any federal or state-specific program or definition. Particular references to medication therapy management within this guide are more focused on targeted interventions for a specific medication related to the pharmacy quality measures, which differ from comprehensive medication reviews. More information on MTM programs is provided in Appendix A of this guide.
FOR MORE INFORMATION:
For more information on the star ratings, changes in the healthcare marketplace and a general overview of payment model changes, refer to "The Pharmacy Performance Imperative: A Guide for Independent Pharmacies" found with other resources on the Know Your Numbers and EQuIPP™ pages in the Health Mart Operations Manual.
The following CE opportunities are also available on Health Mart University:
- HMU: Pharmacy Quality Measures: Know Your Numbers(prerequisite for EQuIPP access)
- HMU: Coaching at the Counter… Opportunities for Enhancing Communication with a Patient-Centered Approach
- HMU: Implementing Medication Synchronization
- HMU: Practical Steps for Integrating MTM into Your Daily Practice
- Disease state–specific education courses and more!
References
2. Centers for Medicare & Medicaid Services. Prescription Drug Coverage — General Information. Available at: http://www.cms.gov/PrescriptionDrugCovGenIn/06PerformanceData.asp. Accessed April 18, 2014.
3. Centers for Medicare & Medicaid Services. Medicare 2014 Part C and D Star Rating Technical Notes. Available at: http://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/Downloads/2014Draft-Tech-Notes.pdf. Accessed April 18, 2014.
