Performance-based pharmacies improve Medicare beneficiary health

Medicare beneficiaries with diabetes, high blood pressure or high cholesterol may achieve better health outcomes when using pharmacies that are part of performance-based networks, according to early results of a pay-for-performance program conducted by SCAN Health Plan and Express Scripts.

JhawarPharmacists are said to be one the most trusted of all healthcare professionals and their frequent interactions with members present opportunities to positively impact patient health, according to Sharon Jhawar, vice president of pharmacy services at SCAN.

“The Medicare space is challenging, competitive and complex,” says Jhawar. “Centers for Medicare and Medicaid Services’ ratings are a moving target, and plan quality is directly tied to patient health outcomes. Plans can only impact patient behavior so much. Therefore we need to partner and align all of the parties on that patient’s care team-pharmacists, nurses and physicians-to truly have an impact. The Quality Network Program and its value-based network design was a logical next step for our plan, and as these results demonstrate, is having a positive impact on patient health.”

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Leveraging actionable data and clinical experience from its Therapeutic Resource Centers, Express Scripts works collaboratively with each pharmacy participating in the two-phase Quality Network Program to review and improve their patients’ performance in five key areas: reducing the use of high-risk medications, compliance with diabetes treatment guidelines (use of high blood pressure therapy in diabetes patients), and greater adherence to diabetes, high blood pressure and high cholesterol medications.

NEXT: Phase II

Similar to CMS’ Star Ratings, pharmacies in the Quality Network receive an overall star rating or quality score, on a scale of 1 to 5, with 5 representing top performance. The methodology used to determine each pharmacy’s score includes both SCAN Health Plan’s quality goals and CMS Star Ratings requirements, with the goal of creating alignment between SCAN, CMS and participating pharmacies.

Phase I, completed in 2014, involved reporting and the “Sentinel Effect,” which is the tendency for improvement as a result of observation, to establish performance benchmarks. Phase II, which began in January, involves quality incentive rewards with more than 1,000 participating chains and independent pharmacies in southern California and Arizona, SCAN Health Plan’s market. In early 2016, top-performing and improved pharmacies will receive incentives, while average or poorly performing pharmacies will receive lower overall reimbursements.

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“The initial data from phase I of the program indicate that simply observing pharmacy performance and providing additional resources leads to more engaging interactions between the pharmacy and the patient that in turn improves patient health; specifically, greater adherence to medication, reduced use of high-risk medications and compliance with diabetes treatment guidelines,” Jhawar says.

“The overall takeaway is that performance-based reimbursement at the retail pharmacy level aligns incentives and promotes patient-centric collaboration among all parties in a patient’s care,” she adds.

As implementation takes place for Phase II of the program, which includes risk and reward for the participating retail pharmacies, Jhawar expects to see even greater improvements in these areas, which will improve members’ health, and subsequently, positively impact CMS Star Ratings for the plan.