Month: April 2016

Metrics and the 90-Day Fill

This month, the EQuIPP platform that pharmacies and pharmacists use to determine how well they are performing added a new measure. The measure is entitled UHC 90-day Fill Rate. The an example of the measure and is shown below.

UH Line
UHC 90-Day Fill Rate

This measure is only displayed by EQuIPP when viewing Goal: Full Measure Set. This is not a CMS measure; it is what is referred to as a display measure or health plan custom metric. Medicare is not using this measure as a measure of plan success–it is an example of a plan creating a measure that it is interested in improving. In fact, it relates directly to the 90-day performance program I wrote about the blog post entitled Is There Anything Special About the 90-Day supply?

The report above is for one of my pharmacies. It appears that I am not meeting the expectations of the plan, with a current score of 50% and their goal of 70%. But in order to really understand the measure, one needs to know what it really means, and how it is being calculated. According to a source at PQS,

This measure tracks the percent of qualifying patients who were last dispensed an extended day supply ( > 60 days). This will focus on the same medications that are included in the PDC adherence metrics for UHC Medicare Advantage.

As I described in my previous 90-day blog post, plans like UnitedHealthcare are looking to improve their compliance (Percentage of Days Covered or PDC) based measures by incentivizing the 90 day supply. But the measure does not actually take compliance into account. The measure is based at the patient level and is calculated as:

Patients with at least one qualifying PDC drug receiving greater than 59-day supplies

the total number of plan patients qualifying for a PDC measure

I should note that a patient needs to qualify for the PDC measure in order to be included. There is a minimum number of fills required during the 6 month period before the patient is included in a PDC measure.

Going back to the PDC basis of this measure, it would be interesting to see how the qualifying patients are doing with respect to compliance without respect to 90 day supplies. Looking at the UHC 90-Day Fill Rate measure details (within EQuIPP),  we see:

Detail Analysis
Measure Details: UHC 90-Day Fill Rate

The details above show 22 total patients reported. The MAPD patients (listed above under Quality Improvement Programs) are a good place to start, because these same patients are broken out by plan in the individual PDC based measures for each PDC drug category. Below are the overall PDC specific details for each drug category.

Statin PDC Details
RASA PDC Detials
Diabetes PDC Detials

Looking at the UnitedHealthcare MAPD lines, the total number of patients totals 14, matching the UHC 90-Day Fill Measure. The other feature that stands out is that all 14 patients (100%) are compliant over the last 6 months over every PDC category.

So despite having perfect (>80% PDC) compliance, my UHC measure reads 50% only because my patients prefer to receive their medications in increments of less than 60 days. Our excellent performance on all of the PDC measures is due, in large part, to the high level of engagement we have with our patients, and this engagement is driven primarily by the 30 day fill cycle. Note that there is no penalty associated with not meeting the UHC 90-Day Fill measure. UnitedHealthcare does, however, reward pharmacies for converting a patient to 90-day fills. Participating in this program, however, only decreases the frequency of the opportunities we have to engage with the patient and impact PDC.

This brings us back to the plan’s decision to create the UHC 90-Day measure and reward pharmacy conversions to 90 day supplies. CMS provides incentives to MAPDs if their network pharmacies perform well on the the CMS Threshold measures. If the impetus of UnitedHealthcare’s 90-day measure is to improve PDC measures, then why don’t they simply use the CMS PDC measures already in place? Why create a new, plan specific, measure which is only loosely correlated to the desired outcome? The only explanation I can muster is that, perhaps, improved PDC is not the plan’s actual goal. It would be nice if UnitedHealthcare more clearly communicated its goals to the pharmacies that are providing patient care.

Each pharmacy will have to decide if they wish to take UnitedHealthcare up on its offer to reward them for these conversions. For us, however, losing opportunities to interact with the patient is not worth it. We will continue to make every encounter count.

The Fragmentation of Patient Care

The other day, I wrote about a case involving a medication for which the plan required to be filled at a specialty pharmacy. This was an example of fragmentation of care. In Pharmacy, fragmentation is often either financial, or the result of contractual requirements imposed by benefit managers or plans. Examples include:

  • maintenance medications that are required be filled by a mail order pharmacy
  • requiring specific, specialty pharmacies to fill certain medications
  • doctors sending patients to multiple pharmacies to help the patient save money on select medications
  • pharmacies offering incentives to transfer mediations, creating transient patients using numerous pharmacies.
  • drug companies directing patients to specific pharmacies for special pricing of their products.

The list could go on, but each example has the same consequence: the complete patient record resides across multiple pharmacies. The record is fragmented. This makes it much more difficult for any one pharmacist or practitioner to have a complete understanding of the patient’s medication therapy, making assessing and monitoring the patient’s therapy much more difficult.

The implications of care fragmentation are significant. If the pharmacist cannot accurately determine if the prescription they are filling is appropriate, inappropriate or even dangerous, problems will arise. Problems, in the context of prescription medications are, at a minimum, undesired. They can be a lot more significant, too; the worst case scenario might death. While the PBMs do pass pharmacies some information about medications filled by other pharmacies, the data is mostly designed to prevent duplicate fills of a given medication. It is paramount, therefore, that pharmacists work combat both fragmentation and its consequences.

Combatting Fragmentation

There is no way to completely eliminate fragmentation as long as our system puts its emphasis on reducing cost, and not on patient outcomes. While an outcomes based system may be something that will eventually become prominent in our country, we cannot afford to wait. We need to combat this problem, and the weapon of choice is communication.

The first problem for the pharmacist is identifying fragmentation. Patients don’t just walk in and announce that they use four different pharmacies. Using tools like electronic claim notifications and rejects can alert you to the existence of some forms of fragmentation. Communicating with the patient, however, is the best way. Regularly ask the patient what other medications they are taking that your pharmacy doesn’t provide. Any time you discover the potential for multiple pharmacy use, it is important to document your findings in the patient’s pharmacy record. More to the point, communications need to be initiated to ensure that all pharmacies involved have a good understanding of the patient’s therapies and outcomes. Once the problem is identified and information exchanged, the immediate crisis is over. It is now time to address the root cause of the fragmentation.

I always start the discussion with the patient. It is important to understand exactly why they are using more than one pharmacy provider. I always emphasize the importance of having a single pharmacy home, but I am always watchful for circumstances that will prevent this from occurring. Once I understand the reasoning, I look for solutions.

  • Whenever possible, I try to consolidate the pharmacies a patient uses. Ultimately, I would prefer to get them to use one pharmacy, their pharmacy home. Obviously, I would prefer that they use my pharmacy, but that is a decision for the patient. Even if I lose a them, they will be better off in the long run with a single pharmacy home.
  • In cases where the patient must use more than one pharmacy, I try to have the patient minimize the total number of pharmacies involved.
  • Finally, I educate the patient. If they must use, or they insist on using, multiple pharmacies, I emphasize that they as the patient, are responsible for making sure that all parties involved are kept up to date on all medications. They must be their own advocate. While some inter-pharmacy communication does occur, it may not be enough to prevent real problems from occurring.

Mis-information is also a problem, and education is a part of the this solution, as well. I have personally observed prescribers sending patients to multiple pharmacies for a variety of reasons. Mostly, though, they are simply trying to help the patient get the best value for their healthcare dollar. Prescribers understand that the medication doesn’t do any good for their patent if they cannot afford it or fail to take it regularly. This is a great place to educate the physician on the value of the pharmacist in the equation. Spend some time visiting with prescribers. Let them know what a good pharmacist does to ensure good compliance. Talk about medication synchronization and compliance packaging. Make sure they understand that a single pharmacy home may have a larger impact on outcomes than price alone. If they have an open mind, you may change their habit.  What is more, you might actually receive additional referrals for your efforts.

Ultimately, fragmentation comes down to choices. Our job is to be sure that people making choices do so with the best information possible. If we do our job well, everyone benefits. Make your encounters count.

 

What is Special about a Pharmacy?

I am seeing more and more drugs that are being moved from traditional retail status, meaning that you can get them from your local pharmacy, to specialty-drug status, available only from a designated pharmacy. According to Specialty Pharmacy Times:

specialty drugs or pharmaceuticals usually require specialty handling, administration, unique inventory management, a high level of patient monitoring, and more intense support than conventional therapies.

If one accepts the definition above, cost alone should not be enough to limit the product’s availability in the retail sector. However, the assignment of specialty status appears increasingly arbitrary, regularly focusing on drug cost. The arbitrary nature of the specialty moniker is most apparent when comparing different insurance plans. The same drug can be considered specialty in one plan, but not special in another.

Tales from the Counter

The state of Iowa recently switched its Medicaid recipients from a fee-for-service program to a for-profit managed care model. Originally, these plans were not going to be allowed to limit mediations to specialty status, but this stipulation was dropped in the 11th hour before implementation. It took less than 24 hours for one of our patients to be affected by this change.

One of our Medicaid patients has been receiving Invega Sustenna from our pharmacy. This patient was switched to one of the three MCOs now managing our Medicaid population.  Like many of our patients receiving medications by intramuscular injection, our pharmacy actually administers the medication to the patient. The prescribers in our area, for a variety of reasons, often do not want administer medications in their offices. These practitioners rely on us to administer the medication. We order the medication, schedule the administration appointment, and administer the injection.

On April 1st, however, the new MCO returned a rejection for the Invega Sustenna. They require that the medication be filled at a specialty pharmacy. Going back to the definition above, the medication exhibits few, if any of the attributes listed. Cost alone appears to be the primary consideration.

A call to the MCO simply confirmed that they required the medication to be filled at a specialty pharmacy. When asked what was special about this medication, they replied that it was an injection. That answer did not impress me; I dispense a lot of not-very-special medications that just happen to be in an injectable form. When asked how they can provide the medication in a timely fashion, they offered to overnight ship it to the patient.  I asked the MCO who was going to give the medication. They told me the patient would self-administer it or that a doctor would give it in their office. It is at this point I broke the bad news to the MCO representative: giving oneself a deep IM injection is not something most want to do, and the prescriber doesn’t give these injections in their office. I informed him that our pharmacy gives the injection to the patient.

After spending some time explaining these realities to the plan, I was able to secure a one time override for the medication because the injection was already scheduled and due to be given. This bought the patient some time, but it does not solve the problem. The medication is still arbitrarily designated as specialty-only. The plan, after learning that our pharmacy both provides and administers Invega Sestina to nearly a dozen similar patients, promised to follow-up and offer us a specialty pharmacy contract. I am not holding my breath. I expect to have the same problem again in a few short weeks.

Specialty pharmacy should be about more than the medication cost. As ASP’s definition states, it should require special equipment, expertise, or something above and beyond simply dispensing the medication. I have no doubt that for some drugs, the designation is warranted. Here, however, I am skeptical. Compared to a standard retail pharmacy, what the plan’s specialty pharmacy could do differently is not immediately apparent. There is nothing special about Invega, it is just an expensive, injectable medication. On the other hand, what we are providing is special. We are providing care.

 

Re-Blog: Big pharmacies are dismantling the industry that keeps US drug costs even sort-of under control

With the FTC considering the pending merger of Walgreens and Rite-Aid, the consequences of pharmacies owning PBMs may once again be considered. It has been several years since FTC approved the CVS  / Caremark merger, and the changes and consequences of that merger are now visible. It is imperative that these issues of potential conflicts of interest are revisited. For an excellent overview, read:

Big pharmacies are dismantling the industry that keeps US drug costs even sort-of under control