Most pharmacists by now are at least aware of EQuIPP scores. These metrics can be used to guide pharmacies looking to improve quality in specific areas as well as their use as a part of the basis for reimbursement from payers. The Top 20% value for a given quality measure was never intended by its creators to be used as a basis for reimbursement. It has always been intended as a motivator for pharmacies to see where the top performers are at. But this did not stop almost every payer in the industry from using it as the basis for most of their performance payments. Virtually every Medicare Part D plan with a DIR fee has attached performance payments to a pharmacy achieving top 20% status in given metrics.
As this blog predicted would happen, the Top 20% watermark for every current EQuIPP quality measure has also become more and more compressed. Pharmacies have been working hard on their practices to improve their quality and by extension their metrics. As a result, individual EQuIPP score required to break into the top 20% have consistently increased with time. Currently, for one plan, a pharmacy has to have over 95% of its patients being compliant for each measure to gain entrance into the top 20% club and, by extension, receive top performance rewards. The compression of this value ultimately undermines the entire validity of the EQuIPP metrics. It has created a watermark that is rapidly becoming all but unobtainable.
For example, consider a pharmacy with > 90% of their patients meeting the compliance scores. This is score well above the 5-star watermark for Medicare. A few years ago this result would have found them included in the top 20%. Today they would be on the outside looking in. In fact, once a pharmacy has increased patient compliance to greater than 90%, there is less and less a pharmacy can effectively do to further increase their performance measures. They have reached a point of diminishing returns. Reaching the top 20% essentially becomes a lottery, with the natural randomness of patient behavior impacting the pharmacy’s score more than the work being done by the pharmacy. Our own pharmacies regularly spent months at a time in the top 20% over the last several years. Today our scores are even higher than they were and yet we bounce in and out of the top 20% by a few tenths or hundredths of a precent every reporting period.
Ultimately, metrics are not going to disappear. They have their place both as a basis for reimbursement as well as motivation for the participants. But the current measures being used have significant limitations. I see little reason for EQuIPP to continue to report a top 20% value. It was never intended as a metric upon which to base reimbursement. It is rapidly becoming a meaningless, unreachable goal. A more meaningful value to report might be a the mean pharmacy performance for plan.
If the EQuIPP measures stopped reporting the top 20% values for individual metrics today, payers would continue to base performance payments on arbitrarily high compliance requirements. The reason, in large part, is that the measures are only surrogate values being used to estimate quality. They do nothing to directly measure patient care and therapeutic outcomes. It is essentially impossible to quantify how much or little a pharmacy achieving a given EQuIPP score actually saved the health system. In order to really impact quality, metrics will need to mature significantly.
Ultimately, it will require a more direct measurement of outcomes. This will better demonstrate the value that an outstanding pharmacy provides to the health system. An example of a such a measure would be total health spend. One commercial insurer based quality program we participate in calcualtes anticipated healthcare spend for each patient based on actuarial and historical data. The pharmacy is then measured by their ability to impact this number. If a pharmacy comes in under-budget with respect to its patients’ health care spend it has credible evidence of savings created for the payer. Any savings a pharmacy can create can be, in part, shared with the pharmacy as a performance bonus. A win-win.
Metrics are important. But while they obviously will have financial reimbursement implications in a pay for performance healthcare system, metrics ultimately should be about improving patient care. The best metrics move beyond simplistic measurements like medication compliance and look at the patient as a whole. The best metrics may not even focus on a given plan or population of patients, but instead on the provider as a whole. We have a long way to go before metrics develop this level of robustness. So until then, make every encounter with your patients count. Reimbursement will eventually depend on it.
