Star Ratings - beyond the PDC
Pharmacies have a lot of money in DIR fees at stake based on their RASA PDC. Sometimes physicians don't prescribe refills in a timely manner and it frustrates the pharmacist. Why do they do that?
About a year ago, I sat down with a physician to discuss ways in which our pharmacy could better serve his needs as a provider. The discussion turned to various quality of care measures that he and his Accountable Care Organization are measured for. One measure of interest was the “Medication Adherence for Hypertension (RAS)” measure – the well-known (to pharmacies) ACE/ARB proportion of days covered (PDC) measure. His clinic has been encouraged by a few different local medicare advantage plans to prescribe ACE and ARB medications as 100 days supplies, because a) our state law allows pharmacies to fill up to 100 days supply so long as there are sufficient refills available b) these plans allow 100 days supplies to be covered and c) only 3 fills of 100 days are necessary to meet the 80% PDC threshold in a year, vs. 4 fills of 90 days or 10 fills of 30 days. He expressed frustration on being measured on that measure while ALSO being measured on the Annual Monitoring of Persistent Medications (since retired by NCQA in March 2019), which measures the number of patients on these medications who have had a serum potassium and serum creatinine recorded in their chart.
Since that conversation, I have been much more understanding of why physicians and other prescribers are hesitant to authorize refills of these medications, despite the impact on the adherence measure. They want to have adequate monitoring of these medications. Adherence to the overall treatment plan, not just receipt of tablets, is the goal.
With that in mind, in the past month I have created a few brief template requests for information to my physician colleagues. These requests read as follows:
“Dr. DOCTOR,
In order to facilitate our ongoing monitoring of PATIENT's antihypertensive therapy, may we have the following information?
Benjamin Jolley, PharmD
Last Blood Pressure:__________ mmHg Date:__________
Last Serum Creatinine:_________ mg/dL Date:__________
Last Serum Potassium:_________ mmol/L Date:__________”
“Dr. DOCTOR,
In order to facilitate our ongoing monitoring of PATIENT's metformin therapy, may we have the following information?
Benjamin Jolley, PharmD
Last HgbA1c:_____________ Date:___________
Last Serum Creatinine:__________ mg/dL Date:_________”
In these requests, I insert the doctor and patients names, fax the note, and then record that I have made the request in a “care coordination note” in our pharmacist’s care plan “chart.”
On Monday, I decided to look at the response rate to my requests over the past month. In doing so, I found that I have made 36 total requests over the past month. Of these, I received a fax back with the requested information in 7 out of 10 requests for diabetes information, and 13 out of 26 requests for hypertension information.
I was pleased with the overall response rate. The actual responses were also useful in a few ways to me. 1) I now know which of my patients have a controlled A1c, and which have an A1c of 11+. 2) I know that one of my patients hasn’t had labs drawn in 5 years, so I can make an intervention there. 3) For the most part, the recorded blood pressures and A1c levels suggested no need for intervention at this time – the disease state is under control, but now I know that and can give them lower emphasis in my monitoring. I will likely request follow up labs on an annual basis for these patients, but will initiate a comprehensive review of medication therapy with the patients whose disease is not controlled.
In pharmacy school, I was taught the “pharmacist’s patient care process” which states that pharmacists go through a cycle of collecting information (what I’m focused on this month), assess that information (controlled, uncontrolled, needs intervention), make a plan to act on it, implement the plan, and then follow up and evaluate (what I am doing right now).
One of the things that I have loved about participating in CPESN and in Flip the Pharmacy has been the opportunity to actually follow this patient care process in my daily practice. The prevailing business model of pharmacy does not follow this patient care process – it simply tries to push prescriptions out the door as quickly as possible without regard to the effect of those prescriptions for good or ill. The business model that Flip the Pharmacy implicitly encourages is one in which the pharmacist is treated as a clinician first, and a dispenser second. Taking this model to its logical end, the pharmacy continues to be paid fairly for prescription dispensing, but a large portion of the pharmacy’s gross margin comes from payments for medication monitoring services and quality of care services. The people willing to pay for these services are generally physicians (due to their own liability and the impact of health plan quality measures), health systems and ACOs, and health plans directly. Contracting with a single site practice like mine for this kind of service is cumbersome for most of these entities except the individual physician. This is why CPESN exists – to allow the larger entities to contract with multiple similar pharmacies for services without the burden of contracting separately with 3100 individual pharmacies.
I would encourage any pharmacist reading this who is frustrated by their physician partners unwillingness to authorize refills of “stars” measures prescriptions to understand where they are coming from, to call them up and ask for an opportunity to chat, and to engage in appropriate monitoring and follow up like we were trained to do in school. By doing so, we will have better relationships with our physician partners, and we will be better able to deliver on contracts for enhanced pharmacy services with payer partners.