Featured Health Business Daily Story, Dec. 22, 2016

Independent Health Stays Ahead Of Stars Curve With Pharmacist Pact

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By Lauren Flynn Kelly, Managing Editor
December 1, 2016Volume 22Issue 23

Through a unique partnership with the Pharmacists’ Association of Western New York (PAWNY), Independent Health in 2015 embarked on a three-month pilot project to improve medication adherence and patient outcomes, marking the first time the insurer has reimbursed pharmacists for their clinical services in its eight-county service area. The program initially focused only on the three areas of medication adherence measured by the CMS star quality ratings and opportunities for tablet splitting. But the pilot results were so encouraging that the project is now in its second phase of expansion as the partners continue to explore ways to address medication-related issues among seniors.

The Buffalo-based insurer and PAWNY tell MAN they had for years been looking for ways in which they could collaborate to improve patient outcomes and that the 5-star ratings system was a natural place to start. Dennis Galluzzo, R.Ph., executive director of PAWNY and owner of Family Medical Pharmacy in Williamsville, N.Y., credits Independent Health with being “open to working with pharmacists as health care providers” and says the partnership is reflective of a “new paradigm” where pharmacists are recognized and reimbursed for more than dispensing medications.

The pilot featured 25 independent pharmacies throughout eight western New York counties that many of the insurer’s Medicare Advantage beneficiaries were already using to obtain their medications. Prior to launching the project, the insurer hosted a continuing education program for the participating pharmacies that focused on the importance of medication adherence and techniques such as motivational interviewing.

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Starting in October 2015, Independent Health used claims data to compile two lists per week for 12 weeks that included the following information:

(1) A list of the pharmacy’s patients who appeared to be noncompliant with their medications for high cholesterol, high blood pressure and/or diabetes. Only Independent Health MA members were included on this list.

(2) A list of the pharmacy’s patients who were eligible for tablet splitting as a way to potentially improve patient adherence. These individuals included MA, commercial, Medicaid and self-funded plan members.

Pharmacists were responsible for contacting each of their patients to find out why they weren’t taking their medications appropriately and counseling them on the importance of medication adherence. Resulting interventions included changing patients to a different medication if they were experiencing side effects with their current therapy, recommending cost-savings opportunities such as tablet splitting or switching to a 90-day supply for a reduced copayment, and consulting with the patients’ physicians. Following a specified reporting process, the pharmacists were reimbursed for each intervention they completed. Moreover, they received an additional payment if the intervention resulted in improved adherence or the initiation of tablet splitting.

Of the 385 adherence-related interventions performed during the pilot, 235 (61.2%) led to improved adherence, based on the same proportion of days covered metric used by CMS. Moreover, half of the 326 interventions that related to tablet splitting resulted in the patient either starting tablet splitting or switching to a lower-cost generic. Pharmacies surveyed after the conclusion of the pilot also indicated strong interest in continuing to deliver those services to their patients beyond the pilot period and said they felt that communication with their patients greatly improved as a result.

While the three-month project impacted only a portion of the insurer’s MA members, it helped Independent Health maintain high star ratings on the three adherence measures, observes Kelly Verrall, manager, medication therapy management, with Independent Health. Prior to the launch of the project, the insurer already had earned 5 stars on the diabetes and hypertension adherence measures, and 4 stars on statin adherence, and saw the rates of adherence for each go up and thus stay within the cut point range to keep those ratings for 2017, she explains.

“Cut points go up every year, so we wanted to stay ahead of that curve and drive adherence as high as we can,” says Verrall. “And to be able to stay a five-star, we know we have to keep working at it.”

As a result of the first pilot’s successes, the insurer and PAWNY in February 2016 began educating MA members who are currently taking medications that are considered high-risk in the elderly (e.g., amitriptyline, cyclobenzaprine, nitrofurantoin, zolpidem) and encouraging them to switch to a safer alternative, which is another star ratings goal. The partners also started doing adherence-related interventions again in May.

While the projects so far have involved the same 25 pharmacies, the partners say they are interested in expanding the program to other pharmacies. In addition, they are looking to extend the diabetes portion of the project beyond adherence to standards of care for the whole condition, which could involve using pharmacists to make sure that patients are regularly checking their blood sugar levels or getting routine eye exams (which are both related to star ratings on the Part C side).

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