HealthApril 04, 2016

Your medication adherence questions answered

Medication adherence is a quality measure for the Medicare Part D Star Ratings system, and it also recently became a quality measure under the new Quality Rating System (QRS) applicable to Marketplace plans established by the Affordable Care Act.

Author: Alexandra Tungol Lin, PharmD

Helping patients adhere with medication therapies to maximize and optimize health outcomes is an important goal for pharmacists in the community retail and ambulatory settings. To help you better understand the requirements and opportunities presented by new medication adherence measures, Alex Lin, the clinical manager of Health Outcomes and Pharmacy Care Management at Blue Cross Blue Shield of Michigan and presenter of our recent webinar “Making It Stick: New Strategies for Medication Adherence”, answers some of your questions:

Q: Why is Proportion of Days Covered (PDC) used rather than Medication Possession Ratio (MPR) to measure medication adherence?

A: Centers for Medicare & Medicare Services (CMS) supports using the Pharmacy Quality Alliance (PQA) PDC measure to quantify medication adherence. And that's because MPR can sometimes overestimate what a patient's adherence rate is, since it does not account for overlaps and early refills, or if a patient switches therapies within the same therapeutic class. PDC, on the other hand, will adjust for switches, shift for overlapping refills, and result in a more accurate calculation of a patient's adherence rate.

Q: What type of pay-for-performance programs are available to pharmacies now?

A: Some health plans have a pay-for-performance program in place for retail pharmacies, and those hold pharmacies accountable to various measures. Some common programs include medication adherence to diabetes treatments, RAS antagonists, and statins. These programs track pharmacies’ performance to determine the percent of the population attributed to the pharmacy that are meeting the plan’s specific goals for these measures. Payments may be allocated to these pharmacies based on improvement in performance or by meeting a certain threshold.

Q: How are free drug samples provided by physicians tracked so that they can be included in adherence monitoring?

A: Free samples would not be included for these medication adherence measures, because they're not being adjudicated through the claims system. Therefore, a patient would not be targeted for that particular measure if they filled using samples only, since PDC is based purely on claims information.

Q: How does a discontinued drug affect PDC?

A: Pharmacy Quality Alliance updates the NDC list for PDC at least once a year. So, it will account for any NDCs that are discontinued. Once a drug has been discontinued for a period of time, it would no longer count toward the measurements for PDC.

Q: How can a pharmacy set up a PDC monitoring system? Is there software that can be purchased?

A: There are multiple vendors out there that provide programs and services that can calculate the Proportion of Days Covered measure.

Q: What are the benchmarks for the three therapeutic class measures: statins, RAS antagonists and diabetes medication?

A: The benchmarks are available in the QRS proof sheets that issuers receive from CMS.

Q: How does the plan calculate PDC when a medication such as GLP-1 is no longer covered and the patient must use a different drug class?

A: In this specific example, this is a diabetes patient, and since all the diabetes medications, excluding insulin, are part of the diabetes PDC, switching to another diabetes medication would count the same toward the diabetes PDC measure.

Since PDC is looking at therapy as a whole among the different diabetes drug classes, even if a patient switches his or her class of diabetes drug, it would all count under the same diabetes PDC calculation (excluding insulin).

Q: Will payers calculate PDC rates and report it back to the pharmacy?

A: Some health plans do provide that reporting to pharmacies, especially if there is a pay-for-performance program that the pharmacy and the health plan have in place. In those instances, the payer or the payer’s data vendor would provide the PDC rates to the pharmacy.

Q: What is the most effective way to promote 90-day supply and utilization of mail order?

A: One very powerful way to drive patients to use that kind of benefit would be having it built into their benefit design to offer a lower co-pay if they use a 90-day supply or if they use mail order. You could even provide co-pay disincentives if a patient does not choose to use 90-day supply or mail order.

Q: When will the Quality Rating System be effective, and on what date’s data will it be based?

A: PDC measures are based on what happened in the year prior. In fall 2016, when these Quality Rating System scores will be publicly available, you will see PDC rates based on claims data that occurred during 2015.

Alexandra Tungol Lin, PharmD, is clinical manager of Health Outcomes & Pharmacy Care Management for Blue Cross Blue Shield of Michigan (BCBSM). She currently is the clinical lead for pharmacy-related Quality Rating System (QRS) measures, including medication adherence, and is the residency program coordinator for BCBSM's PGY-1 Managed Care Pharmacy Residency Program in collaboration with the University of Michigan.

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