CFP 2017 Forum Report v1 - cfpnet.ca · 11/21/2017  · CFP Pharmacy Forum Conference November 21,...

2017 Pharmacy Forum Report 1

CFPPharmacyForumConferenceNovember21,2017

SUMMARYREPORT

Speakers&Sponsors..........................................................................................................2

Agenda................................................................................................................................4

SummaryofKeyTakeawayMessages...............................................................................5

Articlesfromwebsite(www.cfpnet.ca)

1) Puttingvaluetothetest(overview).....................................................................6

2) Timetoshiftcourseonpharmacyresearch(LisaDolovich).................................7

3) Value-basedcarecanbebettercare(U.S.panel)................................................8

4) GreenShield’sroadtovalue-basedpharmacy(LeilaMandlsohn).....................12

5) Pharmacyneedstosteervalue-basedpractice(Canadianpanel).....................14

6) WhatdoCanadianopinionleadersthink?(Audiencepollresults)....................16

7) Valueandthefutureofhealthcare(CatherineHunter)....................................17

KeyQ&ADiscussionPoints:

Evolutionofpharmacydocumentation...................................................................18

QuicklookatU.S.paymentmodels.........................................................................18

Don’tgetstalledonthemetrics...............................................................................19

WhatarePQAandPQS?..........................................................................................19

Patients’perceptionsslowtochange......................................................................20

Formoreinformationcontact: DayleAcornExecutiveDirector,CanadianFoundationforPharmacy

905-997-3238dacorn@cfpnet.ca

2017 Pharmacy Forum Report 2

The Canadian Foundation for Pharmacy sincerely thanks this year’s speakers for their candid insights at the 2017 Pharmacy Forum:

Marshall Moleschi (moderator) Former Registrar, Ontario College of Pharmacists and former Registrar, College of Pharmacists of B.C.; Past-President, Canadian Foundation for Pharmacy

Jim Kirby Senior Director, Pharmacy Services, The Kroger Company

Justin Bates CEO, Neighbourhood Pharmacy Association of Canada

Crystal Lennartz Chief Pharmacist, Health Mart Systems Inc., McKesson Corporation (U.S.)

Mike Cavanagh Co-Owner, Kawartha Lakes Pharmacy & Chair, Ontario Pharmacists Association

Nancy Lum-Wilson Registrar, Ontario College of Pharmacists

Lisa Dolovich Ontario College of Pharmacists Professor in Pharmacy Practice, Leslie Dan Faculty of Pharmacy, University of Toronto & Executive Member, Ontario Pharmacy Evidence Network

Leila Mandlsohn Pharmacy Strategy Consultant, Green Shield Canada

Perry Eisenschmid Then CEO, Canadian Pharmacists Association

Joe Moose Owner, Moose Pharmacy, North Carolina

Catherine Hunter Partner, PwC, and leader of PwC’s Health Services Consulting Practice

Elliott Sogol Senior Vice-President Strategy, Pharmacy Quality Solutions

2017 Pharmacy Forum Report 3

2017 Pharmacy Forum Report 4

Agenda

7:30–8:30

Registration,ContinentalBreakfast

8:30–8:55

WelcomeandIntroductionDayleAcorn–ExecutiveDirector,CFPModerator,MarshallMoleschi

8:55–9:30

TheEvidenceforPharmacyValueDr.LisaDolovich–OntarioCollegeofPharmacistsProfessorinPharmacyPractice,LeslieDanFacultyofPharmacy,UniversityofToronto

9:30–10:50

TheShiftfromDistributiontoOutcomes:Value-BasedPharmacyintheUSElliottSogol–SeniorVicePresidentStrategy,PharmacyQualitySolutionsCrystalLennartz–ChiefPharmacist,HealthMartSystemsInc,McKessonCorporation(US)JimKirby–SeniorDirector,PharmacyServices,TheKrogerCo.JoeMoose–IndependentPharmacistOwner,MoosePharmacies,NorthCarolina

10:50–11:15

RefreshmentBreak

11:15–11:45

Value-BasedPharmacyintheUS:PanelQ&A

11:45-12:20

ValueBasedPharmacyinCanadaLeilaMandlsohn–PharmacyStrategyConsultant,GreenShieldCanada

12:20–1:10

Lunch

1:10–2:20

CanadianPharmacyinTransitionPerryEisenschmid–CEO,CanadianPharmacistsAssociationNancyLum-Wilson–Registrar,OntarioCollegeofPharmacistsJustinBates–CEO,NeighbourhoodPharmacyAssociationofCanadaMikeCavanagh–IndependentPharmacyOwner&Chair,OntarioPharmacistsAssociationPanelQ&A

2:20–3:00

WhereisHealthCareGoing?CatherineHunter–Partner,NationalHealthCareConsultingLeader,PwCCanada

3:00–3:10

WrapupMarshallMoleschi

3:10–3:15 Break

3:15PostForumEvent

SatellitePresentation–EQuIPPSoftwareElliottSogol–SeniorVicePresidentStrategy,PharmacyQualitySolutions

2017 Pharmacy Forum Report 5

SummaryofKeyTakeawayMessages• Pharmacyshouldnotwaitformoreclinicalevidencebeforedevelopingnewpayment

models.• Pharmacyresearchneedstomovefrommicro-measurementofservicestooutcomes-based

researchthatevaluatespharmacists’interventionswithinthebroaderhealthcaresystem.

• Thegoalofresearchisnottomeasurethevalueofpharmacy,butthevalueofimprovedmedicationusethroughoutthehealthcaresystem.

• Pharmacy-leveldocumentationneedstoevolvesoitcaneasilybesharedwithpatientsandotherhealthcareprofessionals.

• Theprinciplesofvalue-basedpharmacyareworthpursuing.Thekeyisforpharmacytositdownwithpayersbeforetheydeterminepaymentmodels.

• Standardizednationalperformancemeasuresareessential,tocircumventdifferentsetsofmeasuresfromdifferentpayers.Transparencyofpaymenttermsisalsocritical.

• Paymentmodelsshouldrewardhighperformerswithbonuspayments,ratherthanpenalizethosethatdonotachievetargetmetrics.

• Medicationsynchronizationlaysthefoundationforefficienciesinworkflowandoperations,andsetsthestageforanappointment-basedmodelofpractice,forexpandedservices.

• GreenShieldCanada(GSC)developeditsvalue-basedpharmacyprogramasanalternativestrategytoclients’growingcallsforcost-cuttingmeasuressuchascappeddispensingfees.

• GSChiredPharmacyQualitySolutionsintheU.S.becauseitisanestablishedproviderofperformancemeasurementservicesandusesstandardizedperformancemeasuresfromanindependent,non-profitorganization(PharmacyQualityAlliance).ItoptedtogothisrouteratherthancreateaproprietaryprogramorawaitthedevelopmentofaCanadiansystem.

• PharmacieswithGSCplanmembersarereceivingPatient-ImpactScoreboardsregarding:adherenceratesforhypertension,cholesterolanddiabetesdrugs;threemeasuresrelatedtochronicdiseasemanagement;high-riskmedicationuseintheelderly;andenrollmentlevelsinGSC’sPharmacistHealthCoachingCardiovascularprogram.

• GSCwillbeginpayingpharmaciesbasedontheirscoressometimein2019.GSChasindicateditsintentistorewardhigh-performingpharmacies.

• CanadianpharmacyassociationsappeartobeleaningtowardCanada-specificmetricstomeasureperformance,ratherthanastraightadoptionofU.S.metrics.

• Pharmacistsneedmoreeducationaboutvalue-basedpharmacyandhowitcanbeimplementedtoadvancetheirpracticeintheinterestofpatientcare.

• Value-basedpharmacyisinveryearlydaysinCanadaandpharmacyleadershavetheopportunitytobeproactivetoensuretheprofessionsteersthisimportantevolutioninprofessionalpracticeandreimbursementmodels.

• AttendeesatCFP’sPharmacyForuminNovember2017werecautiouslysupportiveofavalue-basedpaymentsystemforpharmacy,basedonreal-timetextpolling.

2017 Pharmacy Forum Report 6

ARTICLESFROMWEBSITE(www.cfpnet.ca)Article1(overview)PuttingvaluetothetestValue-basedpaymentiscomingtopharmacyinCanada—andwhilepharmacyleadersagreethattheconceptisgood,thedevilisverymuchinthedetails.AttheCanadianFoundationforPharmacy’s2017PharmacyForuminTorontoonNovember21,pharmacistsfromtheU.S.sharedtheirlearningsunderavalue-basedcaresystem,andurgedpharmacygroupstotakeimmediatestepstoensuretheyarepartofdecision-makingwithprivateandpublicpayers.GreenShieldCanada(GSC)hasalreadyputtheballinmotionwiththelaunchofitsValue-BasedPharmacy(VBP)programinOctober.Theprogramisrollingoutinthreestages,anditsimpactonpharmacyreimbursementlevelswillnottakeeffectuntilsometimein2019.“Theendgoalistoimprovepatients’healthbyrewardingpharmaciesthatprovidehighqualitycare,andwearecommittedtoworkingwithpharmacygroupstodothat,”saidLeilaMandlsohn,PharmacyStrategyConsultantatGSC.WhiletheForum’spanelofrepresentativesforCanadianpharmacygroupslistedanumberofconcernsaboutGSC’sprogram,theyacknowledgedthattheinsurerhasopenedawindowofopportunityforpharmacytotakeleadershipbeforeotherpayersdevelopsimilarbutseparateprograms.“WeapplaudGreenShieldfortakingthebullbythehornsandservingasacatalystforaction.Weacceptthechallenge,”saidPerryEisenschmid,CEOofCanadianPharmacistsAssociation.GSChaspartneredwithPharmacyQualitySolutions(PQS)intheU.S.,aproviderofperformancemeasurementservicesforpublicandprivatepayersandpharmacies.PQSisalicenseduserofthestandardized,nationallyadoptedperformancemeasuresdevelopedbyPharmacyQualityAlliance(PQA),anon-profitorganizationestablishedin2006andpromptedbythefederalgovernment’snewMedicarePartDprescriptiondrugplan.PrivatepayershavesincealsoadoptedPQA’smeasuresthroughvendorssuchasPQS.“PQAisaneutralintermediarybetweenpharmacyandthepayer.ThisisnotGSCcreatingthemeasures.Thisisaprocessthathasbeeninplaceforanumberofyears,”saidMandlsohn.TheForum’sCanadianpanelistsputforwardthepossibilityofamade-in-CanadaversionofPQA,onethatcouldalsodrawuponfeaturesfromothercountries’performance-measurementsystems.AnotheroptionisforCanadianpharmacygroupstojoinPQAwiththeaimtodevelopCanada-specificmetrics.OneoftheU.S.speakers,however,cautionedagainstspendingtoomuchtimedebatingthecurrentmetrics.Whilerefillratesmaynottellthefullstoryaboutadherencelevels,for

“Theendgoalistoimprovepatients’healthbyrewardingpharmaciesthatprovidehighqualitycare.”LeilaMandlsohn,GreenShieldCanada

2017 Pharmacy Forum Report 7

example,theycanbecapturedthroughclaimsdataandserveasastartingpoint.“Itmaynotbebestforthepatientortheprovider,butwehavetostartsomewhere,”saidJoeMoose,co-ownerofsixMoosePharmacystoresinNorthCarolina.Thebiggerpriority,especiallysinceCanadaisstillinearlydays,is“tositdownwith[thepayers]whoaremakingtherules.Youwanttomakesurethatifthey

takeawaymoney,theydothattothenon-performers.Andthentheypaymoretothosewhoarehighperformers.”AllthreeoftheU.S.pharmaciesrepresentedattheForum—representingalargechain(Kroger),alargebannerprogram(McKesson’sHealthMart)andMoosePharmacy—agreedthatthebenefitsofperformance-basedpaymentmodelsoutweighthedrawbacks.“Value-basedcareisheretostayandintheendit’sbetterforpatientsandit’shelpingusbebetteratwhatwedo,”saidJimKirby,SeniorDirectorofPharmacyServicesatKroger.“Wearereallybeingchallengedtoshiftourbusinessmodelfromdistributiontopatient-centric,performance-basedcare,”notedCrystalLennartz,ChiefPharmacistforHealthMart,McKessonCorporation.Sheaddedthatmedicationsynchronizationwithinanappointment-basedmodelofpracticeisakeypartofthetransition.“Medicationsynchronizationistheclosestthingwehavetoasilverbullet.Wehaveincreasedadherence,decreasedgapsincareandcreatedmoretimeforotherpatientservices.”Article2TimetoshiftcourseonpharmacyresearchPresentedbyDr.LisaDolovich,OntarioCollegeofPharmacistsProfessorinPharmacyPractice,LeslieDanFacultyofPharmacy,UniversityofTorontoPharmacyhasdoneacommendablejobinusingclinicalpracticeresearchtodemonstratethevalueofwhatpharmacistsdointhehealthcaresystem.Butthedatacanonlygosofarinshowingpharmacists’worthdaytodayincontributingtobetterpatientoutcomes.ThatwasthemessagerelayedbyspeakerLisaDolovich,theOntarioCollegeofPharmacistsProfessorinPharmacyPracticeattheUniversityofToronto’sLeslieDanFacultyofPharmacy,andanexecutivememberoftheOntarioPharmacyEvidenceNetwork.“Healthisaconstellationandexpectingthatonemedicationchangebypharmacistswillaffecteverythingelsedowntheroadisunrealistic,”saidDolovich.Insteadit’sabouthowpharmacistsintegrateintotheoverallsystemtobringthosebestoutcomestopatientswhowillhavethegreatestimpact.WhilepharmacyshouldbeproudofinitiativesliketheOntarioCardiovascularHealthAwarenessprogram—whichdemonstratedhowpharmacistscanhelpincreasetheuseofhypertensivesandreducehospitalizations—Dolovichsaidthereisneedformanymoresuch

“Value-basedcareisheretostayandintheendit’sbetterforpatientsandit’shelpingusbebetteratwhatwedo.”JimKirby,Kroger

2017 Pharmacy Forum Report 8

initiatives.“Ononehandwehaveimprovementsonspecificthingsbutwhenyoutakeitfurthertohowpharmacyimpactspatients,we’realittlelesscertain,”shesaid.“Theevidenceismixedandweneedtorecognizethis.”Ratherthanstayonthepathofmicro-measurementofwhetheraparticularpharmacyserviceisdelivered,Dolovichsaidthatpharmacyneedstogetonsideoftherestofthehealthcaresystem,whichmeanstrulyunderstandingthecontributionpharmacistscanmakeaspartofasystemofhealthcareprofessionals.“Wehavetoalsoconsiderthatwhilewewanttobepartoftheteam,we’renotthecentreofthesystem—onlythepatientis,”shesaid.“Weneedalotofcomponentsforlearningthehealthcaresystem,includingtheparticipationofpatientsandtheirfamilies.”Dolovichalsosuggestedthatdocumentationevolvesoitcaneasilybesharedwithpatientsandhealthcareprofessionals.“Imagineaworldwherealltherecommendationspharmacistsmakeareexplicitlydocumentedandavailabletopatients,sotheycanreallyseewhatyoudo,”shesaid.“Whatapowerfulvoicethatwouldbeforpatientstohave.”Dolovichtoldtheaudiencethatit’shightimepharmacy—andtheentirehealthcaresystem—shiftsfromvolumetovalue.“Wehavetomeasurehealthoutcomesandcostsandusethattoimprovecaredeliveryandrewardhigh-valuecare,”shesaid.Keytakeaways

• Pharmacyshouldnotwaitformoreclinicalevidencebeforedevelopingnewpaymentmodelsforpharmacy.

• Pharmacyresearchneedstomovefrommicro-measurementofservicestooutcomes-basedresearchthatevaluatespharmacists’interventionswithinthebroaderhealthcaresystem.

• Thegoalofresearchisnottomeasurethevalueofpharmacy,butthevalueofimprovedmedicationusethroughoutthehealthcaresystem.

• Pharmacy-leveldocumentationneedstoevolvesoitcaneasilybesharedwithpatientsandotherhealthcareprofessionals.

Article3Value-basedcarecanbebettercarePresentedbyU.S.panel:ElliottSogol,SeniorVice-President,Strategy,PharmacyQualitySolutions;CrystalLennartz,ChiefPharmacist,HealthMart,McKesson;JimKirby,SeniorDirector,PharmacyServices,Kroger;JoeMoose,PharmacistandCo-Owner,MoosePharmacyProfitabilityisnottheonly“bottomline”affectedbyavalue-basedpharmacy(VBP)paymentsystem.Patientcarecanalsobeimpacted—andforthebetter,accordingtoU.S.panelistsat

“Imagineaworldwherealltherecommendationspharmacistsmakeareexplicitlydocumentedandavailabletopatients,sotheycanreallyseewhatyoudo.”LisaDolovich,UniversityofToronto&OPEN

2017 Pharmacy Forum Report 9

theCFP’sPharmacyForuminNovember2017.TheU.S.pharmacistssharedtheirexperienceswithVBP—alsoreferredtoasvalue-basedpaymentorpharmacy-basedcare—tohelpCanadianpharmacyretailersandassociationsprepareforitslikelyemergencehere,beginningwiththelaunchofGreenShieldCanada’sprograminOctober2017.IntheU.S.,thefederalgovernmentbeganimplementingvalue-basedreimbursementprogramsforhealthplansmorethan10yearsago,aspartofsweepinghealthcarereforms.Pharmacies’performancescorescontributeapproximately50%toaplan’soverallscore(with

physiciansandhospitalscontributingtherest).In2006,thegovernmentcreatedtheMedicarePartDprescriptiondrugplanforcitizensaged65andolder,whichputevenmorefocusonpharmacies’performancesandledtoadditionalpharmacy-onlyvalue-basedprograms.IntheU.S.,it’sestimatedthatabouthalfofallMedicarePartDclaimsareattachedtoavalue-basedpaymentmodel.Inrecentyears,commercialplansbeganadoptingVBP.It’stoosoontoknowthenumbers,butallfouroftheU.S.panelistsexpectVBPtosteadilyaccelerateintheU.S.Controversyisalsogrowing,aspharmaciesandpharmacyadvocacybodiespushbackagainstU.S.pharmacybenefitmanagersthatuseVBPasacost-containmentmeasure,byfinanciallypenalizingpharmaciesthatscorebelowcertainlevelsinadditionto(orinsteadof)rewardingthetop-performers.Yet,despitethecontroversiescausedbypayers,theU.S.speakersstressedthatVBPisinfactbetterforpatientcare.“Value-basedcareisheretostayandintheendit’sbetterforpatientsandit’shelpingusbebetteratwhatwedo,”saidJimKirby,SeniorDirectorofPharmacyServicesatKroger.AddedCrystalLennartz,ChiefPharmacistforHealthMart,McKessonCorporation:“Wearereallybeingchallengedtoshiftourbusinessmodelfromdistributiontopatient-centric,performance-basedcare.”“Weneedtothinkofvalue-basedpaymentmodelsasjustanewtermforpatient-centeredcare,”echoedElliottSogol,SeniorVicePresident,Strategy,forPharmacyQualitySolutions,whoalsospokeonbehalfoftheAmericanPharmacistsAssociation.Infact,whendonerightbyinsurersandpharmacies,value-basedpaymentorvalue-basedcareisgoodforbothprofitabilityandpatientcare.“Ifyou’reafive-starpharmacythenyouwillget

“Weneedtothinkofvalue-basedpaymentmodelsasjustanewtermforpatient-centeredcare.”ElliottSogol,PharmacyQualitySolutions

2017 Pharmacy Forum Report 10

morereimbursement,”saidJoeMoose,co-ownerofMoosePharmacyinNorthCarolina,addingthatthemodelcanworkespeciallywellforcomplexpatients.Havingsaidthat,theU.S.panelistsalsoagreeditisalongroadtorealizethebenefitsforbothpatientsandpharmaciesand,southoftheborderatleast,notallvalue-basedpaymentcontractsarecreatedequal.Somecontainpitfallsthatnegativelyaffectpharmacyrevenue,despiteeffortstomeetthemetricsforqualitycare.Withthismind,thepanelistspresentedtwomainmissionsforCanadianpharmacyassociationsandindividualpharmacies:bepartofthedevelopmentprocesswithinsurers,andgetyourhouseinordertoestablishefficienciesindispensingaswellasintheprovisionofpatientservices.SeatatthetableWhilethetwocountries’healthcaresystemsdiffersignificantly,thepanelistssuggestedthatCanadacanlearnfromtheU.S.experience.First,beproactive.Don’twaitforpayerstocometoyouwiththeirvalue-basedprograms.“InCanadayouareearlyinthegame.Youhavetositdownwith[thepayers]whoaremakingtherules,”saidMoose.Duringdiscussions,sticktothecommongroundforbothsides:betterqualitycaremeansbetteroutcomesforpatientsandlowercostsforpayers.Withthatalwaysinmind,“youwanttomakesurethatiftheytakeawaymoney,theydothattothenon-performers[inpharmacy].Andthentheypaymoretothosewhoarehighperformers,”summarizedMoose.Standardizationandtransparencyarekey.IntheU.S.,thePharmacyQualityAlliance,anon-profitorganization,hasimplementedstandardized,nationalmedication-basedperformancemeasuresforpharmacies.Physicians,ontheotherhand,arefacedwithmeasuresthatdonothavestandardizedspecificationsforcalculations,andasaresult“theyarepullingtheirhairoutbecausetheyhavemultiplemeasuresthatchangewithpayers,”saidSogol.Transparencyofpaymenttermsisespeciallycritical,sincefinalreconciliationshappenmonthsafterprescriptionsaredispensed.IntheU.S.,disbursementsforVBPoccuronetothreetimesayear,notedSogol.Pharmaciesandpharmacyassociationstherearealsograpplingwithpharmacybenefitmanagers’growinguseofdirectandindirectremuneration(DIR)fees.Insomecases,pharmacieshavetopayaDIRfeetojoinaplan’snetworkandtheirgoalistogetthatmoneybackbymeetingthequality-measurerequirements.Ideallyapurebonusisalsoinplaceasanincentive,butthat’snotalwaysthecase.Longstoryshort,what’shappeningintheU.S.underlines“theimportanceofgettingtothetableearlytoframeconversationswithpayers,”stressedKirby.Houseinorder

2017 Pharmacy Forum Report 11

Despitethechallenges,allthreeoftheU.S.pharmacyrepresentativesdescribedthestridestheyaremakingunderaperformance-basedsystem.Forexample,43%ofMcKesson’s4,800HealthMartpharmaciesnowscoreinthetop20%foratleastoneofthequalitymetrics,comparedto22%in2013.“Theconversationhasreallyshiftedtowhatdowedotoenhanceourperformance,”saidLennartz.Efficiencyinthedispensaryisprerequisite,whichincludesmaximizingtheuseoftechnicians,automationand,ifvolumeswarrant,centralfilling.Whatkicksperformance—includingpatientcare—intohighgear,however,aremedicationsynchronizationandanappointment-basedmodelofpractice.“Medicationsynchronizationistheclosestthingwehavetoasilverbullet,”emphasizedLennartz.“Wehaveoptimizedworkflow,improvedinventorymanagementanddecreasedthecostofdispensing.Wehaveincreasedpatientretention,increasedadherence,decreasedgapsincareandcreatedmoretimeforotherpatientservices.”Foreverypatientenrolledinthesynchronizationprogram,thepharmacygetsanadditional2.3prescriptionfillsonaverage,notedKirbyinhispresentation.Oncesynchronizationisunderway,theappointment-basedmodelenablespharmaciststosmoothlystepintotheirroleascareproviders.Eachmonthlypick-upofmedicationsisanopportunitytositdownwithpatientsandfocusontheirneeds.“We’vefoundthateverysinglepatientwhoissynchedhasatleastdrugtherapyproblem.We’vecreatedastructuredprotocolwithmonthlyfollow-upswhenthereisaspecificneedandthenquarterlycheck-ins.Longitudinalinteractionsarekey,”saidKirby.“Truemedicationsynchronizationisaboutconnectingwithpatientsanddevelopingandreinforcingacareplan,”stressedMoose.Improvedadherencetomedicationsisoneofthefirstpositiveoutcomes,whichleadstobetterscores—andhigherlevelsofremuneration—undervalue-basedpaymentsystems.Keytakeaways

• Theprinciplesofvalue-basedpharmacy—thatis,usingperformancemetricstohelpimproveoutcomes,suchasadherenceratesforcertaindrugcategories—areworthpursuingforbetterpatientcare.Thekeyistositdownwithpayersbeforetheydeterminepaymentmodels.

• Standardizednationalperformancemeasuresareessential,tocircumventdifferentsetsofmeasuresfromdifferentpayers.

• Transparencyofpaymenttermsisalsocritical,sincefinaldisbursementswilloccurmonthsafterprescriptionsaredispenses.

• Paymentmodelsshouldrewardhighperformerswithbonuspayments,ratherthanfinanciallypenalizethosewhodonotachievetargetmetrics.

• Medicationsynchronizationlaysthefoundationforefficienciesinworkflowandoperations,andsetsthestageforanappointment-basedmodelofpracticeforexpandedservices.

2017 Pharmacy Forum Report 12

Article4GreenShield’sroadtovalue-basedpharmacyPresentedbyLeilaMandlsohn,PharmacyStrategyConsultant,GreenShieldCanada

WhenGreenShieldCanada(GSC)launcheditsValue-BasedPharmacy(VBP)programinOctober2017,italsolaunchedalivelydebatewithpharmacyassociationsandpharmacies.Whydiditlaunchsuchaprogram?Williteventuallyleadtolowerreimbursementlevelsforpharmacies?Whatmetricsareusedtomeasurethequalityofpharmacists’services?AndwhyhireaU.S.provider?LeilaMandlsohn,PharmacyStrategyConsultantatGSC,tooktothepodiumattheCanadianFoundationforPharmacy’s2017PharmacyForumtoanswertheseandotherquestions.Bywayofbackground,sheexplainedthatmoreoftheinsurer’sclientsareaskingforcost-containment

strategiessuchascappedfees,cappedcoverageandtheremovalofcoverageforcertain(usuallyhigher-cost)drugs.Ratherthanencourageclientstogodownthatroad,GSCtookacloserlookatqualityimprovementprogramsbeingputinplaceonthepublicside(forexample,Ontario’sExcellentCareforAllActthatincludesperformance-linkedcompensationmodelsforhospitalexecutives).“Thatledustoask,howcanweensureplanmembersaregettingaccesstothecaretheyneed,andplansponsorsaregettingvalueforwhattheyspend?”saidMandlsohn,whoaddedthat“theevidenceshowsthatmeasuringqualitydoesimprovepatientoutcomes.”GSCdecidedtopartnerwithPharmacyQualitySolutions(PQS)intheU.S.,anestablishedproviderofperformancemeasurementservicesforpublicandprivatepayersandpharmacies,ratherthancreateaproprietaryprogramorworkwithaCanadianproviderthatwouldhavehadtostartfromscratch.PQSisalicenseduserofthestandardized,nationallyadoptedperformancemeasuresdevelopedbyPharmacyQualityAlliance(PQA),anon-profitorganizationestablishedin2006andpromptedbythefederalgovernment’snewMedicarePartDprescriptiondrugplan.PrivatepayershavesincealsoadoptedPQA’smeasuresthroughvendorssuchasPQS.“PQAisaneutralintermediarybetweenpharmacyandthepayer.ThisisnotGSCcreatingthemeasures.Thisisaprocessthathasbeeninplaceforanumberofyears,”saidMandlsohn.

2017 Pharmacy Forum Report 13

Togenerateits“Patient-ImpactScorecards”forpharmacies,GSCisusingeightmetrics,sevenofwhichcomedirectlyfromPQA:

• Threemetricsthattrackadherenceratesfordrugstotreathypertension,cholesterolanddiabetes,basedonclaimsdataforthe“proportionofdayscovered”;

• Threemetricsrelatedtochronicdiseasemanagement:1)statinuseinpersonswithdiabetes,2)suboptimalcontrolamongpeoplewithasthmaand3)theabsenceofcontrollertherapyamongpeoplewithasthma;and

• Onesafetymetricspecifictohigh-riskmedicationusebytheelderly.TheeighthmetricisspecifictoGSCandreportsonenrollmentlevelsinGSC’sPharmacistHealthCoachingCardiovascularprogram.Whythesemetrics?“Weknowthatadherenceisamajorproblem,andweknowitcanbedirectlyimpactedbypharmacists,”saidMandlsohn.“Theyarerelativelyeasytounderstandandimproveupon,andtheyareapplicabletoCanada.”Theintentistoidentifyhigh-needspatients,andtheVBPscorecardisamechanismtodothat.PharmaciesthatsubscribetothePQSEQuIPPsystemcanidentifyindividualpatientsthroughtheirprescriptionnumbers.Whiletheinsureris“open”toamade-in-Canadavalue-basedsystemandCanada-specificmetrics,“wearehopingtoseeCanadianassociationsjoinPQA.Wethinkthisisanopportunitytoleveragetheworkalreadydone[intheU.S.],”saidMandlesohn.GSCisrollingoutitsVBPprogramoverthreeyears.Inyearone,GSCismailingitsscorecardstopharmaciesandencouragingenrollmentinEQuIPPtoaccessmorepharmacy-specificreports(note:atthetimeoftheCFPconference,PQShadnotyetdeterminedthecostforaCanadianpharmacytosubscribe).Inyeartwo(startinglate2018),forpharmacieswithaminimumrequirednumberofpatientswithGSCdrugplans,theinsurerwillmakescoresavailabletoclientsandtheirplanmembers.“Plansponsorshaveaskedforthat,tohelpplanmembersmakesmarterdecisionswhenseekingservices,”notedMandlsohn.Inyearthree,GSCwilltiereimbursementlevelstopharmacy’sscores.“Thefundamentalgoalisnottocutspending.Theendgoalistoimprovepatienthealthbyrewardingpharmaciesthatprovidehighqualitycare,”stressedMandlsohn.Keytakeaways

• GreenShieldCanada(GSC)beganinvestigatingquality-improvementprogramsinanefforttopresentanalternativestrategytoclients’growingcallsforcost-containmentmeasuressuchascappeddispensingfees.

• GSChiredPharmacyQualitySolutionsintheU.S.becauseitisanestablishedproviderofperformancemeasurementservicesandusesstandardizedperformancemeasuresfrom

“WearehopingtoseeCanadianassociationsjoinPQA.Wethinkthisisanopportunitytoleveragetheworkalreadydone[intheU.S.]”LeilaMandlsohn,GreenShieldCanada

2017 Pharmacy Forum Report 14

anindependent,non-profitorganization(PharmacyQualityAlliance).ItoptedtogothisrouteratherthancreateaproprietaryprogramorawaitthedevelopmentofaCanadiansystem.

• PharmacieswithGSCplanmembersarenowreceivingPatient-ImpactScoreboardsregarding:adherenceratesforhypertension,cholesterolanddiabetesdrugs;threemeasuresrelatedtochronicdiseasemanagement;high-riskmedicationuseintheelderly;andenrollmentlevelsinGSC’sPharmacistHealthCoachingCardiovascularprogram.

• GSCwillbeginpayingpharmaciesbasedontheirscoressometimein2019.GSChasindicateditsintentistorewardhigh-performingpharmacies.

Article5Pharmacyneedstosteervalue-basedpracticeCanadianpanelists:JustinBates,CEO,NeighbourhoodPharmacyAssociationofCanada;PerryEisenschmid,(then)CEO,CanadianPharmacistsAssociation;NancyLum-Wilson,Registrar,OntarioCollegeofPharmacy;MikeCavanagh,PharmacyOwnerandChair,OntarioPharmacistsAssociationApanelofCanadianpharmacystakeholdersweighedinontheinevitablechangesthatwillaffecttheprofessionaspharmacytransitionstoamorevalue-basedmodelofcare.Speakingatthe2017PharmacyForumhostedbytheCanadianFoundationforPharmacy,thepanelistsagreedonsomekeyobjectives:puttingpatientsatthecentreofcareandconnectingkeystakeholdersacrossthehealthcaresystemtocollaborativelymapoutasustainablefuture.Herearethehighlights:NancyLum-Wilson–Callingforastandardizedapproachtocare,shenotedthatvalue-basedservicesshouldbegroundedinoutcomes.“Ourroleisalwaysgoingtobetoprotectthepublicandputthepatientfirst,”shesaid,notingthatthepharmacists’rolewillonlygetmoreprominentastheaccountabilitytopatientsgetsevengreater.“Value-basedpharmacyisagreatplacetobeginbutwehavetolookatitfromanequitystandpointaswell,”shesaid.Ratherthanriskinginequitablecare,orhaving“20differentinsurerspayingpharmacistsin20differentways,”Lum-Wilsonsaidweneedabroaderapproachfocusedonoutcomesratherthandrugs.Sheaskedaudiencememberstoaskthemselveswhethertheyarereallyputtingpatientsaheadofbusinessgoalsandenablingaccesstotimelyandqualitycare.Asaregulator,Lum-WilsonsaidtheOCPwouldcontinuetofocusonpharmacystandardsofpractice.“Whenitcomestopatients,webelieveifyouhaveacodeofethicsandgetpharmaciststostandardallthetime,wewillhavebetteroutcomes.”Giventhatchangeiscomingnotmatterwhat,Lum-Wilsonrecommendedthatitisininpharmacists’bestinterestto“drivethebus.”

2017 Pharmacy Forum Report 15

PerryEisenschmid–Whiletheprofessionshouldn’tbesurprisedbythechangeindirectiontovalue-basedcare,Eisenschmidexpressedconcernaroundsoftwarecostsandotherpotentialpitfalls.“Thelastthingweneedisaprivateinsurercomingupwithitsownmetricsandcompetingmetricsdon’tmakesense,”hesaid.“Plusthere’snoquestionthatpharmacistshaveakeyroletoplay,buttheydon’tcontrolallthefactorsandthatneedstobeflushedout.”Eisenschmidwarnedagainstcreatingmeasuresfocusedonprocessratherthanoutcomes.“Otherwise,thereisriskofcreatingasystemthatismorepunitivethanrewarding,”hesaid.“It’snotafarreachtoimagineaworldwherewearetakingmoneyawayfrompharmacistsnotperformingtokeylevel…andthat’ssomethingweneedtoaddress.”HenotedCPhA’swillingnesstoworkwithstakeholderstocreatea“madeinCanada”pharmacist-ledsolution,whicheitherbuildsonexistinginitiativesordrawsfromwhat’sbest-in-classglobally.JustinBates–Batesechoedtheneedtotakeaninnovative,Canadian-centricapproachtorewardingbehaviorthatleadstoimprovedoutcomesratherthanriskbeingpunitive.“Weneedtoworkonthisonapan-Canadianlevel,”hesaid.“Weneedtoengagepharmacyandpharmacists—Idon’tknowhowyoucandothiswithoutpharmacistsatthetable.”BatestalkedaboutNeighbourhoodPharmacy’srecentinitiativesaroundmodernizingthecurrentreimbursementmodelfrom‘pillstopatients.’“Themodelhasbeenunderthreatforalongtimeandweneedtobringtogethertheentireecosystemtocomeupwithabettermodelthatisaboutpatients,”hesaid.Withinthenextsixmonths,Batessaidtheassociationwouldbeconductinga“morerobustengagementprocess”amongindustrystakeholderstodiscussthefeedbackgleanedsofar.“Weneedamodelworkingwithprivateandpublicsectorthatestablishesbenefitsonbothsides.”MikeCavanagh–Asanindependentpharmacyowner,Cavanaughnotedthatvalue-basedpharmacyiscertainly“daunting”butitcouldalsobebeneficialinencouragingbetterpharmacistsandpharmacies.“Butwhatisfairmetricsandwhodecides?”heasked,notingthatitwasa‘wildwest’outtherecurrently.“Iworrythatchainswouldmobilizeandimplementasystemfaster,thatpushes[independentslike]meout.”Tomakethesystemsuccessful,Cavanaghemphasizedtheneedtocollaboratewithinsurers,prescribers,employersandpatients.“WeneedtogettherightmetricsthatareapplicabletoCanada,”hesaid.“Andaspharmacistswe’regoingtoneedsupportwithlotsoftools,resourcesandexamples.I’dliketoseearoadmaponhowexactlywegetthere.”Keytakeaways

2017 Pharmacy Forum Report 16

• CanadianpharmacyassociationsappeartobeleaningtowardCanada-specificmetricstomeasureperformance,ratherthanastraightadoptionofU.S.metrics.

• Pharmacistsneedmoreeducationaboutwhatvalue-basedpharmacyreallymeansandhowitcanbeimplementedtoadvancetheirpracticeintheinterestofpatientcare.

• Value-basedpharmacyisinveryearlydaysinCanadaandpharmacyleadershavetheopportunitytobeproactivetoensuretheprofessionsteersthisimportantevolutioninprofessionalpracticeandreimbursementmodels.

Article6WhatdoCanadianopinionleadersthink?(Audiencepollresults)AttendeesattheCanadianFoundationforPharmacy’sannualPharmacyForuminNovember2017werecautiouslysupportiveofavalue-basedpaymentsystemforpharmacy,accordingtoreal-timetextpollingconductedbyCFPduringtheevent.Whiletheresultscanbeconsidereddirectionalonly,andnotstatisticallyvalid,theydoprovideaninterestingsnapshotofopinionsintheroom.Morethan80attendedtheevent,mainlyrepresentingpharmacists/pharmacyretailers,pharmacyassociationsandpharmaceuticalmanufacturers.

• Atthestartoftheevent,67%ofattendeesagreedthat“it’sabouttime”forvalue-basedpharmacyanditshouldproceed“fullsteamahead.”Anadditional18%agreedinprinciplebutwantedtowaitandseebeforeacting,and14%wereconcernedaboutthenegativeimpactonpharmacy.

• Interestingly,attheendoftheevent,attendeesappearedtobelessconfident,asthesenumbershadshiftedto56%,15%and21%,respectively.However,theseresultsmayalsoreflectasmallerresponsebaseattheendoftheday.

• WhenaskediftheycanenvisionaspectsoftheU.S.value-basedmodelinCanada,25%responded“Yes,easily,”whilethemajority(67%)optedfor“Yes,withmodifications.”

• 57%agreedthatotherpayers,includingtheprovinces,willmovetowardoutcomes-orvalue-basedreimbursementoverthenextfiveyears;43%believeitwillcomesooner,overthenextyear(7%)ortwoyears(36%).

• 48%werenotsureifpharmacyassociationsaredoingenoughtoprovideinformation,resourcesandadvocacyaroundvalue-basedpayment,inpartbecausethereisagenerallackofunderstanding.44%wouldliketoseepharmacyassociationsdomore.

• Inaquestionaimedatpharmacistsandpharmacyretailersintheroom,53%respondedthattheywillbemakingadjustmentstotheirpracticesitesoverthenextsixmonthstobettermeetGreenShieldCanada’seightmetricsunderitsValue-BasedPharmacyprogram.

• 38%ofattendeesfeltGreenShield’sinitiativeisnotconsistentwiththecurrentregulatoryframeworkinCanada;38%arenotsureand25%believeitmeetsregulatoryrequirements.

2017 Pharmacy Forum Report 17

Article7ValueandthefutureofhealthcarePresentedbyCatherineHunter,Partner&NationalHealthCareConsultingLeader,PwCCanadaCostpressures,newtechnologiesandchangingconsumerexpectationsareshapingthedeliveryofhealthcareinCanada,andproofofvalueisincreasinglythetouchstonefordecision-making,summarizedCatherineHunter,PartneratPwCCanadaandleaderofitsHealthServicesConsultingPractice,attheCanadianFoundationforPharmacy’sPharmacyForuminNovember2017.Hunterhighlightednumerousemergingtrends,drawingfromresearchconductedbyPwCandothers.Amongthem:

• Morepublic-andprivate-sectorcollaborationstodriveinnovationandnewbusinessmodels.Forexample,federalfundingofinnovation“clusters”or“hubs”(suchasCanada’sAGE-WELLtechnologyandagingnetwork).

• Agrowingreadinessamongconsumerstoaccesshealthcarefromateamofhealthcareprofessionalsthatextendswellbeyondphysicians.

• Consumersalsoincreasinglydesireoptionsforvirtualhealthcare.“Throughourday-to-dayinteractionswithtechnology,we’repreparedtoaccesshealthcareinthiswayaswell,”notedHunter.

• Globally,publicpayersareputtingmorefocusonvalueandtherewardingofpositiveoutcomes.

• The“democratization”ofhealthcaretoimproveaccessibility.Forexample,insurancecarriersinCanadahavelaunchedtheirowntelehealthservicesforclients’planmembers.

“Consumersarewillingtoreceivehealthcareinnewways,”assertedHunter.“Pharmacistshavetheopportunitytobeakeydeliverymechanism[forhealthcareservices].”Andpayers’growingdesireforproofofvalue—andabuddingwillingnesstoincentivizepositiveoutcomes—couldbodewellfortheprofessionwhenoneconsidersthemanyservicesofvaluealreadyprovidedbypharmacists,whicharenotrecognizedorreimbursed.

2017 Pharmacy Forum Report 18

KEYQ&ADISCUSSIONPOINTSEvolutionofdocumentation

• Ifpharmacistsdonotdocumenttheirinterventions,theydidn’thappen;however,therearemanylogisticalchallenges,includingthefactthatmanypharmaciesstillrelyonfaxestocommunicatewithphysicians.

• Therearenoeasysolutions:documentationneedstobecomeamuchgreaterprioritythanitis,withnewtoolsandapproachedwithanewmindset,andthatmustbeginwithpharmacyownersandpharmacyheadoffices.

• Documentationmustevolvebeyondbeingachecklistforpharmacists;itneedstocapturepharmacists’interventionsandrecommendationsinawaythatcanbereadily

sharedwithpatientsandotherhealthcareprofessionals.• Equallyimportant,documentationneedstobeapproachedasanuntappedgoldmineincapturingbothquantitativeandqualitativeoutcomesfrompatients,tohelpprovethevalueofpharmacists’serviceswithinthetotalhealthcaresystem.

QuicklookatU.S.paymentmodels

• IntheU.S.,value-basedpaymentplanscanincorporateincentivesorbonusesbasedonaflatratepercapita,orbasedonapercentile.

• Pharmaciesmayinitiallyhavetopay“directandindirectremuneration”(DIR)feesupfront,whicharepartiallyorfullyreimbursedbasedonperformance—andthehighestperformingpharmaciescouldreceivebonuspaymentsthatexceedtheupfrontDIRfees.

• Inastraightforwardpercapitascenario,forexample,thepharmacycouldreceive$25perpatientpermetricoverasix-monthperiod(i.e.,forpatientswhoareadherentbasedonstatedcriteria).

• InapercentilescenariowithDIRfees,let’ssaythattheplantakes$5offthetopperprescription.Ifthepharmacy’sscoreforametricisoverthe80thpercentile,for

“Yes,youhearthenegativestoriesaboutclawbacks.Butthenwhenyouresearchperformancescores,youlearnthatmaybe50%oftheirpatientsareadherent.Isthatokay?Whereasyou’renotgoingtohearcomplaintsfromthehighperformers.Theyarefocusedonthepatientcareperspectiveandperformwellonthequalitymeasurements.”ElliottSogol,PharmacyQualitySolutions

“Nothingthatpharmacistsdocumentshouldbeforevaluationonly.Itneedstobedonebecauseit’simportantclinicallyandneedstobesharedwithotherhealthcareprofessionalsandwithpatients.”LisaDolovich,UniversityofToronto,OPEN

“Payersarenotsayingtheyneedmoreevidence;theyneedmorehelp.[Theyarestartingto]seepharmacistsasbeingabletoconnectwiththepatientswhoarecostingthemalotofmoney.”JoeMoose,MoosePharmacy

2017 Pharmacy Forum Report 19

example,itgets$6back(i.e.,a$1bonus).Ifitisinthe50thto80thpercentile,itgets$3.50back,andremainingpharmaciesgetnothingback.

• TheAmericanPharmacistsAssociationislobbyingpayerswith

percentile-basedpaymentsystemstoimplementprogramsthatarenetneutral,i.e.,wherethehigherpaymentsforhighperformersaredrawnfromthelowerpaymentstolowperformers,sothattheplan’stotalpayouttopharmaciesremainsthesame.

• Somepaymentmodelsalsoassign“riskscores”topatientstosafeguardagainstpharmacistscherry-pickingless-complexpatientsformedicationtherapymanagementservices.Inotherwords,complexpatientsdeemedtobeathigherriskofhospitalizationwouldgeneratehigherbonuspayments.

Don’tgetstalledonthemetrics

• TheU.S.panelcautionedCanadianpharmacyleadersagainstspendingtoomuchtimedebatingthecurrentmetrics,developedbythePharmacyQualityAlliance(PQA).Whilerefillratesmaynottellthefullstoryaboutadherencelevels,forexample,theycanbecapturedthroughclaimsdataandserveasastartingpoint.

• Instead,pharmacyleadersneedtofocusonworkingwiththeinsuranceindustrytodeveloppaymentmodelsthatachievepayers’objectiveswithoutputtingunduefinancialhardshiponpharmacies.

• PQAiscurrentlyworkingonnewmeasuresforpharmacy,particularlyregardingservicesprovidedtomorecomplexorsickerpatients.

WhatarePQAandPQS?

• ThePharmacyQualityAlliance(PQA,www.pqaalliance.org)isnon-profitorganizationestablishedin2006atthebehestoftheU.S.federalgovernment(whenitlauncheditsMedicarePartDprescriptiondrugplan).Morethan200researchers,academics,pharmacyassociations,communitypharmacies,plansponsors,pharmacybenefitmanagers,pharmaceuticalcompanies,patientadvocacygroupsandgovernmentagenciesaremembersofPQA,andarepartoftheprocesstodevelopthemetricsthatareusedtoratehealthplans’performancesbasedonpatientoutcomes,includingtheperformancesofphysiciansandpharmacists(bypharmacy).

• In2017,PQAannounceditsfirstCanadianmember:theOntarioPharmacyEvidenceNetwork.

“Thetimelineonthisisprobablyshorterthanyouthink.Don’twaitforsomeoneelsetofigureitout.Alsoyou’renotgoingtolegislateyourwayoutofthis.Youhavetoinnovateyourwayoutofit.”JoeMoose,MoosePharmacy

“Whendevelopingmetrics,it’ssuperimportantthatyoudon’tfocusonmetricsthatyouwant,butthatyoufocusonmetricsthatpayerswant.Startwithwhattheyneedtomeasureandimproveandworkwiththat.”JoeMoose,MoosePharmacy

2017 Pharmacy Forum Report 20

• PQAhasdeveloped32performancemeasuressofar.Manyfocusonadherence,basedonclaimsdatashowingtheproportionofdayscovered(PDC)forcertainmedications.APDCof80%isrequiredforpatientstobedeemedadherent.

• In2018,PQAisexpectedtoreleasenewpharmacy-specificmetrics.• PharmacyQualitySolutions(PQS)isaleadingU.S.providerofvalue-basedpayment

systemsforpublicandprivatepayers.ItisalicenseduserofPQA’smetrics,andPQAisitsmajorityowner.

• PQScreatedtheEQuIPP(ElectronicQualityImprovementPlatformforPlans&Pharmacies)onlineplatformforhealthcarproviders,insuranceprovidersandpharmacybenefitsmanagementcompaniestoaccessandassessperformanceratings,usingabroadrangeofreportingtools(pharmacies,forexample,canidentify“outlier”patientswiththelowestadherencerates).Accordingtoitswebsite(www.pharmacyquality.com),95%ofU.S.communitypharmaciessubscribetoEQuIPP.

• In2013,EQuIPP’sdatabasecontainedrecordsfor1millionpatientsincludedinsometypeofvalue-basedprogram(i.e.,involvingpharmacies,physiciansorhospitals).By2017,thathadjumpedto20million.MostarebeneficiariesoftheU.S.government-administeredMedicareandMedicaidplansforseniorsandlow-incomecitizens.PQSpredictsgrowthwillcontinuetoaccelerateasmorecommercialplansadoptvalue-basedpaymentsystems.

Patients’perceptionsslowtochange

• Changemanagementappliesasmuchtoconsumersasitdoestopharmacists,notedspeakersandmembersoftheaudience,anditcantakealongtimetochangepeople’sperceptionsofpharmacists’capabilities.

• Whileconsumersgenerallyalreadythinkpositivelyaboutpharmacists,theprofessionneedstoacknowledgethatpatientsatisfactioniscurrentlymorelikelylinkedtoconvenienceratherthanservicesreceived.

• It’simportanttomarketpharmacists’servicesintermsoftheirbenefitstopatients—don’tjustmarketpharmacists’expertise.

“Quality-basedcareisnotgoinganywhere.Getstarted,evenwithsmallsteps,forexamplefocusingonrefillsandmedicationsynchronization.”JimKirby,Kroger

“We’renotasfaralonginshiftingpatientperceptions[aswethoughtwewouldbe].Justaspharmacistshavetogothroughchangemanagement,sotoodopatients.”CrystalLennartz,McKesson

“[Recognize]whenitisalltoonewforthem.Ifapatientsayswearecallingtoomuch,askingtoomanyquestions,weknowwehavetobackoffforabit.”JoeMoose,MoosePharmacy