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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
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.”
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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
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• 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.
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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.
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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
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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
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• 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