CFP Forum tackles quality question

NOVEMBER 2018 – Ready or not, pharmacies will be assessed for the quality of their care to patients, and the results will be publicly reported, as part of a growing movement to improve health outcomes across the healthcare system. This message was one of the key takeaways from the Canadian Foundation for Pharmacy’s 2018 Pharmacy Forum event in Toronto in late October.

This statement does not just reflect efforts on the part of private insurance companies—specifically Green Shield Canada (GSC), which implemented its value-based pharmacy program just over a year ago. While GSC’s program was on the agenda, presenters from the Ontario College of Pharmacists (OCP) and Health Quality Ontario (HQO) also shared information about their new program for continuous quality improvement (QI) in pharmacy, scheduled to begin by mid 2019. The program will use a set of quality indicators to measure and report on the impact of pharmacy practice on patient outcomes and in the healthcare system.

HQO has already implemented QI programs in hospitals, long-term care and family practice. One set of quality indicators, for example, measures wait times for surgeries and procedures. “Community pharmacy has not been an area of focus for HQO yet. It’s exciting to embark on this journey with the College, and to incorporate pharmacy into our overall metrics,” said Anna Greenberg, Vice-President of Health System Performance at HQO.

Margo Orchard, Manager of Strategic Policy at OCP, emphasized that the regulatory body “would never use the indicators for any kind of discipline or quality assurance purposes.” Rather, they are intended to measure the impact of pharmacists’ interventions, and from there determine how improvements can be made. “There also needs to be capacity with the sector to take on these approaches [for quality improvement.] These indicators should be supplemented with education, training and tools.”

In June this year, a roundtable session with invited stakeholders (including patients, pharmacists and other providers) agreed upon five key areas for measurement: the patient/caregiver experience and outcomes; the provider experience; the appropriateness of dispensed medications; medication-related incidents/hospital visits; and transitions of care. An expert panel is currently determining a preliminary set of quality indicators based on these areas, and then OCP will seek feedback from pharmacies and the public. The roundtable’s report, entitled Quality Roundtable: Pharmacy Indicators 2018, is available on OCP’s website.

Nancy Waite, Co-Lead for the Ontario Pharmacy Evidence Network (OPEN) and the Forum’s opening speaker, described pharmacy quality programs in other countries, such as Australia, England, the Netherlands and the U.S. “Systems-level monitoring is very helpful for pharmacies,” she noted. “We have to have data, the right data, that we can do something about.”

While this is the most common approach to QI—described as audits and feedback—its impact is limited. “We have seen overall standard of care improve, though the emphasis tends to be on bringing up low-performing sites.”

To get to the next level, QI needs to incorporate more “hands-on” elements, such as practice facilitators. The HQO/OCP QI program will be an example of that. “HQO is not just about measuring, but also about helping with change. They are very hands-on.” 

With that in mind, OPEN has launched the “Health Hubs” research project, which will bring in an external practice facilitator as well as develop an internal change champion within each participating pharmacy. “We recognize that asking pharmacists to do more is a challenge. So we want to work with HQO to build capacity for quality improvement. We need approaches for change management that pharmacists can actually do in their pharmacy,” said Waite.

An update on GSC 

Ned Pojskic, Pharmacy Practice Leader at GSC, gave an update on the insurer’s value-based pharmacy (VBP). Phase one began in October 2017, when GSC began mailing its “Patient-Impact Scorecards” to pharmacies. These cards score pharmacies based on eight metrics in the areas of adherence, chronic disease management and patient safety. For example, one of the metrics looks at claims data regarding statin use in persons with diabetes. Another metric is specific to high-risk medication use among the elderly.

All the metrics except one were developed by Pharmacy Quality Alliance, a U.S. non-profit organization responsible for developing standardized quality measures for use by public and private payers. The eighth measure is specific to GSC’s proprietary Pharmacist Health Coach Cardiovascular program.

During phase one, GSC has also been encouraging pharmacies to subcribe to EQuIPP, the database that gives pharmacies more detailed reporting on their results (including the identification, through prescription numbers, of “outlier” patients who are bringing scores down). The cost to subscribe is about $600 per year.

GSC recently launched phase two, which shares pharmacies’ scores with plan members. The scores for the metrics are converted into a star rating, with five stars being the top score. The star rating is made public only for pharmacies with a minimum number of patients for three or more of the metrics.

Phase three will see reimbursement tied to the scores, and is scheduled to begin in 2020. “We are working with the Canadian Pharmacists Association and the Neighbourhood Pharmacy Association of Canada, to ensure this makes sense for pharmacy,” said Pojskic. “We will be rewarding the high-performing pharmacies, and penalizing low performers. Based on 10 years of U.S. experience, incentives alone don’t result in changes in performance.”

He added that additional bonuses will also be likely, such as an annual bonus for most-improved pharmacy. “Should not high-performers be reimbursed more? Is it fair to pay low-performers the same as high-performers?” he asked.

While the philosophy behind GSC’s plan may be a step in the right direction, its execution leaves much to be desired, according to Rob Modestino, owner of a Rob’s Whole Health Pharmacy in Lasalle, Ontario. Modestino was part of the pilot project for GSC’s VBP, and his presentation at the Forum detailed some of the challenges that he hopes are resolved before the reimbursement phase kicks in.

For example, the metrics for adherence don’t take into account Ontario’s rules that limit the frequency of claims for blister packs for people on the public plan. “Blister packs can be the best thing for adherence, but I’m being penalized. These patients show up as 40% compliant on the report card. They change my score dramatically,” said Modestino.

The metrics for chronic disease management and high-risk medications are also frustrating, because they rely on physicians agreeing to change prescriptions. To overcome this, he suggests that GSC “allow us to send documentation that shows we tried with the doctor, but they were non-compliant. Then take that patient off the metric.”

Last but not least, the program is time-consuming. “Time is the biggest issue. Someone has to go through the data to identify the outliers,” said Modestino. “Then you’re sending requests to doctors and following up with them, with no compensation involved.”

The Forum wrapped up with a panel discussion on pay-for-performance in pharmacy, featuring representatives from the Canadian Pharmacists Association, Neighbourhood Pharmacy Association of Canada, Ontario Pharmacists Association, Alberta Pharmacists Association and Shoppers Drug Mart.