PBM Applications: MTM, Adherence, and Value Based Care

What is value based care?

- Improves the quality of healthcare

- Overall cost savings

Name some of the groups who dictate value based care.

- NCQA

- CMS

- AHRQ

- IHI

Which group develops the Healthcare Effectiveness Data and Information Set (HEDIS)?

National Committee for Quality Assurance (NCQA)

What is the primary federal agency responsible for overseeing value-based care initiatives?

Center for Medicare and Medicaid Services (CMS)

What is the function of the Agency for Healthcare Research and Quality (AHRQ) ?

Produces evidence to support the development of quality metrics that improve healthcare delivery

What is the function of the Institute for Healthcare Improvement (IHI)?

Develops and promotes quality improvement strategies and collaborates with other organizations to create quality metrics

IHI Quintuple Aim

1. Patient Experience

2. Population Health

3. Reducing Costs

4. Care Team Well-being

5. Health Equity

What is the function of Patient Centered Medical Homes (PCMH)?

- To improve primary care delivery by making it more patient-centered, accessible, and coordinated

- Emphasis on continuity

- Strong focus on preventative care and coordinated care across providers

What are Accountable Care Organizations (ACOs)?

- A type of reimbursement model for improved quality of patient care

- Groups of healthcare providers (such as hospitals or physicians) who voluntarily come together to give coordinated care to patients

Types of ACOs

- Medicare Shared Savings Program (MSSP)

- Commercial ACO

What are some of the key features of bundled payments?

- Improved care coordination

- Cost savings

- Better outcomes

- Incentive for quality over volume

Define capitation.

The set amount per patient per period providers are paid, regardless of how much care the patient requires

Why is Value Based Insurance relevant to pharmacists?

- They can impact ratings compared to other pharmacies

- They increase reimbursement/get incentives for higher performance

- Higher performing pharmacies may get preferred status or preference with patients

How are Medicare Star Ratings ranked?

From 1 star (lowest) to 5 stars (highest)

What is EQUIPP?

- A performance information management tool

- Provides standardized benchmark performance information needed to shape strategies and guide medication-related performance efforts

What are some of the pros and cons of Direct and Indirect Remuneration (DIR) fees?

Pros:

- Reduced out of pocket costs for patients

- Pharmacies have costs taken directly at POS instead of large sums of money several months later

Cons:

- There is no easy way for pharmacies to track the exact cost of DIR fees

- In the first several months, pharmacies pay more upfront in DIR fees