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 Inexorably, healthcare in the United States is marching towards a value payment system.  It’s a slow, ugly, and sometimes bloody process.  While the concept of healthcare paying for performance (good performance and high quality) to reduce overall healthcare spend is revolutionary, the process to get there is evolutionary.  Darwin would be proud.  The rest of us should be working on the evolutionary process to ride with it and not be buried by it.

Since this revolution began, the only thing that remains certain is not only does no one have all the answers, collectively we don’t even know the questions.  We are trying to effect global health, or population health, by treating one patient at a time.  It’s an unwieldly process and one that needs to have the rough edges sanded off.

One way we’ve tried to effect population health is by attempting to establish standards for treatment, goals and metrics.  All of which are designed to help the individual patient get healthier, utilize less healthcare and thereby save money. 

Look at the previous paragraph and think Stars Programs.  Ostensibly, the Stars program was designed to improve patient care.  I even wrote an article early on proclaiming Pharmacy’s future was in the stars.  So, how are we doing?

Pharmacy’s performance numbers have been pulled from paid claims, digitalized, analyzed, spiritualized, bastardized, and utilized in multiple ways, some of them unintended.  While a pharmacy is not officially assigned a “Star” rating, most payers are proceeding to reduce pharmacy reimbursements based on “Star Performance.”  This results in the movement of mountains of cash from providers to middlemen, but does it positively affect the patient?  Are these performance metrics doing what they were designed to do?

The example of the High Risk Medication metric is a good example of the evolutionary process underway.  The High Risk Medication list was intended to act as a guideline in reducing risk associated with certain medications used in the elderly.  Reduce the exposure, reduce the risk, reduce the spend was the theory.  Payers would be incentivized to reduce the use of these medications within their plans member population.  Payers responded by changing formularies, dropping previously covered medications, instituting prior authorizations for “high risk meds”, penalizing their providers for prescribing or dispensing them to members, etc., etc., etc.  And it worked!  The paid claims for these medications went down significantly and plans reaped rewards as a result.  But was this the plan “gaming the metrics” or was it a true, beneficial, patient care improvement?  There was no marked national decline in drug related adverse events or hospital admissions during that time, and from behind the counter we saw patients switching to cash instead of risking a claim denial.  Nearly no affect at all, other than the plans reaped large monetary rewards.

I propose the system of “Stars” as it stands now perpetuates that scenario to a large degree.  Take 90 day supply of medication as an example.  When there is a possible gap in fill on paid prescription claims, the first notice sent out is “switch this person to a 90 day supply.”  In my experience, a patient non-adherent to a 30 day supply will not magically become adherent if they are given a 90 day supply of medication.  It is, however, much easier to make the metrics look favorable with a 90 day paid claim than a 30 day paid claim, considering plans only look at data for a 12 month period based on coverage cycles.  Once more the system is gamed to the benefit of a plan, but the patient is not helped nor outcomes improved.

What is needed are true pharmacy based performance metrics that reflect the positive contribution the pharmacist makes to the health of a patient.  Metrics and measures must be designed that help the patient, not the payer, or even the provider.  Both payer and provider need to be compensated for improving the health of a patient and thereby saving money, not by meeting a metric that can easily be manipulated for the purpose of reaping unearned rewards.

Designing these clinically based metrics is a daunting task.  It is, however, a task that pharmacy can accomplish.  Pharmacists are positioned to provide the necessary resources and input to payer and government as the evolutionary reimbursement decisions are made.  All parties understand that without pharmacist input and participation the costs of future healthcare are unsustainable.  We are at the table.  Our voices and actions must speak loudly.

The Stars, as we know them now will change in the sky, some will fade and blink out, some new ones will emerge and some will be passed by the evolutionary process. What we cannot allow is the for-profit gaming of the system.  All metrics must focus on positive patient outcomes, not corporate profits.  Pharmacists are the voice of the patient at this table.  When we speak for the patient, it benefits us all.

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