Value-Based Pharmacy

There are many programs designed to improve the quality of medication use. Some are internal hospital or community pharmacy programs (often used as a tool for accreditation). Other programs are initiated by patient safety organizations (e.g., ISMP Canada), pharmacy regulatory bodies (e.g., Ontario College of Pharmacists), or national pharmacy associations (e.g., Canadian Society of Hospital Pharmacists, Canadian Pharmaceutical Association), etc. Community pharmacy teams can do a great deal to improve the quality of patients’ medication therapy. However, there is not usually a direct connection between improved quality and payment for services. Third-party payers (i.e., insurance and government medication payment programs) are recognizing that paying a pharmacy to improve the way medications are used by patients can improve the quality and safety of medication therapy, while also lowering costs. Pay-for-performance quality improvement initiatives have been present in the U.S. for years, in the form of quality measures and “Star Ratings.” These initiatives are now making their way to Canada. Green Shield Canada (GSC) is the first payer to introduce a value-based pharmacy pay-for-performance program in Canada.1 GSC assigns a score to individual pharmacies which they plan to use to determine reimbursement, based on claim submission data. This toolbox provides information on community pharmacy quality improvement programs, with a focus on the Green Shield Canada program. It provides resources with strategies to help pharmacies improve GSC’s quality measures. Keep in mind, it will be important to stay on top of updates as the GSC program, and perhaps others like it, are implemented.

Topic Description and Resources
Green Shield Canada (GSC)’s Value-Based Pharmacy Initiative
Value-Based Pharmacy

Green Shield Canada is a national, not-for-profit, insurer that has about 3.3 million plan participants across Canada (about 9% of the population).2 Value-based pharmacy is one part of GSC’s SmartSpend Program. SmartSpend is aimed at improving patient outcomes and increasing the value of health products and services.3

GSC uses information gathered from their medication claim submissions to assess the quality of patient care for certain measures.3 GSC measures, evaluates, and ranks a pharmacy’s performance against a defined set of U.S.-based health outcome metrics.4 These measures translate into a score for individual pharmacies across Canada. Note that GSC only uses claims submissions data when GSC is the first payer.4 The pharmacy’s score is a reflection of medication use in patients who have GSC. Pharmacies that perform better on quality measures will get higher reimbursements, while pharmacies with lower quality scores will get lower reimbursements.3

GSC’s value-based pharmacy initiative was partially based on the U.S. Centers for Medicare & Medicaid Services’ Five-Star Quality Rating System. Questions have been raised about the relevance of these metrics in Canada. The U.S. model is designed to evaluate several aspects of patient care and includes pharmacies and physicians. In Canada, only pharmacies are being evaluated in GSC’s current initiative.4 GSC’s program was designed to “move the profession forward” and not as “a cost-containment initiative. GSC will reward high-performing pharmacies with bonus payments and penalize low performers.”1 One of GSC’s goals is to incentivize performance and align performance with financial reimbursement.1

Phases of GSC’s Value-Based Pharmacy Program

GSC Quality Measures

  • GSC tracks eight quality measures to assess high-priority health issues.1,3
  • The measures were chosen based on well-established clinical guidelines.5
  • The initial quality measures are meant to start changing the “culture of quality assessment and improvement” in an effort to improve healthcare outcomes and lower healthcare costs.6

Phase One: Patient-Impact Scorecards1

  • GSC began sending monthly scorecards to pharmacies in 2017, based on GSC claims information.
  • A pharmacy’s scorecard provides information on their patients’:
    • Adherence
    • Disease management
    • Medication safety
  • Scorecards also include a provincial/territorial average score.6
  • A Pharmacy Quality Rating of one to five stars was added to the scorecard in 2018. One-star ratings indicate the pharmacy is below average. A five-star pharmacy rating indicates a pharmacy is exceptional.5

Phase Two: Patient Access1

  • GSC plan members gained access to pharmacies’ performance information, quality-of-care scores, and star ratings in November 2018.
  • Pharmacies may see patients making choices about which pharmacy to use based on GSC’s score and ratings.
  • Scores are only based on GSC claims data, which account for only a portion of an individual pharmacy’s patients/prescriptions. Scores do not reflect a pharmacy’s entire patient experience. Scores do not include aspects which may be important to patients (e.g., services, customer service, speed of dispensing).

Phase Three: Pharmacy Reimbursement1

  • Full details of the reimbursement plan are not yet available.4
  • Development done in “consultation and collaboration” with “the pharmacy community.”
    • Working in consultation with national and provincial pharmacy organizations and pharmacies.1,4
  • Reimbursement changes for pharmacies to begin based on their performance scores in 2020.5
Value-Based Pharmacy Resources

Electronic Quality Improvement Platform for Plans and Pharmacies (EQuIPP)

  • EQuIPP is an online performance information management platform used by health plans and pharmacies to track performance on quality measures (www.equipp.org/professional.aspx).7
  • Data on the EQuIPP platform is supplied by payers (e.g., Green Shield Canada).
  • This program is not required for GSC’s value-based pharmacy program. However, using EQuIPP can give pharmacists detailed information to help improve their pharmacy’s score.4
  • Annual cost for each pharmacy to access EQuIPP ranges from $150 to $400.4
Green Shield Canada Quality Measures: Adherence
General Medication Adherence

The following three quality measures look at adherence to cholesterol, diabetes, and hypertension medications. Resources from Pharmacist’s Letter Canada/Pharmacy Technician’s Letter Canada to help you positively impact all three of the below adherence measures include:

Adherence to Cholesterol Medications

This measure looks at the proportion of patients age 18 and older taking a statin drug who were adherent to their therapy.8 Resources from Pharmacist’s Letter Canada/Pharmacy Technician’s Letter Canada to help you positively impact this measure include:

Adherence to Diabetes Medications

This measure looks at the proportion of patients age 18 and older taking at least one non-insulin diabetes drug who were adherent to their therapy.8 Resources from Pharmacist’s Letter Canada/Pharmacy Technician’s Letter Canada to help you positively impact this measure include:

Adherence to Hypertension Medications

This measure looks at the proportion of patients age 18 and older taking at least one renin-angiotensin-system-antagonist drug who were adherent to their therapy.8 The goal is at least 80% adherence. Resources from Pharmacist’s Letter Canada/Pharmacy Technician’s Letter Canada to help you positively impact this measure include:

Green Shield Canada Quality Measures: Disease Management Measures
Asthma Management

These two asthma measures look at:8

  1. Suboptimal control: patients who were dispensed asthma medications during the measurement period and received more than three canasters of a short-acting beta agonist within a 90-day period.
  2. Absence of controller therapy: patients who did not receive controller asthma therapy during the same 90-day period in which they received more than three canisters of a short-acting beta agonist.

Resources from Pharmacist’s Letter Canada/Pharmacy Technician’s Letter Canada to help you positively impact this measure include:

Statin Use in Patients over 45 with Diabetes

This measure looks at patients age 40 to 75 who were dispensed a medication for diabetes and also received a statin medication.8 Resources from Pharmacist’s Letter Canada/Pharmacy Technician’s Letter Canada to help you positively impact this measure are included in the above adherence to cholesterol and diabetes medication measures.

Green Shield Canada Cardiovascular Health Coaching Program

This measure looks at patients who met GSC cardiovascular health coaching service’s eligibility criteria and received the service. Information to help you positively impact this measure:

  • Pharmacists must complete GSC’s online training programs to offer cardiovascular health coaching services.9
    • Training is available for pharmacists through the Ontario Pharmacists Association in Alberta, Saskatchewan, Manitoba, Ontario, Nova Scotia, New Brunswick, Newfoundland & Labrador, Prince Edward Island, Nunavut, Yukon, and Northwest Territories. Member’s cost is $100; non-members pay $200.12
    • In British Columbia, pharmacists should access the program through the British Columbia Pharmacy Association. Member’s cost is $100; non-members pay $200.10
    • PharmAchieve (http://pharmachieve.com/register#ces) offers the training program to all Canadian pharmacists (except pharmacists in Quebec) at a cost of $200.12
  • Pharmacists providing cardiovascular health coaching receive $60 for the first consultation, and $20 for each additional consultation. Patients may receive a total of four visits the first year with three visits per year thereafter.10
  • To be eligible, patients must have GSC’s extended health coverage, be less than 65 years old, and have both hypertension and high cholesterol.10,11
Green Shield Canada Quality Measures: Safety Measure
High-Risk Medication Use in the Elderly

This measure looks at patients age 65 and older who receive two or more prescription fills for a high-risk medication.8 Resources from Pharmacist’s Letter Canada/Pharmacy Technician’s Letter Canada to help you positively impact this measure include:

Other Community Pharmacy Quality Improvement Initiatives
Ontario College of Pharmacists (OCP)

The Ontario College of Pharmacists is also developing quality indicators for community pharmacies.13

  • Their intent is to:
    • Promote a culture of quality improvement within the profession of pharmacy.
    • Improve public transparency about the impact of pharmacy on patient outcomes.
    • Help establish pharmacy within the broader health system.
  • Their intent is NOT to use these quality indicators to determine reimbursement.
  • Their quality indicators will be based on the following categories:
    • Appropriateness of dispensed medications.
    • Medication-related hospital visits.
    • Patient/caregiver experience and outcomes.
    • Pharmacy team member experience.
    • Transitions of care.
Additional Quality-Related Organizations
Links to Other Important Quality-Related Organizations in Healthcare Accreditation Canada: www.accreditation.ca.
  • Non-profit organization working to improve the quality of healthcare. They offer accreditation to health and social service organizations.
Health Standards Organization (HSO): www.healthstandards.org.
  • Non-profit organization that develops standards, assessment programs, and processes to improve the quality of healthcare.
Pharmacy Quality Alliance (PQA): www.pqaalliance.org.
  • A U.S.-based, non-profit, multi-stakeholder, consensus-based membership organization committed to improving healthcare quality and patient safety with a focus on the appropriate use of medications.
Pharmacy Quality Solutions (PQS) is a venture of PQA.
  • Provide performance management services to both payers and community pharmacies. Owns and operates the EQuIPP platform.

Project Leader in preparation of this clinical resource (350124): Annette Murray, BScPharm

References

  1. Burnett-Nichols H. New program measures performance of Canadian pharmacies. November 2, 2018. https://www.benefitscanada.com/news/new-program-measures-performance-of-canadian-pharmacies-120276. (Accessed December 12, 2018).
  2. Green Shield Canada. CSR report 2016. https://assets.greenshield.ca/greenshield/About%20GSC/csr/04%20GSC%20CSR%20Report_EN.pdf. (Accessed December 13, 2018).
  3. Green Shield Canada. SmartSpend. https://www.greenshield.ca/en-ca/sponsors-advisors/benefits-of-gsc/smartspend. (Accessed December 12, 2018).
  4. Canadian Pharmacists Association. The facts on the Green Shield Canada (GSC) value-based pharmacy initiative. https://www.pharmacists.ca/cpha-ca/assets/File/cpha-on-the-issues/GSCValuebasedPharmacyInitiativeFactSheet.pdf. (Accessed December 12, 2018).
  5. Green Shield Canada. SmartSpend means value, quality, and patient-focused health care. October 30, 2018. https://www.greenshield.ca/en-ca/news/newsroom/smartspend-means-value-quality-and-patient-focused-health-care. (Accessed December 12, 2018).
  6. Green Shield Canada. Measuring the performance of pharmacies. June 27, 2018. https://www.greenshield.ca/en-ca/news/newsroom/measuring-the-performance-of-pharmacies. (Accessed December 12, 2018).
  7. EQuIPP. Welcome to EQuIPP. https://www.equipp.org/default.aspx. (Accessed December 13, 2018).
  8. providerConnect. Pharmacy Update. August 2017. https://www.providerconnect.ca/Carriers/GreenShield/Pharmacy/PharmacyPublications/en_CA/UpdateAuguest2017_National.PDF. (Accessed December 13, 2018).
  9. Welds K. Drug plan trends report: how drug plans are addressing skyrocketing costs. March 18, 2016. https://www.benefitscanada.com/benefits/health-benefits/drug-plan-trends-report-how-drug-plans-are-addressing-skyrocketing-costs-78443. (Accessed December 13, 2018).
  10. British Columbia Pharmacy Association. Cardiovascular program. https://www.bcpharmacy.ca/education/training-sessions/cardiovascular-program. (Accessed December 12, 2018).
  11. PharmAchieve. Continuing education. http://pharmachieve.com/register#ces. (Accessed December 12, 2018).
  12. providerConnect. Pharmacist health coaching – cardiovascular program information. https://www.providerconnect.ca/HealthCoaching/ProgramInformation.aspx. (Accessed December 12, 2018).
  13. Ontario College of Pharmacists. Quality indicators for pharmacy. December 4, 2018. https://pharmacyconnection.ca/quality-indicators-pharmacy-fall-2018/?utm_source=e-Connect&utm_campaign=162fb6669f-EMAIL_CAMPAIGN_2018_12_06_02_42&utm_medium=email&utm_term=0_9d9e40b686-162fb6669f-63710875. (Accessed December 13, 2018).

Cite this document as follows: Clinical Resource, Value-Based Pharmacy. Pharmacist’s Letter/Pharmacy Technician’s Letter. January 2019.

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