Last summer we told you about our Value-based Pharmacy initiative – a strategy to drive accountability in our health care system and ensure that our plan members are getting the best possible quality of care. (See the GSC Update of July 2017.) The first phase of this initiative focuses on measuring pharmacy performance based on a set of eight measures and provides that information to pharmacies across Canada through monthly Patient Impact Scorecards.
The eight measures, based on well-established clinical guidelines are divided into three categories:
Adherence to drug therapy, chronic disease management, and safety of medication use. The scorecards show each pharmacy their own performance score for the measures, a GSC-established goal that we consider attainable (based on performance of higher-performing pharmacies), and a provincial average score to help them understand their performance compared with other pharmacies.
Pharmacies have been receiving scorecards since October 2017, so eight months in, let’s examine the data and see how they’re doing…
The adherence measures focus on three common chronic conditions – no surprise that these are hypertension (high blood pressure), high cholesterol, and diabetes. As we’ve all learned from past GSC Health Studies, these are conditions that have consistently seen poor medication adherence.
By analyzing GSC claims for certain drugs that treat these chronic conditions, the adherence measure evaluates
how well the pharmacy ensures its GSC patients continue to refill the medications regularly and without gaps. The score for each measure indicates the proportion of patients that are highly adherent to their medication (i.e., patient adherence is 80 per cent or higher).
The disease management measures draw on GSC drug claims data to evaluate how well a pharmacy ensures that patients are getting the best and most appropriate medications to treat their condition. The measures in this category assess whether:
- Patients taking diabetes medications are also taking medications called statins that help prevent a future heart attack or stroke.
- Patients with asthma are using their appropriate medications to keep their condition under control. (Asthma management has two separate measures involving the use of two types of asthma medication: controller therapy and a reliever, or rescue, medication.)
- Patients taking medication for cardiovascular disease are getting health coaching from their pharmacist to help them control their disease.
Some medications have a more significant risk of causing a severe health problem when used by older patients. For example, a reaction to a medication could cause a fall that could result in a hip fracture. The safety measure indicates the percentage of patients age 65 and older who received a high-risk medication.
So how are pharmacies doing?
The average scores for the first eight months of the program reveal an interesting snapshot of Canadian pharmacies’ current approach to patient services and areas where they could improve.
The scores for the adherence measures are good; this is an indication that pharmacists are now taking on more of a role in helping patients be adherent to their medications. It is also a reflection of some of the efforts GSC has undertaken to improve plan member adherence through initiatives such as targeted disease communications, Stick2It – our digital medication reminder program, and, to be frank, our policy to dictate mandatory dispensing of a three-month supply of chronic medications.
The weakest scores are found in the disease management and patient safety categories illustrating that many people aren’t getting the level of medication-related support they need from their health care professionals. For instance, the health coaching score is low, although pharmacists often tell us they want to increase their scope of practice (and revenue streams) through offering these types of programs.
However, this isn’t simply a pharmacist problem – the issue is in our entire health care system. The current situation seems to be one where the physician writes the prescription and the pharmacist fills it, and if there’s a problem, often no one notices. But disease management, really patient management, falls on both the physician and the pharmacist jointly. So there’s a clear opportunity for pharmacists, working collaboratively with physicians, to step up and take on more of that patient management role.
To gain more insight on this, we talked to Ned Pojskic, GSC’s leader, pharmacy and health provider relations. He used the asthma measures as an example of how pharmacy processes can lead to lower scores:
“Asthmatic patients are typically diagnosed by a physician and prescribed drug therapy to control their condition. The therapy often includes a ‘controller’ drug, which is to be used on an ongoing basis to keep asthma symptoms under control, and ‘reliever’ therapy which is to be used only in an acute asthma attack. The pharmacist will usually describe the function of both of these medications to a new asthmatic patient. But if that same patient starts to overuse their reliever medication, because of allergens or weather conditions for example, the pharmacist may continue to fill the prescription without engaging the patient and the physician to reassess disease control and recommend an adjustment to the controller therapy. The physician, on the other hand, is often not aware of the patient’s poor control because the pharmacist continues to supply the patient with the reliever medication.
“Pharmacists have a unique vantage point and window into the problem and therefore have a responsibility to intervene and address the issue. At the moment, the pharmacy workflow and care delivery model doesn’t consistently incorporate this type of patient management and ongoing following of patients, particularly for people with chronic disease. Ultimately, a change in culture is needed – a different way of thinking about who has ownership for the patient.”
How can pharmacies improve their scores?
Through the scorecards, GSC is showing pharmacies where there are opportunities for improvement in the quality of care they offer to patients. But as we see it, the key to performance improvement, and improved outcomes, is partnering with the physician in the ownership of each patient. As Ned explains, “We’re really talking about the bigger clinical picture, which means continuous evaluation of the patient’s status, continuous monitoring of the patient’s entire drug therapy regimen against their disease state, and continuous intervention in situations where necessary. While that may not be in all pharmacists’ mindsets currently, it is in their standard of practice.”
The average scores shown here reveal trends, and GSC’s performance measures represent only a sample of all the different areas where a pharmacist could intervene. But in taking steps to improve their scores, pharmacies that take ownership of diabetic or asthmatic patients, for example, will ultimately take ownership for outcomes of other patients coming to the pharmacy. In other words, it starts the process for the creation of a culture of quality assessment and improvement. Ultimately, it leads to better care for plan members, better outcomes, and lower health care costs.
Providing pharmacies with feedback on their performance is just phase one of GSC’s Value-based Pharmacy initiative. In phase two, plan members will be able to view pharmacy performance through an online search tool. This will enable plan members to choose a pharmacy not only based on factors such as cost and location, but also actual quality of care delivered by that pharmacy. The search tool will be available in late 2018, so stay tuned for more information about this new initiative.
Eventually, in phase three, pharmacy reimbursement will be tied to performance scores to ensure that pharmacies providing higher quality of care are rewarded for their efforts, while pharmacies with suboptimal care may see their reimbursement diminished. This phase is currently in the development stage. We will be sure to keep you updated on phases two and three as they progress.