What You Need To Know

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Performance Ratings

What You Need To Know Performance Driven Healthcare

The U.S. healthcare system is moving to performance based purchasing or performance driven healthcare. CMS created star ratings as a way of ranking Medicare, not commercial, health plans. Star Ratings apply to plans only – not to pharmacies. CMS uses Quality Bonus payments based on measurable improvement in quality of care and services provided to patients. Health plans have developed methods to help increase their own ratings by similarly incentivizing the pharmacies in their network.

Star Ratings apply to plans – not to pharmacies.

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have A pharmacy does not a facility “Star Rating” own each plan will have its pharmacy metrics.

Plan Ratings

Rating metrics are revised annually but adherence and disease state management are consistently prioritized. Most plans have established three main categories of pharmacy evaluation.

Generic Dispensing Rate

2

Medication Therapy Management

3

Vaccine Administration

Medicare Part D Ratings

2

Measures of medication safety

3

Measures of medication adherence

• High risk medications in the elderly

• Oral diabetes medications

• Appropriate treatment of blood pressure in persons with diabetes

• Cholesterol medication • Blood pressure

How Are Medicare Plans Responding?

Formularies, clinical strategies, network contracts, marketing are aligning with star ratings. Pay for Performance Pharmacies may be eligible for bonus payments annually.



= smaller bonus = larger bonus

Preferred Pharmacy Network All pharmacies, preferred and non-preferred, included in plan metric bonus plan.

What is the Industry Doing? Software Providers Many players are supplying rating reports.

Accountable Care Organizations Some are modeling payment systems after rating programs.

Who Manages the Star Rating Program for CMS?

Pharmacy Quality Alliance is a consensus-based, transparent alliance with over 135 members and over 400 active representatives from member organizations. • Established in 2006 as a public-private partnership through leadership of CMS • Now operates as an independent, non-profit 501(c)(3) corporation

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How Do I Know My Ratings?

from EQuIPP receives its data e the same PBMs, so the results ar ernatively, as PBM report cards. Alt Wellness Medhere and Prescribe the switch. receive raw data from

The data to measure your performance can be found within your pharmacy management system. Companies like EQuIPP, Medhere and Prescribe Wellness offer independent data analysis for a monthly fee. Medhere Solution Center is a resource hub for Star Ratings Measures with a focus on adherence.

What Do I Need to Know?

1

Capture the Revenue Opportunity

Store metrics may expand on existing revenue streams if definitive rules evolve and are enforced.

2

Pharmacists as a Provider

The focus on ratings supports the position that pharmacists are a key healthcare provider.

3

Enhance Key Metric Areas

It is proactive and profitable to increase adherence and medication therapy practices more scripts equal more profit.

What is H. D. Smith Doing? H. D. Smith is leading educational efforts regarding the true impact of performance metrics. We will continue to provide educational materials, like our recent webcast, to ensure our customers have the latest information and resources. We will not advocate programs and fees that do not provide a ROI.

866.232.1222 hdsmith.com

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