Engaging Pharmacists to Improve Quality and Economic Performance

1. Engaging Pharmacists to Improve Quality and Economic Performance Quality Improvement Initiative Template for Managers (Release Date May 2009) www.ashp.org/qii Developed in cooperation with Darin L. Smith, Pharm.D.

2. Medication Use Quality

3. Defining Quality • Institute of Medicine (IOM) definition: The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. • Improved quality delivers • Better patient care • Lower costs • Potential for improved reimbursement http://www.iom.edu/CMS/8089.aspx

4. Quality Data Initiatives and Requirements Confronting Hospitals Hospital Quality Alliance Inpatient Reporting System 9th Scope of Work Institute for Safe Medication Practices Accreditation Centers for Medicare & Medicaid Services Outpatient Reporting System Private Collaboratives ACE The Joint Commission SCIP HCAHPS Managed Care Bridges to Excellence Safety Goals Sentinel Event Reporting Data Collection Hospitals Emergency Departments IMPACTs Institute for Healthcare Improvement National Quality Forum Serious Reportable Events 100K/5 Million Lives Campaigns Safe Practices Hospital Measures Infections Agency for Healthcare Research & Quality Ambulatory Quality Alliance National Priorities Partnership HCUP National Patient Safety Foundation PSOs Leapfrog Group Partnership for Patient Safety National Committee for Quality Assurance Quality & Safety Indicators Hospital Rewards Program Safe Practices Safe Practices

5. What is Medication Use Quality? Characteristics: Safe (harm-free, preventable errors avoided) Effective (evidence-based, desired outcomes achieved) Patient-centered (patient prioritized over provider or organizational needs) Efficient (avoids waste) Equitable (disparities do not exist) Timely (influence of wait times on outcomes, safety)

6. Medication Use Quality Measures

7. Medication Use Quality Measures

8. Medication Use Quality Measures

9. Medication Use Quality Measures

10. Present on Admission (POA) Indicators(CMS No Pay Conditions)

11. Role of the Pharmacist

12. Role of the Pharmacist • Provide medication expertise as it relates to order set development/maintenance • Screening targeted patients concurrently • Concurrent intervention with healthcare professionals to insure appropriate prescribing/administration • Documentation of contraindications • Vaccine ordering/administration

13. Role of the Pharmacist • Discharge medication counseling/documentation to achieve desired outcomes • Error proofing of medication use systems to achieve desired outcomes and enhance safety • Provide timely data turn around/feed back to impact change • Disease state management (heart failure, diabetes, etc…) • Antimicrobial stewardship

14. CMS Recognition of Pharmacist Role • Core Measures Specification Manual • Previously specified physician/APN/PA only for documentation of contraindications to medications • Version 2.4b • Effective for discharges 04/01/08 – 09/30/08 • Acceptable for PHARMACIST to document contraindications www.qualitynet.org (“Hospitals–Inpatient” →”Specifications Manual” →”Version 2.4b” →”Alphabetical Data Dictionary” → then for look sections related to various medication contraindications

15. Financial Implications

16. Linking Quality and Payment Expanded Inpatient Pay for Reporting 27 Measures Add Patient Satisfaction and 30-day Mortality Measures Minus 2.0 percentage points 2011 IPPS Proposed Quality Measures?? Measures Minus ?? percentage points Expand Hospital Pay for Reporting 37 Measures 6 VTE Related Minus 2.0 percentage points 2010 IPPS Proposed Quality Measures 72 Measures Minus ?? percentage points Inpatient Pay for Reporting 10 Measures Minus 0.4 percentage points if not reported Expand Hospital Pay for Reporting32 Measures Minus 2.0 percentage points Value-Based Purchasing Pending Congressional Approval? ? ? FY 2006 2005 2006 2007 2008 2009 2010 2011 FY Hospital Acquired Conditions 8 conditions Potential Payment Reductions Candidate Hospital Acquired Conditions 9 additional conditions Potential Payment Reductions Expanded Inpatient Pay for Reporting 21 Measures Minus 2.0 percentage points Outpatient Pay for Reporting 7 Measures Minus 2.0 percentage points

17. Hospitals must report to CMS on 27 quality measures to receive full (3.3%) market basket increase for FY 2008. Hospitals that do not report will lose 2% Medication management measures = 21 Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU)

18. Payment System Evolution Past (Pay for Reporting): Structured to pay for services including correcting the results of poor quality or unsafe care Present/Future (Pay for Performance): CMS moving to reimbursement based on quality of care No reimbursement for poor quality or injuries due to error Present on Admission Indicators True Pay for Performance based on quality Value Based Purchasing (draft legislation)

19. Medicare Hospital Quality Improvement Act of 2008 Senators Baucus and Grassley (draft legislation) Proposed to start in 2012 Funded by a carve out from Medicare inpatient payment (1 to 5%) Increases/decreases in Medicare reimbursement tied to hospital performance on quality indicators (three domains) ● Clinical process of care indicators (RHQDAPU/Hospital Compare) ● Patients’ perspectives of care (HCAHPS) ● Outcomes (Mortality) Value-Based Purchasing • http://finance.senate.gov/press/Bpress/2008press/prb111908c.pdf

20. Value-Based Purchasing • Each clinical process of care indicator evaluated based on: • Attainment score: compares the hospital’s performance to national Benchmark and Threshold levels • Improvement score: compares the hospital’s performance to its prior year’s performance • Indicator is given the higher of the two scores (attainment vs improvement) • The hospital’s grand total score (based on all three domains) is entered into an equation to determine a payment percentage

22. Conclusion • The current fee-for-service payment system rewards excessive use of services and poor quality. • Pay for reporting systems are quickly evolving into pay for performance focusing on quality measures. • The majority of current quality measures are medication management related. • Pharmacists can be major contributors to improving medication related quality indicator performance.