This is part of an ongoing series on how community pharmacies are demonstrating outstanding performance under measures that CMS uses to calculate health plans’ Star Ratings. Although pharmacies are not assigned Star Ratings, a pharmacy’s actions can have a dramatic impact on health plans’ ratings. Those ratings affect plans’ reimbursement and enrollment period.
Flag high-risk medications and create systems to easily recommend alternatives
More than 20% of older adults may be on inappropriate medications.1 Older patients are at greater risk for adverse drug events (ADEs) for multiple reasons, including altered pharmacokinetics, diminished motor and cognitive skills, and the complications of having multiple disease states. Risks can include falls and fractures, gastrointestinal bleeding, delirium, and anticholinergic side effects.
The cost of ADEs from older patients taking potentially inappropriate medications (PIMs) was estimated at $7.2 billion in 2000–2001.2 Studies have estimated that 27% of the ADEs in primary care settings and 42% in long-term care facilities are preventable.
This Topic Is Now Getting More Attention
As part of its Star Ratings for health plans, CMS continues to measure the percentage of plan members age 65 and older who are on medications with a high risk of side effects when a safer drug choice may be available. The list of high-risk medications (HRMs) that CMS is measuring is a subset of the Beers Criteria the American Geriatrics Society updated in 2012.
The Star Ratings measure the percentage of Medicare Part D beneficiaries who receive two or more prescription fills for the same HRM. Like other measures related to medications, CMS gives this measure triple weight in rating health plan performance.3
To qualify for a five-star rating in 2014, health plans needed to have no more than 3% of plan members 65 or older taking an HRM. In January 2015, the goal will increase to 7%.
When a pharmacy receives a prescription for a high-risk medication for an older patient, it can ask open-ended questions to discover what the patient knows about the medication. Then the staff can ask permission to discuss any potential risks associated with taking the medication, and offer to contact the prescriber to discuss possible alternatives.
Focus and Fix on the Fly
Family-owned Beaver Health Mart and Beaver Falls Health Mart in Pennsylvania implemented a program in February 2014 to identify potential HRMs and take action before the fill or refill took place. Their strategy:
- Train pharmacy staff about what the HRMs are, how to talk with patients about the medication risks, and which alternative treatment options the pharmacy can recommend when it calls or faxes a prescriber about a therapy intervention.
- Flag HRMs in the pharmacy-management system with a color-coded or alphanumeric tag, so staff will easily spot them and be able to take action.
- Include HRM reviews in all the pharmacy’s drug utilization and chart reviews.
- Create a fax template to send to physicians when staff identify an HRM. The form explains that during a review of the patient’s prescriptions, the pharmacy noted the person was prescribed a potentially inappropriate medication. The form asks the physician if they might agree to discontinue the medication, and asks them to reply by faxing a form back to the pharmacy indicating either, “Yes, Discontinue,” followed by a prescription for an alternate therapy; or “No, Continue,” followed by space for the physician to explain why the patient should continue to receive the medication.
The fax form explains why the pharmacy is focusing on reviewing the use of HRMs in elderly patients and thanks physicians for partnering with the pharmacy. After using the forms, the pharmacy saw an increase in prescribers asking for recommendations and assistance in their practices to avoid HRMs.
Creating systems to identify and act on HRMs is important, and it is critical to keep staff focused on the importance of these reviews. These Pennsylvania pharmacies saw their performance scores slide above the 3% target on the Electronic Quality Improvement Platform for Plans and Pharmacies (EQuIPP™) dashboard in late spring. Although CMS uses a 12-month reporting cycle, EQuIPP provides a six-month rolling report on Star Ratings measures, which allows pharmacies to spot negative trends and take immediate action to correct the problems.
Older adults also can face medication problems when a hospital discharges them. Read “Retail Pharmacy: A ‘Community Liaison’ in the Discharge Process” for information about potential risks and what your pharmacy can do to minimize them.
This series profiles what some pharmacies have done and does not provide legal or other professional advice. Readers should research legal requirements and tailor any programs to their practices, after consulting appropriate professionals for advice and assistance. For more articles, continuing education, and guides on Star Ratings and pharmacy performance, visit the Driving Pharmacy Performance Education Center sponsored by Health Mart®.
1. “Be a ‘Star’: Get Older Patients Off High-Risk Meds,” American Pharmacists Association, December 1, 2013. [link]
2. “New Criteria Identify Commonly Prescribed Drugs That Are Potentially Risky for Older Adults,” American Geriatrics Society, March 1, 2012. [link]
3. “Medicare 2015 Part C & D Star Ratings Technical Notes Draft,” CMS, Sept. 3, 2014. [link]