Innovative Quality Network Program uses risk and reward design to promote patient health outcomes
LONG BEACH, Calif. and ST. LOUIS, May 5, 2015 – Medicare beneficiaries with diabetes, high blood pressure or high cholesterol may achieve better health outcomes when using pharmacies that are part of performance-based networks, according to early results of a unique program conducted by SCAN Health Plan and Express Scripts (NASDAQ: ESRX).
"Pharmacists are one of the most trusted of all healthcare professionals and their frequent interactions with our members presents enormous opportunities to positively impact patient health," said Sharon Jhawar, vice president of pharmacy services at SCAN. "The Quality Network Program we’ve been undertaking with Express Scripts has shown that pharmacists taking a more active role in the patient/pharmacist relationship can lead to an enhanced patient experience, improved medication safety, and improved quality of care."
Leveraging actionable data and clinical experience from its Therapeutic Resource Centers®, Express Scripts works collaboratively with each pharmacy participating in the two-phase Quality Network Program to review and improve their patients’ performance in five key areas: reducing the use of high-risk medications, compliance with diabetes treatment guidelines (use of high blood pressure therapy in diabetes patients), and greater adherence to diabetes, high blood pressure and high cholesterol medications.
Phase I, completed in 2014, involved reporting and the "Sentinel Effect," which is the tendency for improvement as a result of observation, to establish performance benchmarks. Phase II, which began in January, involves quality incentive rewards with more than 1,000 participating chains and independent pharmacies in southern California, SCAN Health Plan’s market. In early 2016, top-performing and improved pharmacies will receive incentives, while average or poorly performing pharmacies will receive lower overall reimbursements.
"In this increasingly competitive and complex Medicare space, the Quality Network Program and its value-based network design was a logical next step for our plan—a third prong in our multi-channel, quality improvement strategy–working with physicians, patients, and now pharmacists, with the hope of aligning incentives and promoting patient-centric collaboration," said Jhawar.
The Sentinel Effect
Similar to Centers for Medicare and Medicaid Services’ (CMS) Star Ratings, pharmacies in the Quality Network receive an overall star rating or quality score, on a scale of 1-5, with 5 representing top performance. The methodology used to determine each pharmacy’s score includes both SCAN Health Plan’s quality goals and CMS Star Ratings requirements, with the goal of creating alignment between SCAN, CMS and participating pharmacies.
Applying this methodology, phase I results demonstrated that when compared to a national sample of retail pharmacies, the pharmacies in the Quality Network achieved 60 percent higher performance scores for reducing the use of high-risk medications among SCAN members, and 23 percent higher scores for improving compliance with diabetes treatment guidelines among SCAN members. In addition, when compared to a sample of non-SCAN members using the same Quality Network pharmacies, the Quality Network achieved 34 percent higher scores for high-risk medications and 8 percent higher scores for diabetes treatment among SCAN members.
"The performance increase on these measures in this program indicates SCAN members are using safer medication alternatives and more appropriate diabetes treatment as a result of the interventions and counseling they receive from pharmacists," said Rebecca Rabbitt, PharmD, vice president Medicare solutions, Express Scripts. "The overall implication is that value-based networks may lead to better patient outcomes."
Risk and Reward
Phase II makes the Quality Network one of the first pay-for-performance initiatives within the pharmacy industry. Express Scripts will support the success of participating pharmacies in Phase II by providing regular performance reporting and review, actionable data resources, and a SCAN Health Plan-specific high risk medications alternatives list.
The next phase of the program gives extra credit to pharmacies who demonstrate consistent high performance over time, as well as those who show demonstrable improvement during the evaluation period.
"In a time of constant change and higher performance expectations, Express Scripts works collaboratively with plans on innovative approaches to evolve with and stay ahead of complex healthcare challenges facing the industry," says Darren Gettings, Express Scripts’ vice president of retail channel management and strategy. "This oneof-a-kind Quality Network Program is one example of an effective, outcomes-based strategy that aligns all parties in a patient’s pharmacy care."
About SCAN Health Plan®
SCAN is one of the nation’s largest not-for-profit Medicare Advantage plans currently serving approximately 170,000 members in California. Further information may be obtained at scanhealthplan.com or on Facebook at facebook.com/scanhealthplan.
About Express Scripts
Express Scripts manages more than a billion prescriptions each year for tens of millions of patients. On behalf of our clients — employers, health plans, unions and government health programs — we make the use of prescription drugs safer and more affordable. Express Scripts uniquely combines three capabilities — behavioral sciences, clinical specialization and actionable data — to create Health Decision ScienceSM, our innovative approach to help individuals make the best drug choices, pharmacy choices and health choices. Better decisions mean healthier outcomes.
Headquartered in St. Louis, Express Scripts provides integrated pharmacy-benefit management services, including network-pharmacy claims processing, home delivery, specialty benefit management, benefit-design consultation, drug-utilization review, formulary management, and medical and drug data analysis services. The company also distributes a full range of biopharmaceutical products and provides extensive cost-management and patient-care services.
For more information, visit Lab.Express-Scripts.com or follow @ExpressScripts on Twitter.
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Jennifer Luddy, Express Scripts
Ross Goldberg, SCAN Health Plan
818-597-8453, ext. 1