Pharmacy P4P Program

Goal

The IEHP Pharmacy Pay-For-Performance (P4P) Program is set up to improve Pharmacy Services through the IEHP community pharmacy providers. This is considered to be one of the first large-scale Pharmacy P4P programs in United States. To ensure our goals are aligned with all stakeholders in this program, IEHP is partnering with the Pharmacy Quality Solutions (PQS) to administer this program. PQS’ quality measurement metrics are endorsed by Centers for Medicare & Medicaid Services (CMS) (for Part D Star Rating Measures) and they are considered to be the leading group to enhance Pharmacy Quality Improvement in the industry. Together, our goal is to help validate the roles of community pharmacies in promoting Healthcare Quality and define a pharmacy payment model for outcome-based MTM services.

2018 Pharmacy P4P Program

In 2018, IEHP Pharmacy P4P Program will focus on medication safety. Pharmacists are the gatekeeper for medicines prescribed for our Members. In order to help Pharmacists to become a better gatekeeper, IEHP utilizes online Drug Utilization Review (DUR) edits to provide potential issue alerts to our Network Pharmacists. Through the P4P structure, we will study how the current DUR program should be improved. To see the importance of a Pharmacist's role when it comes to dispensing a safe medication to our Members, see the following video: 

Dangerous Doses: Pharmacies miss half of dangerous drug combinations (Chicago Tribune) 

For more information about the 2017 and prior IEHP Pharmacy P4P Program detail, please click here.

IEHP P4P Provider Meeting

  • 1st Meeting on January 29, 2013
  • Attendees include community Pharmacists, chains representatives, IEHP Chief medical Officer, and Senior Director of Pharmaceutical Services
  • The P4P meeting takes place at least on a bi-annual basis after implementation

P4P Program Timeline*

Phase Proposed Timeline
Workgroup Phase January - March 2013 (Completed)
Implementation Phase with PQA February - July 2013 (Completed)
Enrollment and Implementation July - September 2013 (Completed)
Phase I Launch October 2013 (Completed)
Bi-Annual Evaluation April - May Annually (Ongoing)
Pharmacy Transformation Program
April 2016 (Completed)
Phase II: Pharmacy Home Program
July 4, 2016 - Dec 31, 2017
Phase III: Safe Rx Network Jan 2018 - Dec 2018

**All schedules are subject to change

Program Eligibility Criteria

  • Must be a Contracted IEHP (via IEHP contracted PBM) Community Pharmacy Provider
  • IEHP Pharmacy Provider in good standing (free of outstanding fraud, waste and abuse investigation)
  • Store location within San Bernardino and Riverside Counties
  • Committed to review DUR alerts and provide apprpriate interventions
  • Annual IEHP Rx Volume over 1,000 (500/6 months)
  • Pharmacy must be in business during the entire evaluation period

Tier 1- IEHP Pharmacy Network

Tier1

Tier 1 Network consists of all In-Network Pharmacies. All pharmacies are rated based on the Pharmacy Quality metrics and applicable pharmacy services criteria. The Pharmacy Quality data will be displayed on the Pharmacy Directory. No P4P payment applies to this Tier.

   
Participants: All In-Network Pharmacies 
Qualifier: All In-Network Pharmacies 
Credentialing Application:  Optional
Measurements: Pharmacy Quality Measurements DUR Screening Performance

Pharmacy Quality Measurements

For IEHP P4P Program Report Card Use
Measures 1 Star 2 Star 3 Star 4 Star 5 Star
Proportion of Day Covered - Diabetes <80.4% 80.4-85.3% 85.4-90.2% 90.3-94.2% >94.2%
Proportion of Day Covered - HTN <80.3% 80.3 - 84.2% 84.3-87.9% 88-89.9% >89.9%

Proportion of Day Covered - Statins

<78.3%

78.3 - 82.2% 82.3 - 86.9% 87-90.9% >90.9%

Statin Use in Persons with Diabetes

<60.6%

60.6-65.4% 65.5-70.9% 71-74.9% >74.9%

Asthma - Absence of Controller Therapy

>54.3%

45.4-54.3% 38.2-45.3% 32-38.1% <32%
Asthma - Suboptimal Control

>15.7%

13.9-15.7%

9.6-13.8%

8.1-9.5%

<8.0%

Generic Dispensing Rate (GDR)

83%

83-83.9% 84-84.9% >85% >88%

Measurement Title Measurement Description

Proportion of Days Covered (PDC)

The percentage of patients 18 years and older who met the Proportion of Days Covered (PDC) threshold of 80 percent during the measurement period.
Report a rate for each of the following:
  • Renin Angiotensin System (RAS) Antagonists
  • Statin
  • Biguanide
  • Sulfonylurea
  • Thiazolidinedione
  • DiPeptidyl Peptidase (DPP)-IV Inhibitor
  • Diabetes Roll-up
  • Anti-retroviral (this measure has a threshold of 90% for at least 2 medications)
Diabetes: Apprpriate Treatment of Hypertension The percentage of patients who were dispensed a medication for diabetes that were also dispensed a direct renin inhibitor medication, a angiotensin converting enzyme inhibitor (ACE), or angiotensin II receptor blockers (ARB).
Medication Therapy for Persons with Asthma
The percentage of patients with asthma who were dispensed more than 3 canisters of a short-acting beta2 agonist inhaler over a 90-day period and who did not receive controller therapy during the same 90-day period. Two rates are reported.
  • Suboptimal Control. The percentage of patients with persistent asthma who were dispensed more than 3 canisters of a short-acting beta2 agonist inhaler during the same 90-day period.
  • Absence of Controller Therapy. The percentage of patients with asthma during the measurement period who were dispensed more than 3 canisters of short acting beta2 agonist inhalers over a 90-day period and who did not receive controller therapy during the same 90-day period.
Statin Use in Persons with Diabetes The percentage of patients ages 40-75 years who were dispensed a medication for diabetes that receive a statin medication.

Tier 2 - Safe Rx Pharmacy Network

Tier2IEHP Safe Rx Pharmacy campaign promotes Safe Rx practice. One of the main components in Safe Rx Pharmacy Campaign is to enhance the DUR process.

Drug Utilization Review (DUR) alerts provides patient safety information to pharmacists at the point-of-sales (POS). Proper DUR management will help prevent adverse or medication-related events. Tier 2 focuses on proper oversight of all Drug Utilization Review (DUR) alerts. P4P payments will be based on appropriate screening and management of DUR alerts. 

 Participants: All In-Network Pharmacies 
 Qualifier: Meet Program Eligibility Criteria 
 Credentialing: Must complete IEHP Pharmacy Credentialing Application 
 Measurement: Percentage (%) of total paid claims with Safety Drug Utilization Review (DUR) alerts 


 DUR edits under P4P Program
 Type of Edit  Argus Standard Reason for service (RFS Code) Argus Error Code
DDI DD – Drug / Drug Interaction 45
Duplicate Therapy TD – Therapeutic Duplication 47
High Dose - Adult HD - High Dose Alert 64
High Dose - Geriatric  HD - High Dose Alert 162
High Dose - Pediatric HD - High Dose Alert 165
High Risk Medication for Elderly AG - Age Alert 267
Pharmacists will be required to review all relevant DURs, screen and determine the most appropriate interventions, and override using DUR PPS codes below.
 Professional Service Codes (PSC)
 Code Definition Comment/Example
 PE Patient Educated Patient educated regarding concern; action or new information provided
 P0 Patient Consulted Patient consulted regarding concern; action or new information provided
 R0 RPH consulted other source RPH review other source information such as CUREs, Pharmacy Historty, medical charts, etc...(RPH required to document source and info gained from source)
 SW Literature search - review RPH researches literature for clarification on side effects or interaction (RPH required to document source and info gained from source)
 M0 Prescriber consulted MD office contacted
 *Interventions P0, R0, and M0 uses the number zero (0).

 Result of Service Codes (RSC)
 Code Definition
 1A Filled as is, false positive 
 1B Filled Rx as is
 1C Filled with different dose
 1D Filled with different directions
 1F Filled with different quantity
 1G Filled with prescriber approval
 4A Prescribed with acknowledgements

P4P Payment determination:

  • Overall P4P Incentive: Budget for P4P for 2018 is $10 million
    • Payment calculation is performed every 6 months
  • DUR intervention payment:  $5 million will be allocated for all paid prescriptions with payable PSC/RSC codes
    • The P4P payment per claim will be determined based on final paid prescription volume with payable PSC/RSC codes
  • DUR bonus payment:  $3 million will be allocated to calculate bonus payment for efforts that mitigate risk by NOT filling a prescription with DUR risk.  
    • Pharmacy will receive bonus payment if the % Paid prescription volume with PSC/RSC of the total Paid prescription is lower than IEHP threshold.
    • Bonus payment will be calculated by combining the total prescription volume without DUR from the pharmacies that meet the threshold
    • 100% payout for $3 million allocated for Tier 2 program
  • Text Message Incentive Program:  $1 million will be allocated to encourage pharmacy to implement text message system to provide notification to the IEHP Members.  Pharmacy must meet the requirement to receive incentives.  Independent pharmacies will receive $2500 per store (independent pharmacy chains with  10 or more pharmacies are considered chains).  Each Chain will receive $25,000 for meeting the requirement and opt-in threshold. 
    • Pharmacy Text Program requirement:
      • IEHP Members Opt-in rate >50%
      •  Text message status include “prescription is processed” and “ready for pick up”
  • Member Satisfaction Survey:  $1 million will be allocated for achieving high member satisfaction rating.  Data to be populated for Quality Rating display.
Actions to Take When Presented with DUR Alerts
Intervention Intervention Result PSC and RSC Codes Outcome and Payment
Review other sources such as chart notes, CUREs, prescription history to determine clinical appropriateness Continue to dispense R0 + any RSC Code DUR Invention Payment
Not to dispense and consult with physician to modify medication No code is necessary DUR Bonus Payment
Educate patients regarding the alerts Continue to dispense  PE + any RSC Code No payment
Review and consult patients, then determine clinical appropriateness Continue to dispense P0 + any RSC Code No payment (part of Pharmacists' responsibility)
Not to dispense and consult with physician to modify medication No code is necessary DUR Bonus Payment
Research literature to determine clinical appropriateness Continue to dispense  SW + any RSC Code DUR Intervention Payment
Not to dispense and consult with physician to modify medication No code is necessary DUR Bonus Payment
Review alerts with the physician to determine clinical appropirateness Continue to dispense  M0 + any RSC Code DUR Intervention Payment
Not to dispense and modify to another medication No code is necessary DUR Bonus Payment

 Codes Outcome
 R0 + any code 2 Postiive
 PE + any code 2 No payment
 P0 + any code 2 No payment
 SW + any code 2 Positive
 M0 + any code 2 Positive

Premier Safe Rx Pharmacy Status

  • High performing pharmacy (top 10 percentile) based on DUR performance will be deemed as Premier Safe Rx Pharmacy
  • Premier Safe Rx Pharmacy will have distinct designation in the IEHP Pharmacy Directory and will be featured in the IEHP "Your Pharmacy" Program
  • More informationwill be available in 4Q2018

Tier 3 - Point-of-Care (POC) MTM Pharmacy

CommPharmTier3

Tier3POC

 Participants:
  • All In-Network Pharmacies 
Qualifiers:
  • Pharmacies meeting the Tier 2 eligibility criteria
  • Overall Pharmacy Quality rating >4
  • Existing collaborative agreement with IEHP contracted physicians
Credentialing:
  • Must complete IEHP Pharmacy Credentialing Application
  • Pharmacy credentialing - meet 2 or 4
Application process: 
  • Pharmacists must complete the IEHP PHarmacy Credentialing application
  • Pharmacists must create collaborative agreement with physicians in your neighborhood
  • Pharmacist must utilize the approved collaborative agreement provided by IEHP
  • IEHP will review the application and provide further instructions
MTM Services Detail:
  • Pharmacy will be using an IEHP approved MTM tool to perform MTM services
  • IEHP will work with the pharmacists to set up policy and process for the MTM program

2018 P4P DUR List

These four prospective DUR elements below have been selected to be the new core measures of the IEHP Pharmacy P4P Program in order to ensure appropriate clinical care at pharmacy point-of-sale. 
  • High Risk Medications in the Elderly
  • Drug-Drug Interactions
  • High Dose
  • Therapeutic Duplication
Pharmacy providers will have the opportunity to utilize pharmacy service codes to override at point-of-sale, if appropriate, and to reach out to the prescriber, if needed.

High Risk Medications in the Elderly (HRM)

The American Geriatrics Society (AGS) publishes a list of potentially inappropriate medications for older adults known as Beers Criteria, which was last updated in 2015.  Currently, IEHP utilizes this reference to define formulary drugs that are deemed high-risk for IEHP Medicare members who are 65 years of age or older.  We recommend to apply the same reference to IEHP Medi-Cal formulary drugs as well, which includes the drugs listed below.

  • Amitriptyline
  • Benztropine
  • Carbinoxamine
  • Clemastine
  • Clomipramine
  • Cyclobenzaprine
  • Cyproheptadine
  • Digoxin
  • Disopyramide
  • Doxepin
  • Ergoloid
  • Estradiol
  • Estropipate
  • Glyburide
  • Glyburide/Metformin
  • Guanfacine
  • Hydroxyzine
  • Imipramine
  • Indomethacin
  • Megestrol
  • Meprobamate
  • Methocarbamol
  • Methyldopa
  • Methyldopa/Hydrochlorothiazide
  • Nitrofurantoin
  • Norethindrone
  • Phenobarbital
  • Promethazine
  • Thioridazine
  • Trihexyphenidyl
  • Trimipramine
  • Zaleplon
  • Zolpidem

Drug-Drug Interactions

First DataBank (FDB) stratifies drug-drug interactions into four severity levels, ranging from contraindicated to undetermined.  FDB defines Severity Level 1 drug-drug interactions as drug combinations that generally should not be dispensed or administered to the same patient.  Currently, IEHP allows Severity Level 1 drug-drug interactions to process at point-of-sale.  However, given the severity of the interaction, we recommend to block Severity Level 1 drug-drug interactions.

High Dose

FDB maintains dosing modules that are designed to identify potentially incorrect dosing.  These modules obtain their information from several references, including manufacturer documentation and clinical literature, in order to develop recommendations for dosage range.  Currently, IEHP allows most drugs to process at point-of-sale if the daily dose submitted is greater than one-times the FDB reference upper limit but less than or at two-times the FDB reference upper limit for all age groups.  We recommend to block a subset of drugs if the daily dose submitted is greater than one-times the FDB reference upper limit in order to prevent adverse events associated with high doses. The following therapeutic drug classes were chosen because supratherapeutic doses would either be ineffective, have concerns for abuse, or may cause harm.

  • Miotics and Other Intraocular Pressure Reducers
  • Ophthalmic Antibiotics
  • Eye Antihistamines
  • Non-Narcotic Antitussive-1st Generation Antihistamine Combinations
  • Anti-Anxiety Drugs
  • Otic Preparations, Anti-Inflammatory-Antibiotics
  • Selective Serotonin Reuptake Inhibitors
  • Proton-Pump Inhibitors
  • Narcotic Antitussive-1st Generation Antihistamine
  • Antihistamines - 2nd Generation
  • Penicillins
  • Nasal Antihistamine
  • Antihyperlipidemic - HMG CoA Reductase Inhibitors
  • Non-Narcotic Antitussive-1st Generation Antihistamine-Decongestant
  • Skeletal Muscle Relaxants
  • Narcotic Antitussive-Expectorant Combination
  • Barbiturates
  • Tx For Attention Deficit-Hyperactive(ADHD)/Narcolepsy
  • Narcotic Antituss-1st Gen. Antihistamine-Decongest
  • Tx For Attention Deficit-Hyperactive(AHD), NRI-Type
  • Macrolides
  • Ear Preparations, Antibiotics
  • Narcotic Antitussive-Anticholinergic Combinations
  • Tx For ADHD - Selective Alpha-2 Receptor Agonist
  • Non-Narcotic Antitussive-Decongestant-Expectorant Combinations
  • Antitussives, Non-Narcotic

Therapeutic Duplication

FDB utilizes specialized therapeutic drug classes to detect duplicate therapy.  FDB defines duplicate therapy as unintentional duplication “use” indications, duplicative pharmacology, or duplicative mechanisms of action that not considered “adjunctive therapy.” Duplicate therapy not only indicates inefficient use of medications, but also indicates potential medication risk to the member.  For these reasons, we recommend to block therapeutic duplication for certain drug classes.  The following therapeutic drug classes were chosen because members should not be on more than one drug within the therapeutic drug class, with the exception of anticonvulsants, where members may receive up to two drugs. The allowances indicate having multiple drugs within the category allowable prior to denying for POS resolution. This takes into account where certain therapeutic classes as part of therapy maybe on more than one medication for treatment.

DURCategory
*Please note 0=Allowance would deny same ingredient as well.

Pharmacy DUR Performance Report Section (Will be available in 2018)

For any questions regarding Pharmacy P4P payments or reports please contact: PharmacyP4P@iehp.org