Pharmacy P4P Program 2013 to 2017

IEHP Pharmacy Home Program

P4P Educational Resources provided by Therapeutic Research Center:

  • For Pharmacists

P4P Program Package

  • For Pharmacy Technicians

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  • For Prescribers

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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.

IEHP P4P Workgroup

  • 1st Meeting on January 29, 2013
  • Workgroup consists of community Pharmacists, chains representatives, IEHP Chief Medical Officer, and Senior Director of Pharmaceutical Services
  • Will continue to meet on a regular basis throughout the planning and implementation process. The workgroup will meet at least on a bi-annual basis after implementation
  • If you have any questions about this workgroup, please email PharmacyP4P@iehp.org

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 (Ongoing)
Phase II: Pharmacy Home Program
July 4, 2016 - July 31, 2017

**All schedules are subject to change

P4P Threshold Measures (NEW 2016-2017)

*P4P Payment Threshold


For IEHP P4P Program Report Card Use
Measures 100% P4P
Payment Level
1 Star 2 Star 3 Star 4 Star 5 Star
Proportion of Day Covered - Diabetes >90.2% <80.4% 80.4-85.3% 85.4-90.2% 90.3-94.2% >94.2%
Proportion of Day Covered - HTN >87.9% <80.3% 80.3 - 84.2% 84.3-87.9% 88-89.9% >89.9%

Proportion of Day Covered - Statins

>86.90%

<78.3%

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

Statin Use in Persons with Diabetes

>70.9%

<60.6%

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

Asthma - Absence of Controller Therapy

<38.2%

>54.3%

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

<9.6%

>15.7%

13.9-15.7%

9.6-13.8%

8.1-9.5%

<8.0%

Generic Dispensing Rate (GDR)

>85.00%

83%

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

New Measurements Scoring Methodology

*Adjustment in 2016-17

Measures Allocation for 2016-2017 Program

Proportion of Days Covered - 3 separate measures

(HTN, Diabetes, and Statin)

3x1.5=4.5
Asthma Suboptimal Control (NEW)
2*
Absence of Controller Therapy
2*
Statin Use in Diabetes (NEW)
1
Generic Rate
0.5*
Total 10
  • Payment Threshold
    • Meet or Exceed Target: Full %
    • Fail to Meet Benchmark: 0%
  • Store will get full point only if meeting or exceeding the benchmark score
  • Total possible points: 10 = 100% (each point is 10%)
  • P4P dollar/Total volume = P4P value in dollar/volume
  • Store P4P payout: Performance% x (P4P value)
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:
  • Beta-blocker (BB)
  • 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: Appropriate 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.

P4P 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
  • Annual IEHP Rx Volume over 1,000 (500/6 months)
  • Pharmacy must be in business during the entire evaluation period
  • Base criteria on number of members qualifying for majority of clinical measures (require at least 10 members qualifying for 4 out of 7 clinical measures) (NEW for 2015 - 2016)

Performance Level Evaluation

  • Based on the final prescription volume, create a volume-based P4P dollar per claim. Pharmacies with higher volume will get proportional increase for P4P payments
  • 100% for meeting the target and equally divided by measurements or composite score (P4P Payment)
  • Payout Schedule - Bi-annually
  • Top 10 Pharmacies based on the Composite Score will be named "IEHP Pharmacy Provider of the Year"
  • In addition to posting the "Top IEHP Pharmacy Provider of the Year", IEHP will also display Top Pharmacies in each category monthly

Pharmacy P4P Program Application is now Closed

Effective 9/15/2016,  the application for the IEHP Pharmacy P4P program will be closed as we transition our Pharmacy Quality Management development effort to the IEHP Pharmacy Home Program.  For more information about the IEHP Pharmacy Home Program, please see the Pharmacy Home Program webpage .

Pharmacy Home Program

Pharmacy Home logo 

Start Date:  July 4, 2016 - July 31, 2017

The IEHP Pharmacy Home Program is program where IEHP teams up with pharmacies to help Members get needed care. This program focuses on care for diabetes, high blood pressure, high cholesterol or asthma.

How IEHP Pharmacy Home Works

In this program, IEHP teams up with qualified in-network pharmacies to help eligible Members better manage their medicines. This comprehensive service puts information about Members’ medicine and related care in one place. It is based on the “medical home” model—with the Member at the center.

As part of this program, a Pharmacist in the IEHP network will review Members’ medicines to ensure that both their prescribed and over-the-counter medicines are working safely together. IEHP aims to help these Members get needed medicines and use them properly.

Qualified Members get these FREE extra benefits from IEHP Pharmacy Home:

  • Customized face-to-face consultation – an in-network Pharmacist will discuss treatment goals with Members and help them to achieve these goals by the end of each program year
  • Comprehensive medicine review – an IEHP Pharmacist will review how our Members’ prescriptions and over-the-counter medicines may affect each other.
  • Guidance on taking medicines the right way – our Members will receive details on how to take their medicines correctly and will get recommendations on avoiding adverse side effects

Criteria:

  • High Performing Pharmacy only- 4 and 5 Stars- # Pharmacies based on the prior year's P4P Score
  • MTM Pharmacy Network Status will be re-qualified every year

The IEHP Pharmacy Home Information session was held for our participating pharmacies to go over details, expectations, and questions regarding the launch of the program. An overview of the program guidelines and a recording of the webinar is available for download below.

P4P Communication/Notice(s):

09/13/2017 P4P Workshop Presentation Slides
P4P Program Meeting Invitatin - September 13, 2017
03/15/2017 P4P Workshop Presentation Slides
P4P Program Meeting Invitation - March 15, 2017

09/16/2016 Pharmacy P4P Program Update

07/27/2016 P4P Workshop Presentation Slides

P4P Program Meeting Invitation - July 27, 2016  
03/16/2016 Pharmacy P4P Program Update
 
02/23/2015 Pharmacy P4P Program Update

11/09/2015 Pharmacy P4P Program Update

10/01/2015 Pharmacy P4P Program Update

09/09/2015 2015-2016 Pharmacy P4P Program Update
06/22/2015 Pharmacy P4P Program Update - Additional P4P Bonus Details
 
P4P Program Meeting Invitation - July 15, 2015
 
04/07/2015 Pharmacy P4P Program Update

01/21/2015 P4P Workshop Presentation Slides

12/29/2014 Pharmacy P4P Program Update - Scorecard

P4P Program Workshop Invitation - January 21, 2015

P4P Program Meeting Invitation - May 20, 2014

P4P Program Workshop Invitation - April 23, 2014

03/28/2014 Pharmacy P4P Program Update - Scorecard

01/08/2014 P4P Program Workflow and Process

09/20/2013 Pharmacy Times - P4P Program Details - Update

P4P Program Pre-Launch Meeting Invitation - September 18, 2013
09/05/2013 Pharmacy Times - P4P Program Details

IEHP Pay-For-Performance (P4P) Reports:

P4P Monthly Results Detail Report (July 2017)
P4P Performance Summary Report (July 2017)
P4P Star Trend Report (July 2017)

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