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Pharmacy P4P Program

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    Latest Update (as of 6/01/18):
     The DUR P4P Perfomance Reports for May 2018 are now available! Please click on "DUR P4P Performance Reports" in the above menu to view the latest report.
    04/30/18:The DUR P4P Perfomance Reports for March 2018 are now available! Please click on "DUR P4P Performance Reports" in the above menu to view the latest report.

    04/19/18: The DUR P4P Perfomance Reports for February 2018 are now available! Please click on "DUR P4P Performance Reports" in the above menu to view the latest report.

    04/09/18: Individual pharmacy reports are now available! We are emailing them out individually to each pharmacy provider according to the contact information on file. If you haven’t heard from us by 4/20/2018, it is possible that we don’t have your most updated contact information. Please e-mail the P4P pharmacy mailbox (PharmacyP4P@iehp.org) with your current e-mail address. 

    03/15/18: We've added a the DUR override how-to video for pharmacists at Point-of-Sale under our "DUR SafeRx Toolkit" section.

    3/07/18: The DUR P4P Perfomance Reports for January 2018 are now available! Please click on "DUR P4P Performance Reports" in the above menu to view the latest report.

    2/23/18: Please click here to complete a 3-minute P4P program survey! This is a 3-minute on-boarding survey (designed by MedHere Today Consulting, IEHP’s pharmacy quality consultants for the P4P program)! This survey will provide key baseline information to IEHP to best understand the program’s impact on your pharmacy practice.
    Survey link: https://www.surveymonkey.com/r/RetailSafeRx2018

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







    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. 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 gatekeepers for medicines prescribed for our Members. In order to assist Pharmacists in making the appropropriate decisions at point-of-sale (POS), IEHP currently utilizes Drug Utilization Review (DUR) edits to provide alerts to our network Pharmacists regarding potential drug safety issues. Through the P4P structure, IEHP will pilot a reimbursement model based on decisions made when Pharmacists are presented with these cases.  Through the feedback from providers and retrospective review of P4P data, IEHP will be able to refine the current DUR program and improve the overall outcomes for our members. The ultimate goal of the program is to evaluate the true impact of our community pharmacists and to recognize the importance of medication therapy management (MTM).

    To see the importance of a Pharmacist's role when it comes to dispensing a safe medication, 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

    • The P4P meeting takes place at least on a bi-annual basis (an invitation will be sent out to all existing P4P providers in regards to date/time; if you are not a current provider but would like to attend please contact IEHP)
    • Attendees include community Pharmacists, chains representatives, IEHP Chief Medical Officer, and Senior Director of Pharmaceutical Services

    P4P Program Timeline**


    Phase

    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)

    Pharmacy Transformation Program

    April 2016 (Completed)

    Phase II: Pharmacy Home Program

    July 4, 2016 - December 31, 2017

    Phase III: Safe Rx Network

    January 2018 - December 2018

    Bi-Annual Evaluation

    April - May Annually (Ongoing)

    **All schedules are subject to change
    ____ Current stage


    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

    Phase III: Safe Rx Network


    Tier 2 - Safe Rx Pharmacy Network

    IEHP Safe Rx Pharmacy campaign promotes Safe Rx practice. One of the main components in Safe Rx Pharmacy Campaign is to improve drug utilization review (DUR). 


    Participants:

    All In-Network Pharmacies 

    Qualifiers:

    Must opt in to P4P Program and meet program eligibility criteria

    Credentialing:

    Must complete IEHP Pharmacy Credentialing Application

    Measurement:

    DUR interventions, percentage (%) of total processed claims with safety DUR alerts, percentage (%) of overall inappropriate claims avoided


    Drug Utilization Review (DUR) alerts provide patient safety information to pharmacists at point-of-sale (POS). These alerts include a range of safety-related issues to caution pharmacists that the medication may not be appropriate for the member. Pharmacists who actively review DUR alerts and intervene can mitigate the risk of 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. 

    There are four DUR alert categories under Tier 2:
    1. Drug-drug interactions, Severity Level 1 
    2. High Dose Exceeding First DataBank (FDB) Maximum Recommended Dose 
    3. Therapeutic and Ingredient Duplication 
    4. High Risk Medications for the Elderly

    Please click here for the communication sent out regarding the drugs that will fall under these categories.

    Drug Alert Categories

    Pharmacists will be required to review all relevant DURs, screen and determine the most appropriate interventions, and override using DUR PSC and RSC codes listed 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 History, 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

    Prescribers’ office contacted

     *Interventions P0, R0, and M0 uses the number zero (0).


    DUR Override Code Sequence

    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
        • All qualified pharmacies will be eligible for payment base on claim volume
    • DUR bonus payment:  $3 million will be allocated to calculate bonus payment for efforts that mitigate risk by NOT filling an inappropriate prescription after receiving a DUR notification.
        • Pharmacy will receive bonus payment if the % Paid prescription volume with PSC/RSC of the total Paid prescription is lower than IEHP threshold.
        • IEHP will pay out 100% of the $3 million allocated for this measure for those pharmacies that meet threshold based on claim volume.
        • Those pharmacies that do not meet the threshold will not receive a proportion of this payment.
    • 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 $2,500 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 delayed” 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.
    P4P Payment Matrix

    What To Do When Encountering 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 Intervention 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

    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 appropriateness

    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

    PSC/RSC Outcomes

     Codes

    Outcome

     R0 + any code 2

    Positive

     PE + any code 2

    No payment

     P0 + any code 2

    No payment

     SW + any code 2

    Positive

     M0 + any code 2

    Positive

    DUR Safe Rx Toolkit for Pharmacists
    1. Talking points to explain Pharmacy P4P program to prescriber (pdf)
    2. Explaining the DUR override process – a how-to video for pharmacists at point-of-sale (mp4)
    3. Pharmacist working tool - DUR Alerts pocket guide (pdf)

      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 information will be available in 4Q2018

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

      • Create MTM using collaborative agreement model-identify high risk MTM criteria
      • Enhanced MTM program structure in community Rx setting
      • Program Budget: $5 million
      • Preparation for launch time may take more than 1 year (until 2019) due to the time to obtain “Advanced pharmacy practice” status

      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 (signed, dated and with detailed protocol) provided by IEHP
      • Pharmacists received Advanced Pharmacist Practice (APP) certification by Board of Pharmacy

      Credentialing:

      • Must complete IEHP Pharmacy Credentialing Application
      • Pharmacy credentialing - meet 2 or 4

      Application process: 

      • Pharmacists must complete the IEHP Pharmacy Credentialing application

      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

      Pharmacy DUR Performance Reports

      Pharmacy P4P Report Card Explanation

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