By Karen Welds
Pharmacies across Canada will have received their first “Patient-Impact Scorecards” from Green Shield Canada (GSC) during the last week of October, marking the official start of the insurer’s ground-breaking—and heavily debated—Value-Based Pharmacy program. (Click here to view sample.)
Since GSC announced the program in August, reactions from pharmacists, pharmacy retailers and pharmacy associations have been mixed to say the least. While pharmacy stakeholders generally support measuring the quality of pharmacists’ services as a way to improve health outcomes, they are concerned about GSC’s specific measures, the fact that it is using a U.S. provider and the risk of multiple programs from multiple insurers. Not to mention concerns about GSC’s plan, in year three, to tie reimbursement to pharmacies’ scores.
“It’s important for the pharmacy association community to get actively engaged in developing an appropriate set of outcome measures for patients and the evaluation of pharmacies in Canada, that would be available for all private payers to use. The last thing we want is five different sets of measures from five different payers,” says Perry Eisenschmid, CEO of the Canadian Pharmacists Association (CPhA).
Had a Canadian system been available, GSC would have considered it, says Ned Pojskic, the insurer’s pharmacy strategy leader. However, it did not pursue the creation of such an option with pharmacy associations here “because there is a perfectly viable system in the U.S., that took a decade to develop.”
Pojskic adds that GSC’s arrangement with Pharmacy Quality Solutions (PQS), its U.S. provider, is not proprietary. “In the U.S. numerous insurers are a part of it, and it’s available for all Canadian insurers as well.” PQS manages EQuIPP, the online platform where pharmacies can access their scores and a range of analytical reports.
The measures themselves come from the Pharmacy Quality Alliance (PQA), a non-profit organization established in 2006 to develop standardized performance measures. PQS is one of PQA’s licensed users. More than 200 research and academic institutions, pharmacy associations, community pharmacies, benefits providers, pharmaceutical companies and government agencies are members of PQA, and as such can participate in the creation of measures.
CPhA is in the process of becoming a member of PQA. “We want to get in at the ground floor so we are more informed about their measures, to understand whether they’re appropriate for the Canadian market,” says Eisenschmid. “If not, we could look at what changes would be necessary, or in some cases identify made-in-Canada measures. We could also take from work done in other countries.”
“We are 100% supportive if CPhA wants to work with PQA and PQS,” notes Pojskic, but he’s concerned that the development of Canada-only measures will unnecessarily complicate—and delay—matters. “There is nothing U.S. or Canadian about these measures, they are just universally good practices for the pharmacy profession that are ultimately rooted in clinical treatment guidelines.”
According to its website, PQA has developed 18 measures so far, such as the concurrent use of opioids and benzodiazepines and the use of high-risk medications by the elderly. Many have to do with adherence to medications, based on claims data capturing the proportion of days covered (PDC). Patients with a PDC of at least 80% for a number of specified drugs are deemed adherent.
“Ensuring that patients get their scripts filled every 30 days would technically be adherence, based on how they measure it, but that does not necessarily lead to good patient outcomes,” says Eisenschmid. “There are better things we could measure that are related to adherence and result in better patient care.”
GSC is using seven of PQA’s measures, including three to determine PDC-derived adherence rates for drugs to treat hypertension, cholesterol and diabetes. In their score cards, pharmacies see how their patients’ adherence rates compare to the provincial average as well as GSC’s goal, which is based on the 60th percentile of pharmacy performance across Canada. Baseline data from PQS show that nearly half of pharmacies already meet GSC’s targets for 2018. “This is higher than we expected, which is great,” says Pojskic.
For the next year GSC will focus on raising awareness among pharmacists by mailing its scorecards and encouraging enrollment in EQuIPP. “Even if you have only a few GSC patients, you can still use the information to improve your practice if you’d like,” says Pojskic.
During year two, when scores will be made available to clients and their plan members, only pharmacies with a minimum required number of GSC plan members will be part of the process. The same holds true during year three, when reimbursement enters the equation. GSC’s October Pharmacy Update bulletin states: “While our longer-term plan will be to create a tie to reimbursement, that will occur through dialogue with the pharmacy community and will not be a cost containment initiative. … In the end, our pharmacy reimbursement amounts may in fact go up overall, but the payoff to our clients will come through healthier employees.”
What the benefits side thinks
For their part, benefits advisors appear to be positive overall about GSC’s Value-Based Pharmacy program. “Our system is in dire need of innovation,” observes Matthew Loscher, sales advisor at The Benefits Company in Windsor, Ont. “For years we’ve been hearing a lot about the importance of getting the proper prescription and adherence, but the system is not properly set up to manage this. Someone has to pull it all together and it’s great that Green Shield is willing to step into the gap and do that.”
The time has also come for performance-based reimbursement, says Loscher, who predicts public plans will eventually jump on board. “Why should there not be an expected standard of care? Why not rank pharmacies? Only pharmacies that aren’t performing at a certain level would be negatively affected. This is a no-brainer.”
Kandy Cantwell, managing partner of Montridge Advisory Group in Vancouver, B.C., agrees that Value-Based Pharmacy is a step in the right direction. “I applaud Green Shield for trying to bring about a system that has accountability and sustainability built into it. This will help pharmacists identify patients who may need more help with adherence.”
Cantwell also believes that pharmacy in Canada should take more of a leadership role, whether on its own or as part of PQA and PQS. “I would like to see more ownership from pharmacy so it can lead to one system that every insurance company can buy into, so long as there is transparency in how the data is collected and presented.”
Karen Welds is a journalist and editor specializing in healthcare and benefits issues.
This article was originally published in the November issue of Pharmacy Practice+Business.