Pay for Performance (P4P)
Elliott M Sogol PhD, RPh, FAPhA
VP Professional Relations
Pharmacy Quality Solutions
As the US Healthcare system continues to evolve into a quality based - value driven
marketplace, pharmacists are challenged with a changing environment. Quality performance measures
are now being reviewed by multiple payers, PBMs, plans, and CMS. These measures may begin to affect
preferred pharmacy network (PPN) opportunities through quality based networks (QBN) or value based
networks (VBN). Based on the changing environment we are seeing the creation of pharmacy pay for
performance (P4P), quality incentive bonus (QIB), or quality incentive programs (QIP) which are being
based minimally on the CMS STAR ratings medication metrics. Currently there are two specific areas
measured related to medication use: patient safety and medication adherence. The patient safety focus
is on high risk medications (HRM) in the elderly while the medication adherence metrics track the
proportion of days covered (PDC) for three therapeutic areas: non-insulin diabetic medications, statins,
and Renin Angiotensin System Antagonists (RASA) medications. According to Allied Health News, P4P
Programs in healthcare is an effort to increase the quality of medical care in the U.S. while at the same
time reigning in the often staggering costs.1 P4P programs have been in existence in many health care
areas since at least the early 1990s, however as the Affordable Care Act continues to roll out, these
programs are growing across the entire health care system. P4P for pharmacy providers is in its infancy
but is expanding quickly in the community pharmacy arena.
What does that mean to the profession of pharmacy as a whole?
Health plans are beginning to offer incentives, in addition to reimbursement for drug products,
to pharmacies for high quality services. The specifics of each program may differ in regard to eligibility
and payment, however the basic quality metrics remain consistent leveraging the CMS metrics. Many
health plans are partnering with Pharmacy Quality Solutions (PQS) using their EQuIPP web based
platform to gauge a pharmacy’s performance; PQS acts as a neutral intermediary between health plans
and pharmacies. For pharmacists this is an opportunity to gain financial incentives for improving patient
outcomes.
There are multiple program designs for P4P programs. While these programs are in their infancy for
pharmacy some already exist in a variety of programs and designs.
Possible Designs of P4P Programs
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Pharmacies evaluated on medication-use measures
 All or some from the CMS Star Ratings program
 May include additional measures that are in consideration by CMS or from other
quality-related groups
Pharmacies receive bonus payments based on a specified date rage for performance
achievement and/or performance improvement
Some models will be “pay to play” wherein pharmacies take a share of the risk and only
high performing pharmacies receive bonus payments for good clinical performance.
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Pharmacy P4P eligibility and/or bonus based upon the number of patients for each
measure in addition to attainment of goals.
Some goals are fixed, others based on relative performance
 Dollars go to top performers
One example of a P4P program is the Inland Empire Health Plan (IEHP) of southern California
QIP which started in the fall of 2013. This program currently includes several metrics: CMS endorsed
measures plus a generic dispensing rate and an asthma measure. The goal is to improve pharmacy
services through IEHP community pharmacy providers and to validate the role of community pharmacy
in promoting and affecting healthcare quality. This program is one of the first large scale pharmacy P4P
programs in the United States. IEHP has recruited community pharmacists and chain representatives
with internal stakeholders including the IEHP Chief Medical Officer, Senior Director of Pharmaceutical
Services, and the Associate Medical Director of Pharmaceutical Services to form an active workgroup
IEHP is just one example of P4P program opportunities for community pharmacies. It is clear
that the time is now for pharmacy to take an active role in this new arena. By paying close attention to
star measure performance ratings, eligible pharmacies may be able to receive quality incentive
payments that can be used to advance community pharmacy services.
Community pharmacy moving forward
It is important that community pharmacists understand the measures, know P4P programs exist,
and realize that each one is unique in its metrics, eligibility, and payment calculation. Although this may
seem overwhelming, here is an opportunity to increase patient satisfaction, achieve better patient
outcomes by addressing gaps in care/therapy and reduce the variation in these quality metrics while
possibly receiving bonus dollar for doing so. From an adherence perspective working with patients to
become more adherent will also provide greater financial rewards and loyalty. How a pharmacy
prioritizes ways to improve across the metrics is a key to knowing which area(s) to concentrate on.
Once improvement strategies are identified, the pharmacy can implement changes toward a patient
centered care service that focuses on specific quality outcome goals.
All of these services and goals affect the everyday life of a community pharmacist. In addition,
these programs promote a patient centric ideal and offer another way to collaborate with our
neighborhood prescribers and practices in the community. By working collaboratively with our health
care professional colleagues, better patient outcomes, reduced adverse drug events and even fewer
hospitalizations could result. Focusing on quality measures by proactively reaching out to patients may
improve an already trusted and valued patient-pharmacist relationship.
What should you ask about P4P programs that you are hearing about?
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Is there a clear timeframe for evaluation and payments?
Are there clear goals/thresholds for success?
What performance measures will be included?
How will the program be communicating to your pharmacy/pharmacies?
Finally, creating an action plan on how to implement interventions or strategies for
improvement is critical as well as plans on maintaining successful patient cases. Putting in place an
intervention that does not include follow up to help patients who become adherent and stay adherent
only prolongs the issue. Specific tracking and follow up communications can keep the patient on track.
Will this be a new service as to how the pharmacy operates? Is there a set of communications you can
put in place for your pharmacy staff members so they understand quality and have a clear plan and set
expectations prior to the start of the program?
Pharmacy technicians, interns, and students can play a vital role in all aspects of patient care and
identification of specific metric issues for each patient.
Together we can help patients manage and use their medications for their benefit while
providing high level of quality focused on all of our patients, one patient at a time.
References:
1.
http://www.bestalliedhealthprograms.com/allied-health-news/what-is-pay-for-performance-healthcare