Quality Network Solution Improves Medicare Beneficiary Health

May 5, 2015
Express Scripts’ innovative Quality Network Program uses quality incentives to improve patient health outcomes.
  • Medicare
  • Diabetes
  • High Blood Cholesterol
  • High Blood Pressure/Heart Disease
  • Seniors

As one of the nation’s largest, not-for-profit Medicare Advantage plans, SCAN Health Plan has a great privilege and responsibility to offer its 170,000 members a continually enhanced care experience.  When we do our job well, it means we are being good stewards of Medicare dollars, and that our members are healthier.

However, the increasingly challenging and complex Medicare environment means we need to find new and better ways that support the health and independence of our members. Preparing for the future means pulling all levers available and leaning on our business partners to help us better manage performance for members and our bottom line.

In 2014, Express Scripts and SCAN implemented a Quality Network Solution for our retail pharmacy network. The program’s value-based design was a logical next step in our multi-channel, quality improvement strategy that uses value-based reimbursement principles to align incentives and promote patient-centric collaboration among physicians, patients and, now, pharmacists.

Quality Incentives

Leveraging actionable data and clinical experience from its Therapeutic Resource Centers®, Express Scripts works collaboratively with each pharmacy participating in the two-phase Quality Network Solution to review and improve performance in five key areas:

  • Reducing the use of high-risk medications in the elderly,
  • Diabetes treatment (use of high blood pressure therapy in diabetes patients), and
  • Adherence to diabetes, high blood pressure and high cholesterol medications.

Completed in 2014, Phase I reporting enabled the pharmacies, SCAN and Express Scripts to benchmark relative performance on quality outcomes. During Phase 1, we saw the “Sentinel Effect” - the known tendency for improvement as a result of observation – begin to move the needle on quality among participating pharmacies.

Phase II, which began in January 2015, involves quality incentive rewards with more than 1,000 participating chains and independent pharmacies in Southern California and Arizona, SCAN’s markets. In early 2016, top-performing and improved pharmacies will receive incentives, while average or poorly performing pharmacies will receive lower overall reimbursements.

The Sentinel Effect

Similar to Centers for Medicare and Medicaid Services’ (CMS) Star Ratings, pharmacies in the Quality Network receive an overall star rating or quality score, on a scale of 1-5, with 5 representing top performance. The methodology used to determine each pharmacy’s score includes both SCAN Health Plan’s quality goals and CMS Star Ratings requirements, with the goal of creating alignment between SCAN, CMS and participating pharmacies.

Applying this methodology, phase I results demonstrated that when compared to a national sample of retail pharmacies, the pharmacies in the Quality Network achieved higher performance ratings for high-risk medications and diabetes treatment of 60% and 23%, respectively. In addition, when compared to a sample of non-SCAN members using the same Quality Network pharmacies, the Quality Network achieved 34% higher scores for high-risk medications and 8% higher scores for diabetes treatment among SCAN members.

Enhanced Patient and Pharmacist Relationship

Pharmacists are one of the most trusted of all healthcare professionals and their frequent interactions with our Medicare members presents enormous opportunities to positively impact patient health.

The preliminary performance increases seen in Phase I indicate SCAN members are using safer medication alternatives and more appropriate diabetes treatment as a result of the interventions and counseling they receive from pharmacists taking a more active role in the patient/pharmacist relationship. The overall implication is that value-based networks may lead to better patient outcomes.

Risk and Reward

Phase II makes the Quality Network one of the first pay-for-performance initiatives within the pharmacy industry. Express Scripts will continue to support the success of participating pharmacies in Phase II by providing regular performance reporting and review, actionable data resources, and a SCAN Health Plan-specific high risk medications alternatives list.

The next phase of the program gives extra credit to SCAN pharmacies who demonstrate consistent high performance over time, as well as those who show demonstrable improvement during the evaluation period.

The SCAN mission is to keep our members healthy and independent. We are committed to working with all the providers involved in our members’ care to help ensure the best possible outcomes. The Quality Network Solution is a sterling example of an effective, patient-centric, outcomes-based strategy that rewards providers for delivering better care that results in healthier members.

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