1. Pharmacy Provider Meeting March 15, 2017
Chris Chan, Pharm.D.
Sr. Director
Pharmaceutical Services
Inland Empire Health Plan

2. Agenda P4P Milestones P4P Program Results
Outstanding Pharmacy/Pharmacy of the Year Award
IEHP Pharmacy Home Program Stat
2018 P4P
Other Pharmacy Communications

3. PDC Diabetes 16

4. PDC Statin 16

5. PDC RAS 16

6. High Risk Medication (HRM)

7. CMC SUD 2016

8. Opioid High Dose

9. Opioid Multiple Provider

10. Opioid High Dose Multiple Provider

11. Antipsychotic Use In Persons with Dementia - Community

12. P4P Program Avg Star Ratings

13. 2016 2nd P4P Period Program Results
Apr 16-Sept 16 Payment
* 407 Pharmacies
* 87 Unique Pharmacies
* $2,842,733 total amount awarded
* Highest single store payment: $37,124

14. P4P Program Results Star Rating Comparison Sep-15 Oct-15 Nov-15 Dec-15
Jan-16
Feb-16
Mar-16
Apr-16
May-16
Jun-16
Jul-16
Aug-16
Sep-16
Oct-16
Nov-16 12 21 30 34 27 23 25 9 8 10 1
533 19 15 11 13 18 51 28 14 4 6 2
109 89 79 43
105
124
327
192 95
135
122
350
297 3
529
261
267
229
291
281
284
888
574
277
295
272
226
536
123
126
186
153
163
148
456
334
176
185
218 66 75 5
342 78 84 94 70 71
210
142
Total Rx
2061
591
601
597
659
665
666
1932
1270
641
638
639
636
624

15. Pharmacists’ Letter
Review P4P clinical resources and earn CE credits!!!

16. USC APP Course

17. Congratulations to the Outstanding Pharmacies
P4P Performance Awards
Congratulations to the Outstanding Pharmacies

18. Outstanding in Service & Performance
WALGREENS PHARMACY

19. Outstanding in Service & Performance
CVS Pharmacy
9849
9648
9654
8436
5958

20. Outstanding in Service & Performance
Inland Pharmacy

21. P4P Performance Award
Pharmacy of the Year

22. Pharmacy of the Year
North Rialto Drug

23. Pharmacy Home

24. IEHP Pharmacy Home Program
Outcome-based MTM
700+ Active Patients
Budget: $5M Annually

25. IEHP Outcome-Based MTM Program
Outcome Measurement
Disease State
Inclusion Criteria
Outcome measurement
Outcome Target
Documentation Requirement
Service Payment (tentative)
Diabetes
A1C>9
A1C at end of 12 months; number of A1C labs
A1C<8 ; 2 labs in last 12 months
A1C lab and medication interventions/ education; must have 2 A1c labs in last 12 months
$20 per MTM consultation, maximum 1 per month (max $240 per patient)
Measure number of care gaps addressed
HTN
Blood Pressure> 140/90
BP at end of 12 months
BP <140/90
BP trends and the last recording
Hyperlipidemia
LDL >130
LDL at end of 12 months
LDL<100
LDL and interventions/education
Asthma/COPD
Uncontrolled asthma- lack of controllers, lower than 80% adherence rate, or high ratio of short-acting inhaler
Rx data
Adherence Measure (controller) and number of albuterol fills
Claims data

26. Pharmacy Home

27. CMR Cases Created vs Cases Completed

28. Program Activity: CMR Completion Rate
IEHP Pharmacy Home Program
Data Period: 07/06/2016 Through 02/28/2017
Definitions of Metrics:
Section 1: Column Chart
CMR Completion Rate: [the patients with a served CMR] / [the number of patient with a CMR]. The numerator groups cases/patients served to date by their completion date. The denominator groups cases/patients created to date by their creation date.
* CMR Completion Rate = [# Patients with a Served CMR to date] / [# Patients with CMR to date]

29. CMR Cases Created vs Cases Completed
Jul
Aug
Sept
Oct
Nov
Dec
Jan
Feb
To-Date
Cases Created
2189
3611 5 1
5806
Cases Completed
118
421
233
173 11
1377
Served 92
268
124
121
735
Patient Decline 42 22 15
103
Pharmacist Decline 21
111
275 37 9
539
Admin Closed
1290
2108
134
104
120
4429
Open Cases
Care Gaps Generated
1646
2369 74
4293
Adherence
444
801 10 6
1347
Omission
1202
1568 64
2946
Safety Alerts Generated
851
1046
1239
1900
Patient Offer Letters Sent
2372

30. CMR Case Completion Trends
IEHP Pharmacy Home Program
Data Period: 07/06/2016 Through 02/28/2017
Definitions of Metrics:
Section 1: Pie Chart
Total Cases Served At Retail Face to Face: cases served where service is describe as face to face. These are cumulative counts from the beginning of the calendar year.
Total Cases Served At Retail Telephonic: cases served where service is describe as over the phone. These are cumulative counts from the beginning of the calendar year.
Section 2: Stacked Column Chart and Table
** Date Range of Chart: Chart shows last 12 months of data for cross-over year programs and full calendar year for non-cross-over year programs.
Declined - Call Center: Cumulative number of cases declined at Call Center from the start of the calendar year through the end of the month.
Declined - Retail: Cumulative number of cases declined at Retail from the start of the calendar year through the end of the month.
Served - Call Center: Cumulative number of cases served at Call Center from the start of the calendar year through the end of the month.
Served - Retail: Cumulative number of cases served at Retail from the start of the calendar year through the end of the month.
Counts shown above each stack column: Cumulative number of completed cases from the start of the calendar year through the end of the month.
Mar-16
Apr-16
May-16
Jun-16
Jul-16
Aug-16
Sep-16
Oct-16
Nov-16
Dec-16
Jan-17
Feb-17
Served – Retail 92
360
484
613
734
735
Served - Call Center
Declined – Retail 26
179
476
580
632
642
Declined - Call Center
72.5.1

31. CMR Cases Created vs Cases Completed
TMR
Jul
Aug
Sept
Oct
Nov
Dec
Jan
Feb
To Date
Cases Created 12 44 67
117
209
195 96
857
Cases Completed 2 17 28 51
256 93 63
710

32. CMR Cases Created vs Cases Completed

33. Program Results: Safety Alerts (Red Flags) Resolution Summary
IEHP Pharmacy Home Program
Data Period: 07/06/2016 Through 02/28/2017
Pharmacist Documentation of Served Cases
Served Cases with Safety Alerts
278
Total Served Safety Alerts
469
Average # Safety Alerts Per Case
1.7
% Resolved: Change in Therapy
6.4%
% Resolved: Status Pending
50.1%
% Resolved: No Change in Therapy
43.5%
Claims Based Results
# Drugs Eliminated = 0
Definitions of Metrics:
Section 1: Table (Upper Left)
Served Cases with Safety Alerts: The number of served cases with 1 or more pharmacist completed safety alerts.
Total Safety Alerts: The total number of pharmacist completed safety alerts across all served cases.
% Resolved – Change in Therapy: the percentage of cases resolved with the following resolutions:
Discontinuation authorized by prescriber
Strength/form/SIG change authorized by prescriber
Substitution authorized by prescriber and patient
% Resolved – Status Pending: the percentage of cases resolved with the following resolutions:
Educated patient
Prescriber to review/monitor
% Resolved – No Change in Therapy: the percentage of cases resolved with the following resolutions:
Not an issue for pharmacist
No longer applicable
Not an issue for prescriber
Recommendation declined by prescriber
Section 2: Column Chart (Upper Right)
Resolution Summary (% of Served Cases): Resolutions of served of cases as a percentage of all served cases with Safety Alerts. Top 6 resolutions are shown.
Section 3: Pie Chart (Lower Left)
Patients That Have Eliminated At Least One Drug (based on Rx claims data):
[# of Patients who eliminate at least one drug associated with a safety alert] / [# of Patients with 1 or more safety alert]
Patients are deemed to have eliminated a drug if there are no more refills of the drug 42 days after the current fill’s days of supply is exhausted.
Patients That Have Yet to Eliminate One Drug: 1 – [Patients That Have Eliminated At Least One Drug]
Section 4: Column Chart (Lower Right)
** Date Range of Chart: Chart shows last 12 months of data for cross-over year programs and full calendar year for non-cross-over year programs.
Served Patients by Month vs. Patients with Drug Eliminations:
Served Patients are those patients who have a case with a safety alert that has been served.
Patients with Drug Eliminations are those patients who have a case with a safety alert that has been served and Rx claims data indicates that a drug associated with a safety alert has been eliminated.
The data is aggregated into months by the date that the patient was served.
* Drugs are deemed eliminated when they have not been re-filled 42 days after the current active fill’s supply is exhausted.

34. Total Served Safety Alerts
Program Results: Safety Alerts (Red Flags) Resolution Summary
IEHP Pharmacy Home Program
Data Period: 07/06/2016 Through 02/28/2017
Total Served Safety Alerts
# Drugs Eliminated
469
Definitions of Metrics:
Section 1: Table
Served Cases with Safety Alerts: The number of served cases with 1 or more pharmacist completed safety alerts.
Total Safety Alerts: The total number of pharmacist completed safety alerts across all served cases.
Average # Safety Alerts Per Case: [# of alerts on served cases] / [# of served cases]
% Resolved – Change in Therapy: the percentage of cases resolved with the following resolutions:
Discontinuation authorized by prescriber
Strength/form/SIG change authorized by prescriber
Substitution authorized by prescriber and patient
% Resolved – Status Pending: the percentage of cases resolved with the following resolutions:
Educated patient
Prescriber to review/monitor
% Resolved – No Change in Therapy: the percentage of cases resolved with the following resolutions:
No longer applicable
Not an issue for pharmacist
Not an issue for prescriber
Recommendation declined by prescriber
Section 2: Column Chart
Alerts Generated vs. Drugs Eliminated:
Alerts Generated counts the number of alerts (there can be more than one per case) by type to date since the start of the program year.
Drugs Eliminated counts the number of drugs associated with the alerts that have been eliminated to date since the start of the program year.
Patients are deemed to have eliminated a drug if there are no more refills of the drug 42 days after the current fill’s days of supply is exhausted.
* Drug are deemed eliminated when they have not been re-filled 42 days after the current active fill’s supply is exhausted.

35. Program Results: Adherence Care Gaps Summary
IEHP Pharmacy Home Program
Data Period: 07/06/2016 Through 02/28/2017
Pharmacist Documentation of Served Cases
Served Cases with Adherence Alerts
263
Total Adherence Alerts
345
Adherence Alerts Validated As True
224
% of Adherence Alerts Validated As True
64.9%
Claims Based Results
Median Days to Adherence = 33
Definitions of Metrics:
Section 1: Table (Upper Left)
Served Cases with Adherence Alerts: The number of served cases with 1 or more pharmacist completed adherence alerts.
Total Adherence Alerts: The total number of pharmacist completed adherence alerts across all served cases.
Adherence Alerts Validated as True: The total number of pharmacist completed adherence alerts marked as "true" alerts by pharmacists.
% Adherence Alerts Validated as True: [Adherence Alerts Validated as True] ÷ [Total Adherence Alerts]
Median Days to Adherence: Among patients that achieved 80% PDC, the median number of days after the case served date required to achieve 80% PDC on the medication that generated a true adherence alert (or the first medication if there are multiple medications that generated alerts).
Section 2: Column Chart (Upper Right)
Interventions Taken (% of True Adherence Gaps): The percentage of each type of intervention indicated by pharmacists on TRUE adherence alerts.
Note: "Patient will consult with prescriber" is an aggregate of all reasons beginning with "Patient will consult with the prescriber..." These are:
Patient Consult Prescriber For Alternative Drug
Patient Consult Prescriber For Regimen Modification
Patient Consult Prescriber For Renew Prescription
Section 3: Pie Chart (Lower Left)
Members Becoming Adherent to at Least One Drug: Among served patients with True Care Gaps,
[# of Patients achieving 80%+ PDC on 1 or more drugs that generated a true adherence alert] / [# of Patients with 1 or more true adherence alert]
Members Not Yet Becoming Adherent to at least 1 Drug: 1 - [Members Becoming Adherent to at Least One Drug]
Section 4: Column Chart (Lower Right)
Days Post Session in Which Adherence Was Achieved on at least One Drug: Among patients that achieved 80% PDC, the minimum # of days after the case served date required to achieve 80% PDC on one medication that generated a true adherence alert
* Adherence is achieved when a patient has 80% or greater PDC on at least one of their target medications for which they were identified as non-adherent.

36. Program Results: Omission Care Gaps Summary
IEHP Pharmacy Home Program
Data Period: 07/06/2016 Through 02/28/2017
Pharmacist Documentation of Served Cases
Served Cases with Omission Alerts
603
Total Omission Alerts
767
Omission Alerts Validated As True
523
% of Omission Alerts Validated As True
68.2%
Claims Based Results
Median Days to Closing Omission = 19
Definitions of Metrics:
Section 1: Table (Upper Left)
Served Cases with Omission Alerts: The number of served cases with 1 or more pharmacist completed Omission alerts.
Total Omission Alerts: The total number of pharmacist completed Omission alerts across all served cases.
Omission Alerts Validated as True: The total number of pharmacist completed Omission alerts marked as "true" alerts by pharmacists.
True Alerts as % of Total Alerts: [Omission Alerts Validated as True] ÷ [Total Omission Alerts]
Median Days to Closing Omission: Among patients that had at least 1 fill for at least one target medication in the period, the median number of days after the case served date patients filled their first target drug.
Section 2: Column Chart (Upper Right)
Interventions Taken (% of True Omission Gaps): The percentage of each type of intervention indicated by pharmacists on Omission alerts determined to be valid.
Note: "Patient will consult with prescriber" is an aggregate of all reasons beginning with " Patient will consult with the prescriber..." These are:
Patient Consult Prescriber For Alternative Drug
Patient Consult Prescriber For New Prescription
Patient Consult Prescriber For Regimen Modification
Section 3: Pie Chart (Lower Left)
Members Closing at Least One Omission Gap: Among served patients with True Omission Care Gaps,
[# of Patients filling 1 or more medicines that generated a true omission alert] / [# of Patients with 1 or more true Omission alert]
Members Not Yet Closing Omission Gap: 1 - [Members Closing at Least One Omission Gap]
Section 4: Column Chart (Lower Right)
Days Post Session in Which Patient Closed Omission Gap on at least One Drug: For each patient closing at least one care gap, the # of days after their case served date until their first fill of the target drug that generated a true omission alert. In case of multiple target meds for a patient, use the lowest # of days.

37. P4P Concept
Dispensing
P4P & Pharmacy Home
Clinical Services

38. Program Goals
P4P
Increase awareness around Pharmacy Quality Management
Provide “transition” funding for Pharmacy to “transform” their practice
Transformation
Workflow efficiency
Maximize the use of technology to handle Rx volume and enhance compliance
Pharmacy Home
Build Clinical model to handle outcome-based MTM or other clinical services

39. 2018 Focusing on Transition Time: Things we are doing as a pharmacist
More Specific Guidance
Value-based Clinical Services- MTM
Prospective and Retrospective DUR
Drug dispensing Services

40. Draft P4P Changes (2018) Current P4P and Pharmacy Home
(Ends in Sep 17)
New DUR edits
(Starts in Apr 17)
Tier 1
Display
Tier 2
HPPN
P4P Extension (Oct-Dec17)
Tier 3
POC MTM

41. Changes At-a-glance Consolidate P4P and Pharmacy Home Programs
Current P4P measures will be used as “display” for monitoring purposes
Current P4P $ will shift toward Tier 2 HPPN
New Tier 2 P4P payment For HPPN based on DUR (appropriate use of medication)
Tier 3 POC MTM Pharmacy based on SB493 (APP) provision

42. Tier 1- IEHP Pharmacy Network
Participants: All Pharmacies
Qualifier: Meet Program Eligibility Criteria
Credentialing Application: Optional
Tier 1 is a Qualifier Stage for Tier 2, all Pharmacies should monitor and improve their performance over all measurements.
Display Measurements:
Adherence score – Diabetes, HTN, and Statins
Opioid drug use
Asthma
# of paid claims with DUR alerts by pharmacy
Customer service score

43. Tier 2- High Performing Pharmacy Network (HPPN)
Provision of basic pharmacy services at high performance level (i.e. adherence, appropriate use of drugs)
Ensure proper oversight of all Drug Utilization Review (DUR) alerts
P4P dollars distributed based on TBD methodology
Participants: Pharmacies meeting the qualifiers listed below Qualifiers: Qualifier composite score-Star rating >4 for months; if score is <4 stars, pharmacy may be qualified by offering enhanced services from the IEHP credentialing list
Credentialing: Must complete IEHP Pharmacy Credentialing Application and meet Tier 2 Network requirement
Measurement: Percentage (%) of total paid claims with Safety Drug Utilization Review (DUR) alerts
Tier 2 services: Provide higher level of pharmacy services by ensuring proper Drug Utilization Review (DUR) alerts are resolved.
Measurement: DUR %

44. Tier 3- Point-of-care (POC) MTM Pharmacy
Participants: Pharmacies meeting the qualifiers listed below
Qualifiers: Qualifier composite score-Star rating>4 and have existing collaborative agreement with IEHP contracted physicians
Credentialing: Must complete IEHP Pharmacy Credentialing Application and meet Tier Network requirement
Tier 3 services: Provide MTM services for patients covered under the collaborative agreements; MTM services will focus on chronic conditions and monitored through outcomes

45. Discussion DUR edits Vaccine Network 2017 Pharmacy Strategic Program
Academic Detailing
Pharmacy Communications- Address
Credentialing Info
Upcoming Total Pain Care Program

46. Questions?