Podcast Host Nick Dorich, PharmD, PQS Associate Director of Pharmacy Accounts, moderates a discussion and review of the health equity highlights from the PQA Annual Meeting 2023 in Nashville, TN. The guests for this episode include Christie Teigland, VP, Research Science and Advanced Analytics at Inovalon, and Lisa Hines, PharmD, CPHQ, Chief Quality and Innovation Officer at the Pharmacy Quality Alliance.
Teigland speaks about the coming health equity index and Hines' talks about the PQA risk adjustment model.
PQA Annual Meeting Exploring Solutions to Improve Equity in Medication Use Quality Slides
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So once plans identify which groups of members have the biggest disparities in a specific measure, let's say adherence to your hypertension medication pharmacist can really help. They can help with outreach. They can help with education. As to the importance of taking your medications regularly, the consequences, if they don't, they can support delivery of the medication. If that's a problem, they can identify, you know, sources of support with copays or just finding out what barriers are preventing patients from taking their medications.
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Welcome to the Pharmacy Quality Solutions Quality corner show where quality measurement leads to better patient outcomes. This show will be your go to source for all things related to quality improvement and medication use and health care. We will hit on trending health topics as they relate to performance measurements and find common ground for payers and practitioners. We will discuss how the EQUIPP platform can help you with your performance goals.
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We will also make sure to keep you up to date on pharmacy quality news. Please note that the topics discussed are based on the information available at the date and time of reporting. Information or guidelines are updated periodically and we will always recommend that our listeners research and review any guidelines that are newly published. Buckle up and put your thinking cap on.
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The Quality Corner show starts now.
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Welcome to this review of the 2023 Pharmacy Quality Alliance Annual meeting with Lisa Hines and Christie Teigland. Christie and Lisa both presented at the meeting this year, and we pulled them aside for this interview as their presentation for some of the most in-demand sessions from this year's meeting, Christy's talk focused on the coming Health equity index and Lisa's with reference to the Health risk adjustment model.
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So we're going to go ahead and welcome our guest. First, Christie, welcome to the show. And how are you doing today?
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I'm doing great and happy to be here. Thank you for inviting me.
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Absolutely. We're pleased to have you. And then Lisa, welcome back to the Quality Corner show. How have you been doing?
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Well, my pleasure. Love this session and happy to be here. To recap some highlights from our meeting.
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Absolutely. Well, appreciate having you both, the both of you here. I'm going to take a quick moment before we get into the actual questions. Christie, do you mind giving us a brief introduction for yourself and explain what what it is that you do at a no villain?
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Absolutely. I'm a PhD economist by training. I've been working in health care, though for more than 25 years. I'm currently vice president in our Research, Science and Advanced Analytics team at Inovalon. I’m in our Data Insights, Data Solutions division. So I get to play with all of the data that Inovalon often gets from working with health plans across the United States.
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So I do studies focused on quality measurement, development and testing, which is some of the work I've done with PQA. We work on health disparities, health equity for more than ten years. I also do all kinds of life science research, health economics, outcomes, research, treatment patterns, research. So I work with health plans, providers, life science, across the board to really provide actionable real world data insights.
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Excellent. Well, Christie, excited to have you here and definitely sound like the right expert to talk about health equity, which we're going to get into in just a short moment. But Lisa, you've been on the show before, but do you do you mind reminding the audience what it is that you do?
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Sure. My pleasure. I'm Lisa Hines, Chief quality and innovation officer at PQA. I oversee our research and quality measurement teams and the overall strategy, and I have had the pleasure of working with Christie on our various panels. It was instrumental in advising our risk adjustment Advisory panel in the development of our risk adjustment model, as well as some of the testing.
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And she's currently chair of our health, one of one of the chairs of our Health Equity and Technical expert panel. So I'm thrilled to be here with Christie.
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Excellent. We've got quite the dynamic duo and I'm excited for this question and answer session that we'll have with our audience. Before I jump into the background and the questions, I will note that PQA has also provided us with some of the slides that were included for their presentation. So while you are listening to this episode, please be sure to check out the show notes and to be able to access that information.
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Now for the purposes of background in the 2024 Medicare Advantage and Part D final rule issued on April 5th, the Centers for Medicare and Medicaid Services finalized two important proposals to reduce medication use. Quality disparities in a variety of populations. Specifically, CMS will implement a new health equity index and separately implement risk adjustment models for adherence measures and the Part D Star ratings program.
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So, Christie, we're going to start with you, and we're going to start talking about that health equity index. So can you help us understand, you know, basically what's the what's the one minute elevator pitch to understand the CMS Health equity index?
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Yes, sure. The health equity index is really an enhancement as to the Medicare Advantage five star program. But the goal is really to incentivize contracts to do better with socially at risk beneficiaries. So what this health equity index summary measure will do is summarize the performance at the contract level across a subset of the star measures, and it's going to be included as part of the rating system by 2027.
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It's going to be part of the plan's star rating as well as the reward factors that that they might be able to receive. So it's going to be based on two years of data. A contract has to be measured on at least half of the measures to get a score. It's really going to only impact contracts with 500 or more members.
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So it's kind of specific. And in the end, the contracts have to have a minimum number of members then have social risk factor. So it's pretty technical, but it's a composition of existing measures that plan should be familiar with.
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Excellent. Thank you, Christie, for that initial answer response. And I'll note for our listeners, when we look at Medicare, Medicare plans and talking about items that are done at a contract level, that may be a specific subset for a health plan in the population that they're serving, the benefits they're offering in those areas or communities. Now, Christi, a follow up question or the first of many follow up questions that we're going to have.
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What is going to be really included with the health equity, the composite health equity index, And to why is it going to be important for the plans to understand you already noted about some of this that is going to have financial incentives, but do you mind drilling down a little bit further for us.
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So how it's going to work is that within each contract they are going to calculate the measures that are included in this index two ways. One, for members without social risk factors and one for members with social risk factors. The risk factors, they're going to start with are people who are disabled, people who are dual eligible for Medicaid or people who are low income subsidy status.
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CMS has said that they will add other ramifications of social determinants of health that they know are important, but they just don't have the data right now. Things like race, ethnicity, income, education. But for now it's just disability, dual eligible, low income subsidy. So contract performance rates for the members that have those social risk factors will then be ranked against other contracts right?
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They're going to rank them from best or worst, and only that top one third of contracts for each measure will get a point. For that measure. If they are in the middle. Third, they don't get any points for that measure, and if they're in the bottom third, they actually get subtracted. A point by a point. So how the index works is that they figure out where you land on each of the measures.
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They add them up and average them to get your health equity index score. So the score is going to be between minus one. That's the worst you could do. You got you got minus one for every single measure you're in the bottom third up two plus one. You you were in the top third for every single measure. And the reward factor is going to be point four times your score.
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So if you got the maximum value of one, you scored in the top third for every measure, you could get nearly a half a point added to your star rating. And that's really significant for MA plans. It can translate into hundreds of thousands of dollars.
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Yeah, that's absolutely right. Christie, for the Medicare Advantage plans. The difference of a half star rating could be quite monumental for how they're going to be working with their beneficiaries and which to us as the pharmacies, they're the patients. But for the health plan, it's their beneficiaries. It's their enrollees. Now, Christi, I've got two additional questions for you focusing on this topic.
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And so far we've talked about it from the payer or the health plan perspective, but for technology vendors and then in particular the downstream health care providers such as pharmacies who are going to be working with health plans to address patient care and perhaps address elements of the health equity index, what do they need to be prepared for and how can they perhaps make some changes in their practice to help address these items
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You know, for payers, the time to get started is now. They really need to start looking at their data now to be able to make an impact on their score when they're published in 2027. Remember that they're going to use two years of history data and we all know those of us working quality measurement, that it takes time to move those measures.
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So first of all, clients can use their own internal data to see how they're doing internally. How are they doing with members with social risk factors compared to members without? So they can really see where they have the largest disparity gaps. But what they also need and this is where the vendors come in, is access to benchmark data on how other M.E. contracts Medicare Advantage contracts are performing, right?
00:10:49:20 - 00:11:27:15
So that so that they can sort of mock up and figure out where they're going to land on this health equity index. So this is one place a novel on. And my research team has been helping Big AM Medicare Advantage plans figure out where they're going to rank on each measure, where their biggest disparities are, project, what their scores likely to look at and so forth on the pharmacy side, the pharmacy partners can definitely play a role because a big number of these five star measures are medication related, including three of the triple weighted medication adherence measures that I know Lisa's going to be talking about in a minute.
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So once plans identify which groups of members have the biggest disparities in a specific measure, let's say adherence to your hypertension medication pharmacist can really help. They can help with outreach. They can help with education. As to the importance of taking your medications regularly, the consequences, if they don't, they can support delivery of the medication. If that's a problem, they can identify sources of support with copays or just finding out what barriers are preventing patients from taking their medications.
00:12:06:00 - 00:12:33:01
As I've learned from my work with the Pharmacy Quality Alliance, the pharmacists are often the closest to patients. They see them. Most often they have a relationship of trust. So this can go a really long way to identify and address those sensitive social issues that we know people might not feel comfortable talking about with their health plan or even their physician because they're not sure how the information is going to be used.
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So pharmacies definitely have a key role. It takes a village.
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Christie, speaking on behalf of myself as someone who is trained and educated, educated as a pharmacist, I thank you for that last 60 seconds or so, which is really my motivation as to why we do the things we do in the pharmacy profession. Absolutely. Great call out that you provided. On how and why pharmacist why pharmacists in the pharmacy profession can play a role so that's really exciting to hear from from someone like yourself.
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Now final question, I'll ask for you before we go over to Lisa. But that health equity index, this is really designed at a population level to make sure that we're improving care and outcomes. How do you expect that it will show improve care and outcomes for our socially at risk beneficiaries? You know.
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The health equity index, you know, finally puts actual skin in the game with dollars attached to improving performance for disadvantaged members. I think we all believe it's the right thing to do. But now there's really evidence on the return on investment of doing the right thing and I really believe that's going to incentivize plans who might be behind in addressing health equity to take real action.
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Also, the construct of the health equity index, it's composed of multiple outcome measures and really gives health plans an opportunity to focus their resources on where the biggest disparities are within their plan. And that's going to be different across different Medicare Advantage plans. So, you know, that just seems forcing this exercise of comparing outcomes for members with and without social risk factors can really help, you know, uncover areas where maybe plans are doing really well with dual eligibles or low income folks.
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But there's going to be some other areas where they might not be, you know, where they're underperforming and that's where they really need to focus their limited resources, their interventions to really make a difference. So I'm a believer in data driven decision making. And I think this new initiative is really is really going to, as I said, you know, give the right incentives for plans to invest in doing the right thing.
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Perfect. Thank you, Christie. So I'm going to transition us to our couple of questions with Lisa. But Christie, hang tight. We may have a bonus question here for you at the end to get your final thoughts. Lisa, as this goes. Seems we covered this in the direction, but recently, CMS recently decided to implement a risk adjustment model for the adherence measures in the Part D Star ratings program.
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Can you explain for the audience what these socioeconomic or graphic risk adjustment factors are? And then what's really the goal with this implementation?
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Sure. Yeah, I'd be happy to. Risk adjustment is often called case mix adjustment in the measurement space, and it's a statistical model to account for patient related factors that may impact health outcomes, but may be out of the control of the measured entity, which in this place is the health plan. In terms of sociodemographic or we refer to it as s.d.s.
00:15:50:10 - 00:16:22:09
That is refers to social and demographic factors. So the demographic factors in our risk adjustment model include sex and age, and then the social factors are aligned with what Christie was talking about, the low income subsidy status, dual Medicare, Medicaid eligibility and disability. So risk adjustment accounts for these factors that are known to influence adherence with the goal to make fair and correct conclusions about the quality of care provided.
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Excellent. Lisa. So that's our description. That's kind of our what, if you will. What about the the when when is the when when are these risk adjustment factors going to be included? What is the timeline? And then what are the implications for CMS decision to implement this for the model and for the adherence measures?
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Sure. It's this model has it's much anticipated. So we're excited that it's being implemented and this is through the rulemaking process because they're these adherence measures are star measures. CMS announced that the risk adjustment model for adherence will be phased in over three years. They'll first display the ACA risk adjusted adherence measures in the 2026 display page that corresponds with measurement year 2024 and the legacy or unadjusted adherence measures will remain in the star ratings.
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The risk adjusted measures will then replace the existing measures beginning in 2028. Star ratings in that corresponds to the 2026 measurement year schemas. Also intends to incorporate risk adjustment operationally. So sharing those measure rates in their reports to the Part D plan sponsors in the last monthly patient safety report of the measurement year. So so Plan sponsors will get a glimpse of what those risk adjusted rates are looking like in the background.
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Thanks, Lisa. So the key part here, you referenced this, Christie referenced this, this there has to be data collection first so that plans so that the contracts have have an idea around what those numbers are and then how they build that into their process for for their quality improvement initiatives. Lisa, Moving to my next question, a consideration. This all sounds good and this all sounds positive as it relates to getting good data, getting better data and getting a better sense on the care for patients and the work done by those health plans and then downstream providers.
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Are there potential drawbacks or limitations when it comes to risk adjustment? That I think is a question that a lot of folks may ask. So interested to hear. What are your thoughts on how that could be impacting the program?
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Sure, there are possible unintended consequences for risk adjusting social variables and that, you know, these are theoretical but possible establishing a lower standard of care for certain patients or obscuring the differences in quality among providers. And so a balanced approach needs to be taken when when pursuing risk adjustment. And also risk adjustment only addresses the patient factors. And there could be provider level care characteristics impacting performance on the measure, such as the robustness of the local health care workforce.
00:19:10:17 - 00:19:35:08
So overall, a balanced and thorough consideration of the pros and cons are critical to deciding if and how to risk adjust quality measures. And that is why stratification of unadjusted measure rates is important. To identify the disparities to be able to take action. And also, you know, the health equity index is additional motivation to reduce the disparities.
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Excellent. Lisa, final primary question that I have for you related to this topic, and it's going to be related to peak AIDS efforts more broadly, how else is P.K. evaluating its approach to quality and measurement to address health equity?
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Yeah. So as I mentioned, we have a health equity technical expert panel that was launched this month and Christie is one of the co-chairs. The panel's goal is to develop recommendations for stratifying peak aid measures, expanding to other variables. For example, we're discussing race and ethnicity and the availability of data sources in different lines of business. So we're also going to look at other approaches to ensure our measures are accurately capturing quality while advancing health equity.
00:20:20:19 - 00:20:49:05
And we can look at this in measure testing and then also provide recommendations for measures that are implemented in existing programs. The panel is highly technical. We are focusing on statistical methods that are needed for stratification and risk adjustment and therefore have highly specialized individuals on the panel. We also have patients on the panel with diverse backgrounds participating to help us stay focused on their needs and perspectives.
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And we're really looking forward to seeing this panel's progress this year and into 2024.
00:20:54:21 - 00:21:14:07
Excellent. Work is never done, Lisa. And I think that's a message that we get loud and clear as it relates to this. So before we close, I appreciate Christy, Lisa, having both of you here on the show to go through and talk about some of the highlights from your sessions. I know we didn't cover everything we're going to, again, references, folks they can check out in our show notes, The slides that were presented as well.
00:21:14:12 - 00:21:30:05
Got one final question for each of you. And Christie. I'll start with the question for for you. When should health plans be starting their their efforts around the health equity index? And was that what is the answer to that question? They should have started already.
00:21:30:07 - 00:21:57:18
Yeah, the answer is they should have started already. I think, you know, some plans are in a little bit of denial because this is complicated. Right. And they don't even know where to start. So, you know, under starting to understand how it's going to be constructed, figuring out just internally with your own data stratifying measures, if you have that capability to calculate quality measures, Lots of plans have those teams of analytic folks, but some plans don't.
00:21:57:22 - 00:22:18:14
So if you don't, you can find a data partner to help you with that. If you do, you should be looking internally. How are your members with social risk factors performing on these measures compared to members who don't have any of those social risk factors? Because that's going to really help you see where your disparities are. Where should I start to focus my resources?
00:22:18:18 - 00:22:44:16
Because to budge these measures and to make a difference on health equity, you know, takes a lot of time and effort. We talked about pulling in pharmacists. Well, you have to pull in community providers, right, to help with outreach to members. So all of this takes time. And, you know, the two years of data that will be going into that first published rate is going to start collecting soon.
00:22:44:16 - 00:23:09:10
So absolutely, the time is now. You know, they can reach out to Inovalon and go to our website novel uncommon Christie.firstname.lastname@example.org I can certainly guide you in the right direction and fill in help you fill in the gaps, help you get started, help you with the right steps.
00:23:09:10 - 00:23:13:21
So but but yeah, it's not too early to get started on this.
00:23:13:23 - 00:23:38:00
Perfect. Christie Yeah, not too early. Might be too late to have an impact on those initial years of the data and operational changes. Lisa, final different question for you and for our listeners that are coming from the pharmacy perspective that that's here, where can they go to find, you know, practical examples on how pharmacy can impact social determinants of health, addressing health equity?
00:23:38:02 - 00:23:47:00
Are there any, you know, resources or information that has worked on or perhaps leaders with some of the a task force that may be able to help provide some insight?
00:23:47:02 - 00:24:31:14
Yeah, that's a great question. And follows on to Christie's kind of passionate points about what pharmacists and pharmacies are doing to address social determinants. Pick your Way has an do a resource guide available on our website. We continue to update it and advancing advancing it over time and it is frequently referenced as a great resource. So we're committed to continuing to maintain this as a good example of an example of what good looks like, you know, positive case studies in addressing social factors, including food deserts and transportation issues.
00:24:31:16 - 00:24:41:16
Excellent. Lisa, appreciate that. And before we go, I know a real quick item, Lisa, If folks want to hear more from you or from P.K., what's the best way to reach out?
00:24:41:18 - 00:25:08:01
So the best way to reach out is we actually have a technical assistance form on our website. You navigate to our website and go to the measures tab and then measure use. And you can always email me at Hynes at PQA Alliance dot org and there's a general technical assistance email that's measure Youth allowance dot org.
00:25:08:03 - 00:25:32:22
Thank you very much. Well, Christie, Lisa, I thank you both for appearing on the show today and taking some time out of your busy schedule here as we're in the early days of summer 2023. Again, not too early to start working on those health equity and risk adjustment items, whether you are a health plan or whether you're a pharmacy supporting a health plan in those areas, whether you're a health plan or a pharmacy, we're doing it to help support the patients and that the people that are in our communities.
00:25:32:22 - 00:25:52:06
So that's really the biggest winner out of all of this is the people that we are that we are living, working and serving next to. So, Christie, Lisa, I appreciate having both of you on the show. Thank you for your time and audience with that. We have wrapped up this episode, so we thank you for joining us today and we hope you listen to our next episode of The Quality Corner Show.
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Before we go, we have one final message from the PQS team.
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