Medication Safety Pearls: Best Practices

Medication Safety Pearls.

1. Medication Safety Pearls
Quality Perspective
AZADEH ALI-MOGHADDAM, PHARM D
[email protected]
MEDICARE PART D CLINICAL PHARMACIST
BLUE CROSS BLUE SHIELD OF MICHIGAN
MAY 2017

2. Agenda:
 Discuss the basics of Drug Plans with the focus on Medicare Part D
 Discuss Stars Rating and its importance in ranking Medicare Part D plans
 Explain how medication safety is being practiced in Medicare Part D

3. Introduction to Drug Plans:
Commercial
•Employer-sponsored insurance
•Insurance purchased on the individual market
Medicare
•people age 65 or older,
•people under age 65 with certain disabilities, and
•people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a
kidney transplant).
Medicaid
•For low-income people
Dual Eligibility – people that qualify for both Medicaid and Medicare at the same time

4. Medicare Program has….
 Medicare Part A: Hospital Insurance
 Medicare Part B: Medical Insurance
 Medicare Part D: Prescription Drug Coverage
 D for DRUG!
 It covers drug cost
 It is an insurance provided by private insurers

5. CMS and its mission
 The Centers for Medicare & Medicaid Services (CMS) is part
of the U.S. Department of Health and Human Services.
 It oversees many federal healthcare programs including
Medicare C and D to improve the quality of care and general
health status for Medicare beneficiaries.
 CMS defines Stars Ratings to rank Medicare plans quality and
performance.

6. What is CMS Stars Rating?
1
3
2
4
5
If a Medicare plan gets
Stars rating of <3 for 3
consecutive years, CMS
will revoke their
Medicare contract.
If a Medicare plan gets a
Stars rating of 4 or 5,
CMS will issue them a
BONUS!!!

7. Stars measures fall into 4 domains in
prescriptionprescription drugs services:
◦Drug plan customer service
◦Member complaints and changes in drug
plan performance
◦Member experience with plan’s drug
services
◦Drug safetyDrug safety and accuracy of drug pricing

8. Drug Safety Measures
Medication Adherence to Oral Diabetes Medications
Medication Adherence for Hypertension (RAS antagonists)
Medication Adherence for Cholesterol (Statins)
Medication Therapy Management
Statin Use in Diabetes
High Risk Medications in the Elderly

9. Medication Safety in Managed Care
New drug
released
New safety alert
on a medication
New CMS
safety
measure
Formulary Team
Formulary
placement

10. Drug formulary and P&T
 A drug formulary is a list of prescription drugs, both
generic and brand name, used by practitioners to
identify drugs that offer the greatest overall value.
Pharmacy and Therapeutics Committee (P&T):
 A committee of physicians, nurse practitioners, and
pharmacists maintain the formulary.

11. Medication Safety in Managed Care
Utilization Management:
•Prior Authorization
•Step Therapy
•Quantity Limitation

12. Medication Safety in Managed Care
 Prior Authorization (PA):
If patient wants to use their insurance benefit to get a
medication which needs PA, the physician should
obtain approval from health insurance.
 PA is a technique for minimizing costs
Benefits are only paid if the medical care has been pre-
approved by the insurance company.

13. Medication Safety in Managed Care
STEP THERAPY (ST) QUANTITY LIMIT (QL)
The amount of drug that
patient can have in a
particular period of time.
Move to a pricy/
risky medication
Start from a cost
effective medication

14. Medication Safety in Managed Care
Example of CMS Safety measure:
 High risk Medication in elderly
 Adults >65 should not be on medications which were
on Beer’s list
 Due to increased risk of fall and fracture

15. Medication Safety in Managed Care
Drug Utilization Review (DUR)
•Authorized, structured, and ongoing review of
medications being prescribed by providers, dispensed by
pharmacists, and taken by patients.
CMS required DURs:
•Concurrent DUR- cDUR
•Retrospective DUR- rDUR

16. Concurrent DUR- cDUR
Drug-disease interactions
Drug-drug interactions
Drug dosage modifications
Drug-patient precautions (age, gender, pregnancy, etc.)
Over and underutilization
Therapeutic Interchange
These are mostly soft blocks and can be over-ridden by dispensing pharmacist
and some are hard blocks.

17. Retrospective DUR- rDUR
Patient History
Evidence based
medicine (EBM)
Medication
History
Reviewed by
managed care
pharmacist
Medication safety
related issues will
be brought up to
the prescriber

18. Retrospective DUR- rDUR
Examples of rDUR:
-Opioid overutilization- MED >120mg
-Opioid-Benzo concurrent use
-Opioid-Benzo-Skeletal muscle relaxant concurrent use

19. Adherence to cholesterol, diabetes, and
hypertension medications
 Three triple weighted Stars measures.
 >80% of the time medications should be in
member’s hand throughout the year.

20. What do we do in insurance company to
make sure members are taking their
medications?

21. What do we do in insurance company to
make sure members are taking their
medications?
Physician outreach
 Academic Detailing
 Incentive programs
Member outreach
 Clinical interventions
 Non-Clinical interventions
Pharmacy outreach
 Pay for Performance

22. Conclusion:
Medication safety is the base of what we do at
managed care on daily basis.
We make sure members receive the correct therapy
at the correct time.
CMS has quality measures to make sure that
Medicare plans are doing their job best way possible.

23. Any Questions?
AZADEH ALI-MOGHADDAM
[email protected]

24. Assessment Questions
1. Who is eligible for Medicare Part D?
A.Adults older than 65 years-old
B.Younger than 65 years-old with disability
C.Any patient with End Sage Renal Disease (ESRD)
D.All the above

25. Assessment Questions
2. What is the ranking system for Medicare Part D?
A.Stars rating
B.Number of the members
C.The amount of money the plan makes
D.None of the above

26. Assessment Questions
3. What happens if a Medicare plan receives a Star score of lower
than 3 for three consecutive years?
A.The plan receives a bonus from CMS
B.The Medicare contract will be revoked
C.Nothing happens to the plan
D.CMS will incentivize the plan

27. Assessment Questions
4. Managed care pharmacy incorporates medication safety
principles into the following activities:
A.Placing a new drug on the formulary
B.Concurrent and retrospective drug utilization review
C.When a new safety measure is proposed by CMS
D.All of the above