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KEY POINTS

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  • The United States healthcare system is moving from a fee-for-service payment model to one of value-based purchasing, with provisions set forth in legislation for accountable care organizations, medical homes, bundled payments, and a focus on quality.

  • Value-based purchasing is a payment method that provides financial incentives to providers who meet certain quality standards in order to foster clinical and financial accountability.

  • Measurement of quality is expanding rapidly throughout the US healthcare system. Quality in healthcare is most often measured through the use of performance indicators, also known as performance measures.

  • It is essential for MTM providers to understand the quality metrics that apply to medication therapy management, which will influence the focus of their practice models.

  • The Medicare Advantage and Medicare Prescription Drug Plan Quality Strategy provide a framework for measuring quality performance for both Medicare Advantage and Medicare Prescription Drug (Medicare parts C and D) plans. Centers for Medicare and Medicaid (CMS) measures the quality of Medicare Part C and Part D plans with the Star Ratings System.

  • By publicly reporting the ratings, CMS encourages Part C and Part D sponsors to improve service quality to attract enrollees to their plan. The measures are also used to determine quality bonus payments (QBPs) for Medicare Advantage (MA) organizations.

  • Medicare Part D ratings include measures for medication use under the domain of patient safety and accuracy of drug pricing. MTM program providers should be mindful of the medication use, safety, and adherence measures as they provide MTM services on behalf of Medicare Part D plans.

  • In fall 2012 CMS publicly reported data on the first MTM specific quality measure, which evaluates the percentage of MTM-eligible beneficiaries who received a comprehensive medication review. The measure was developed, tested, and endorsed by the Pharmacy Quality Alliance.

  • CMS intends to adopt further process and outcomes measures for MTM once they are developed and endorsed.

  • Beyond the Star Ratings and quality measures reported by CMS, MTM programs and vendors, like all healthcare providers, should ensure the quality of the services they provide. Payers should be able to rely on the accuracy, completeness, and appropriateness of patient interactions, written communications to patients and providers, and MTM encounter records.

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INTRODUCTION

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A Focus on Quality

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The 2003 Medicare Modernization Act began moving the United States toward a value-based healthcare system. This was echoed in the Patient Protection and Affordable Care Act of 2009, in which the word value is mentioned at least 214 times.1 The Act reforms Medicare payments, with a shift from a fee-for-service model to one of value-based purchasing, with provisions for accountable care organizations, medical homes, and bundled payments. There is also a focus on quality, exemplified by programs such as the Hospital Value-Based Purchasing Program and updates to the Physician Quality Reporting Program, including financial incentives (Table 4-1).1,2, and 3

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