Every month I await the e-mail from PQA telling me that my latest EQuIPP scores are ready. If I want to impact my scores, I need to understand the numbers behind them. Today I thought I would remind everyone how the EQuIPP compliance score, the PDC or Percentage of Days Covered, is calculated for a pharmacy.
While compliance might seem like an easy topic, it is far more complicated: compliance for patients is aggregated into a score representing the overall compliance of all patients in the pharmacy. Several assumptions are being made in order to do this.
Defining Patient Compliance
If I miss a dose once a month, most would consider me compliant. But what about missing one a week? A line needs to be drawn somewhere, and EQuIPP has arbitrarily drawn this line at 80% of days covered. This means that someone missing 5 or fewer days worth of medication in an average month is considered compliant. According to PQA, compliance is a binary (YES / NO) attribute. Either the patient is compliant, or they are not compliant, in any given month.
But EQuIPP cannot tell if a patient takes a drug 80% of the time. They are relegated to using claims data. Percentage of Days Covered (PDC) is calculated based on dispensing data from the pharmacy. PDC accounts for early or late refills by looking at the total number of days worth of drug the patient has in their possession during a period of time. For example, if a patient fills a 30 day supply of medication, and then refills the prescription 25 days later (5 days early) the second month, and 40 days later (10 days late) the third month, the PDC would be calculated based on the previous two fills as:
60 days of medication / 65 days elapsed * 100 = 92% — Based on the EQuIPP definition, the patient is compliant.
Note that the assumption is that the patient is out of medication when the refill is processed. This assumption can create erroneous calculations when used over short periods of time. In the example above, this assumption may actually overstate compliance as the patient has only taken 50 days worth of medication in 65 days and was just picking up a refill before going on vacation. It can take several months for the PDC to stabilize and more accurately reflect patient compliance. This creates additional questions for which I don’t have good answers. For example: what is the start date for the calculation? For a new patient to the plan, it will be their first fill date after they enter the plan. But for a patient that did not change plans, how far back is the first fill date? I am assuming that the PDC is using calculating compliance over some defined period of time, probably 6 to 12 months.
Defining Compliance for the Pharmacy
Every patient included in the EQuIPP measures will be labeled as either Compliant or Non-Compliant for a given month. From this pool of patients, the pharmacy’s compliance rate is calculated. This is simply the number of compliant patients over the total number of patients. A rolling 6 month average of this calculation is the number seen in the EQuiPP dashboard.
Improving Your Measure
As many have observed, the easiest way to impact a pharmacy’s PDC for a given drug category is to target patients just falling short of the 80% threshold for compliance. Consider a pharmacy with a Diabetes PDC score of 80% with 100 patients enrolled. The CMS threshold for this measure is currently 82% and the Top 20% threshold is 92.5%. In order to move the pharmacy above the CMS threshold, two patients that are currently non-compliant need to become compliant. Likewise, moving 13 patients into compliance will move the pharmacy into the top 20%. Targeting patients with compliance between 75-79% will have the best chance for quick and easy success for the pharmacy.
To do this, a pharmacy has to identify the low hanging fruits: the patients falling just short of 80% compliance. The EQuIPP platform has the capability to show you outliers, but in practice, we have not found this very useful. Other products (Mevesi, PrescribeWellness, McKesson and others), have platforms to help you identify the outliers. These tools are retrospective in nature because they generally use data that is pulled from your dispensing system at regular intervals. All of these tools are designed to be used outside the dispensing workflow to create a list of potential patients to target. Once you have the list, you need an implementation plan to put the data to work. Other tools, like PharmClin, flag patients during the dispensing workflow, allowing you to target the patient in real time, avoiding the need for additional implementation. I prefer real-time identification of patients for two reasons: it takes less time and effort to identify the patients needing targeting and the data is always current.
Taking Action
If you are starting with a list of targets, you will need a battle plan. One possible tactic is to place a note or flag on the patient record to alert the pharmacist or technician that the patient is a target when they initiate a new prescription or refill. This allows the pharmacy staff to approach the patient at the time they pick-up the medications. Another method is to contact patients outside the prescription workflow by appointment or by phone. Ultimately, the goal is to initiate a conversation with the patient.
At this point, with the patient in front of me or on the phone, I tend to be careful with how I proceed. Remember, claims data gives us very little real information. The patient may not actually be non-compliant: they may have a very valid reason for their compliance history. For this reason, I always try to be neutral when starting a compliance conversation. I might ask, for example:
I see that your refills for metformin are less frequent that I would expect. Has the dose the doctor wants you to take changed?
We often find perfectly reasonable reasons for PDC based compliance problems. Physician samples, dose changes not communicated to the pharmacy, and alternative drug supplies are commonly seen explanations found in our practice. If the dose has changed, we can fix the compliance problem by getting a new prescription from the prescriber. For other explanations, I simply document the intervention with the patient and revisit compliance in 3 months. Our use of the clinical documentation system PharmClin makes the this easy and automatically allows us to schedule a follow-up for the problem.
Sometimes, I find that the patient doesn’t tolerate the drug well, and has backed off of the dose as a result. The physician may have instructed the patient to do this temporarily, with instructions to gradually increase the dose. Metformin is a common example. Finding this, I work with the patient and prescriber to ensure that the patient achieves the desired outcome without unnecessary effects. This might mean helping the patient with their gradual dose increase, or recommending a different drug entirely. Either way, the “compliance” problem can be both documented and successfully addressed.
Addressing Non-Compliance
Most pharmacies use a medication synchronization program to address compliance problems. While this is a valid plan, it is most appropriate in the case that a patient forgets to order refills or stop in to pick up refills. I am careful and investigate a host of other possible reasons that the patient doesn’t refill their prescription on time before asking them if they are interested in synchronization. Again, I proceed with caution. Is the reason financial? Might the reason be related to the time of administration or restrictions on what can or cannot be taken with the medication? I work hard to understand the reasons before creating a patient specific plan. If the issue is financial, finding a less expensive alternative might be needed. If the patient simply struggles with getting to the pharmacy, offering our delivery service is a reasonable intervention. Finally, if the patient forgets to order refills or has difficulty remembering to pick up medications at the pharmacy, the benefits of synchronization are a great way to help the patient become more compliant.
MedSync
One final note about medication synchronization. While this tool can be very successful in addressing compliance issues, the reasons for its success in our pharmacy are not what you might think. Filling a prescription on a regular frequency will, of course, correct the claims based PDC score. But in our pharmacy, med synchronization’s success comes from the increased level of engagement our staff have with the patient. By calling the patient each month, we can ascertain if any changes have been made and gather important informant about any problems the patient is experiencing. Additionally, we are able to approach the patient about other topics including what their therapeutic outcomes are and if they are meeting them. In short, we work hard to make every encounter count!
