Achieving excellence: The strategic growth of GHP Pharmacy Programs

Kelly Faust, Kristen Scheib, Tricia Heitzman and David Griffith

The GHP Pharmacy Programs team was established in early 2020 with the strategic goal of developing and implementing initiatives aimed at enhancing pharmacy Star ratings, improving HEDIS pharmacy measure outcomes, and optimizing drug utilization reviews (DUR). Prior to the formation of this dedicated team, these efforts were managed by just 2 pharmacists and 1 technician, who balanced these responsibilities alongside other departmental initiatives in GHP Pharmacy. The creation of a focused team marked a pivotal shift toward more structured, data-driven performance improvement.

Although some improvement was observed in key measures, sustaining continued progress and achieving meaningful cost savings proved challenging. In response, senior leadership approved the establishment of the GHP Pharmacy Programs team. This newly formed team evolved to include 3 specialized sub-teams: GHP Pharmacy Star Adherence, GHP Medication Therapy Management (MTM) and GHP HEDIS/Drug Utilization Review — each focused on driving targeted improvements within their respective areas. This structure enabled deeper expertise, clearer accountability, and more agile response to performance trends.

The GHP Pharmacy Star Adherence team is tasked with improving all 3 Star Adherence measures (cholesterol, diabetes, hypertension), the statin use in persons with diabetes (SUPD) measure, and other quality Star measures through various outreach activities including live calls, IVR calls, MyChart messages and letters. The team was slowly built up starting in 2020 and today consists of 1 pharmacist coordinator, 2 pharmacists, 3 certified technicians and 7 pharmacy service representatives. This growth reflects the increasing complexity and scale of adherence outreach efforts.

The total number of members that met the criteria for at least 1 of the 3 measures rose from approximately 57,000 in 2019 to nearly 70,000 in 2024. During that time, the team was built, RxAnte was implemented to better identify members for outreach and track outreach activity, and initiatives were created to better incorporate collaboration within Clinical Enterprise Pharmacy. In 2024, the team made over 34,000 live calls and reached more than 47% of the members attempted. In direct reflection of these improvements to the process, team composition, increased outreach and collaboration, the adherence and SUPD rates have risen considerably from 2019 to 2024.

From 2015 – 2019 there was a limited outreach plan for the 3 adherence measures.

In 2020, outreach efforts increased.

Star 2026 (MY 2024) data is yet to be finalized; however, early indicators as of Aug. 1, 2025, show that both contracts should again see improvement compared to 2023 except for HMO Diabetes, which maintained its 2023 rate.

From 2021 – 2022 staffing was increased to its current state to increase the number of outreaches made to support continued rate improvement.

The GHP MTM team is tasked with administering the components of the CMS Medication Therapy Management program, including the Comprehensive Medication Review (CMR) and Targeted Medication Review (TMR). Prior to 2022, the MTM program was outsourced to a vendor, OutcomesMTM, with 1 GHP pharmacist assigned to oversee the process, validate measure data and report to CMS.

With the results of the CMR completion rate for the Star measure being less than desirable, senior leadership decided in September 2021 that starting Jan. 1, 2022, the MTM process would be brought in-house. For 2022 and 2023, the completion of CMRs and TMRs was done with in-house staffing, while reporting and documentation remained in the OutcomesMTM platform and the roster of MTM-eligible members was maintained in Excel. In 2024, the process was completely moved into Epic, including all reporting, documentation and housing of the MTM-eligible member list. This transition significantly improved workflow efficiency and eliminated duplicate documentation.

To be successful, the process required collaboration between GHP Pharmacy, CCPS, MTDM, Geisinger 65 Forward and Geisinger Retail Pharmacy. The CMR completion rate exceeded expectations, rising from approximately 66% in 2021 to over 94% in 2023. Completion rates for 2024 are yet to be released; however, early reporting indicates they should be at 94% once again.

The HEDIS/DUR team was officially formed in 2021, with 2 pharmacists fully dedicated to improving HEDIS rates and DUR initiative outcomes. Prior to 2021, pharmacists on the Star Adherence team were also tasked with impacting HEDIS rates and DUR initiatives. In 2022, a technician position was added to increase the team’s capacity and impact.

Since its creation, the team has revised or developed over 25 different initiatives that remain active today. These initiatives include retrospective drug utilization reviews aimed at improving patient outcomes; ensuring medication safety; optimizing therapeutic outcomes; identifying fraud, waste and abuse; and improving pharmacy HEDIS rates.

In 2024, these initiatives accounted for close to 14,000 letters sent to members, more than 2,000 phone calls to members, more than 1,000 letters sent to providers and more than 400 claims corrected through 66 outreach calls to pharmacies. These efforts resulted in approximately $1.8 million in savings and bonus payments. While the team is small in size, its value and impact are substantial.

The creation of the GHP Pharmacy Programs team, along with collaboration across various pillars within Clinical Enterprise Pharmacy, has yielded significant benefits. Many of these initiatives would not have achieved their current level of success without this partnership, underscoring the impactful results that can be attained when GHP Pharmacy and Clinical Enterprise Pharmacy work together effectively. This model serves as a blueprint for scalable, interdisciplinary approaches to improving health plan performance and patient outcomes.