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The Pharmacy Quality Alliance:Promoting High-Value Health Care

via Transparency in Pharmacy Performance

Dave Domann, MS, R.Ph

Johnson & Johnson

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OBJECTIVES::

Describe PQA’s mission and its stakeholders

Discuss the status of PQA initiatives to develop and test performance measures for pharmacies

Delineate various uses of the PQA measures

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Ensuring Quality in Healthcare

“The fundamental challenge in health care is how to jump-start a new kind of competition – competition on results in improving health and serving patients.”

Redefining Health Care – Michael Porter, Elizabeth Olmsted Teisberg

Porter ME, Teisberg EO, Redefining Health Care: Creating Value-Based Competition on Results. Harvard Business School Press, Boston Massachusetts, 2006.

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The Mission of the PQA is to:

Improve health care quality and patient safety through a collaborative process in which key stakeholders agree on a strategy for measuring performance at the pharmacy and pharmacist-levels; collecting data in the least burdensome way; and reporting meaningful information to consumers, pharmacists, employers, health insurance plans, and other healthcare decision-makers to help make informed choices, improve outcomes and stimulate the development of new payment models.

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Who’s at the PQA Table?

Pharmacy Quality Alliance (PQA)

• PQA was formed in April 2006

• CMS was instrumental in creation of PQA, but does not control PQA

• Self-sustaining through dues of > 60 member organizations

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Steering Committee Organizations

Agency for Healthcare Research and Quality (AHRQ) The Brookings Institution AARP Academy of Managed Care Pharmacy (AMCP) American Society of Consultant Pharmacists America’s Health Insurance Plans (AHIP) American Pharmacists Association (APhA) Centers for Medicare & Medicaid Services, (CMS) Express Scripts, Inc. GlaxoSmithKline National Alliance of State Pharmacy Associations National Association of Chain Drug Stores (NACDS) National Community Pharmacists Association (NCPA) Pitney Bowes Teva Pharmaceuticals USA

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Pharmacy Quality Alliance’s Four Primary Groups

Director

Quality MetricsResearch

Coordinating CouncilData Aggregation

and Reporting

Director of Practice Improvement

Education &Communications

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PQA Activities - 2006

PQA formed in April 2006 From April through November 2006:

– Conducted environmental scan for existing measures of pharmacy performance

– Developed guidelines for public reports, and pharmacy feedback reports, about pharmacy performance

– Formed workgroups and cluster groups to develop measure concepts

– Endorsed 37 measure concepts– Developed plans for further development and testing of

measures

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PQA Activities - 2007

Contracted with NCQA and APC to develop specifications for claims-based measures of performance and pilot test the measures.

Contracted with American Institutes for Research (AIR) and UNC School of Pharmacy to develop and pilot-test a questionnaire for consumers (CAHPS-Pharmacy)

PQA’s Starter Set of Measures - 2007

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1. Proportion  of  Days  Covered:   Beta  Blockers  

2. Proportion  of  Days  Covered:   (ACEI/ARB)  

3. Proportion  of  Days  Covered:   Calcium  Channel  Blockers  

4. Proportion  of  Days  Covered:   Dyslipidemia  Medications  

5. Proportion  of  Days  Covered:   Diabetes  Meds  (Sulphonylureas, Biguanides, TZDs)  

6. Gap  in  Therapy:   Beta  Blockers  

7. Gap  in  Therapy:   (ACEI/ARB)  

8. Gap  in  Therapy:   Calcium  Channel  Blockers  

9. Gap  in  Therapy:   Dyslipidemia  Medications  

10. Gap  in  Therapy:   Diabetes  Medications   (Sulphonylureas, Biguanides, TZDs)

11. Diabetes:  Excessive  Doses  of  Oral  Medications  

12. Diabetes:  Suboptimal  Treatment  of  Hypertension  

13. Asthma:   Suboptimal  Control  

14. Asthma:   Absence  of  Controller  Therapy  

15. High‐Risk  Medications  in  the  Elderly  

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PQA Adherence / Persistence Measures

• A significant gap is defined as 30 days or greater

• Individual measures focus on a specific drug class (e.g., beta blockers)

Measure Title

Measure Description/Definition

Gap in Therapy

Percentage of prevalent users who experienced a significant gap in medication therapy.

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Single Gap

Index Fill Refill DueActual

Refill Date

Single Gap = 37

days

90 day supply

Jan 15 Apr 15 May 22

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PQA Appropriateness Measure: Suboptimal Treatment of HT in Diabetes

Suboptimal treatment:Diabetes

Percentage of patients dispensed medications for diabetes and hypertension who are not receiving an ACEI or ARB.

Measure Title Measure Description/Definition

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Consumer Assessment of Healthcare Providers and Systems

Developed by American Institutes for Research – University of North Carolina

CAHPS Pharmacy Survey

CAHPS results are used to

Assess the patient-centeredness and quality of care from the patient’s perspective,

Facilitate consumer choice; and

Improve quality of care.

What’s Next for PQA ?

Demonstration Projects– Phase I 2008-09– Phase II 2009-11

Selection of Generation II measures

Educational programs for pharmacists, students, and other stakeholders

Participation in Quality Alliance Steering Committee (QASC)

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Demonstration Projects

Phase I demonstration projects will focus on determining:

Resource requirements for aggregating data Generating pharmacy performance reports Gaining feedback about the reports from

pharmacy personnel

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Demonstration Projects

Four Project Areas Health Plan, or Prescription Drug Plan (PDP), generating

performance reports for its network of pharmacy providers

A coalition of Health Plans, or PDPs, that work together to create aggregate performance reports for pharmacies in a geographic region

Community pharmacy corporation that creates an internal performance report system

Other models for pharmacy performance report generation and dissemination

PQA Demonstrations

• Call for Proposals was released early February

• 17 brief proposals received

• 10 invited to submit full proposals

• 3-5 will be funded (final selection made in May)

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PQA Demonstrations

• NCQA will provide technical assistance

• AHRQ will fund an “evaluation contractor”

• Phase I should be completed in mid-2009, and Phase II should start soon after

• Phase II will focus on performance improvement20

Cluster Groups - 2008

Cardiovascular Disorders

Consumer Feedback and Assessment

Cost of Care Diabetes Respiratory Disorders Medication Adherence

Medication Reconciliation

Mental Health MTM Services Patient Safety / e-

prescribing Prevention and

Wellness

Educational Programs

Educational Modules for Pharmacy School Curricula

Continuing Education Programs for Pharmacists

PQA Speakers Bureau to Communicate Pharmacy Quality Measurement to Quality Improvement Audiences

How will PQA measures be used?

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Potential Uses of PQA measures

• Quality/Performance Improvement• Tested in Phase II demonstrations

• Public Reporting / Consumer Empowerment

• Contract & Network Decisions

• Pay for Performance (P4P)

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Public Reports

• Information on hospital and physician quality is increasingly available to the public.

• CMS may provide expanded performance information on drug plan finder in 2008

• Drug plans, or regional coalitions, may start providing pharmacy reports in near future.

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Public reports could be embedded in drug plan websites…

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PharmacyQuality.com

Pharmacy Performance:What’s Your Grade?

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Compare Pharmacies

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Find My Pharmacy

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Network Decisions

• Pharmacies that score above a threshold of quality could be included in a high performance network for a health plan (with higher payment for products / services)

• Pharmacies that consistently perform poorly could be eliminated from the network (risk adjustment will be crucial for this decision).

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Will PQA lead us to P4P Models in Pharmacy?

In P4P, financial incentives are linked to quality measures. Thus, potentially, pharmacies that score higher on PQA measures could get a bonus or higher dispensing fees, under a different financial model.

Hospitals, physicians, and home health have all been testing P4P models of payment, but the results have been mixed. P4P appears to stimulate improvement in some indicators but not all, and the long-term effect on health outcomes is not yet known.

Pharmacy P4P Example: Current Performance

MedicationAdherence

MedicationSafety

Appropriateness:Asthma / Diabetes

# of patients 200 300 100

# Quality measures

7 3 4

Composite Quality Score

60% (120 adherent pts)

90% (270 pts meet criteria)

93%(93 pts meet criteria)

Incentive $ 10/pt (for adherent pts)

$ 2/pt $ 3/pt

Bonus Payment $10 x 120 = $ 1,200 $4 x 270 = $ 1,080 $3 x 93 = $ 279

This example is presented for illustration only!

PQA has not endorsed any model for pharmacy P4P

Pharmacy P4P Example:Improvement Model

MedicationAdherence

MedicationSafety

Appropriateness:Asthma / Diabetes

# of patients 200 300 100

Score in 2006 60% 90% 93%

Score in 2007 70% 93% 92%

Incentive $ 1/ pt / 1% increase $ 0.50 / pt / 1% inc $ 2 / pt / 1% increase

Bonus Payment $1 x 200 x 10 = $2000

$0.5 x 300 x 3 = $ 450

$ 2 x 100 x 0 = $ 0

This example is presented for illustration only!

PQA has not endorsed any model for pharmacy P4P

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Implications

“I don't fear pay for performance. I fear pay for performance for measures that don't really matter.”

Benjamin Brewer, MD

Wall Street Journal, January 29, 2008

– What are “quality” quality measures?– Who is responsible/accountable for the care?– Who is the quality “attributable” to?

Physician, Nurse, Patient, Pharmacist, Health Plan, PBM?

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Questions??....Always welcomed!

For more information:

www.pqaalliance.org