The%20Pharmacy%20Quality%20Alliance:%20Promoting%20High-Value%20Health%20Care%20via%20Transparency%20in%20Pharmacy%20Performance

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The Pharmacy Quality AlliancePromoting
High-Value Health Carevia Transparency in
Pharmacy Performance
Dave Domann, MS, R.Ph Johnson Johnson
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OBJECTIVES

• Describe PQAs 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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Whos at the PQA Table?
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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 gt 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
• Americas 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 Alliances Four Primary Groups
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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)

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PQAs Starter Set of Measures - 2007

• 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
Measure Title Measure Description/Definition
Gap in Therapy Percentage of prevalent users who experienced a significant gap in medication therapy.

• A significant gap is defined as 30 days or
  greater
• Individual measures focus on a specific drug
  class (e.g., beta blockers)

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Single Gap
Actual Refill Date
Index Fill
Refill Due
Jan 15
Apr 15
May 22
Single Gap 37 days
90 day supply
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PQA Appropriateness Measure Suboptimal Treatment
of HT in Diabetes
Measure Title Measure Description/Definition
Suboptimal treatment Diabetes Percentage of patients dispensed medications for diabetes and hypertension who are not receiving an ACEI or ARB.

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CAHPS Pharmacy Survey

• Consumer
• Assessment of
• Healthcare
• Providers and
• Systems
• Developed by American Institutes for Research
  University of North Carolina

• CAHPS results are used to
• Assess the patient-centeredness and quality of
  care from the patients perspective,
• Facilitate consumer choice and
• Improve quality of care.

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Whats 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

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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 improvement

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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

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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

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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
• Whats 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.

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Pharmacy P4P Example Current Performance
Medication Adherence Medication Safety 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
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Pharmacy P4P ExampleImprovement Model
Medication Adherence Medication Safety 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