Opinion

Fifteen Years of Improving Medication Use Quality to Support Value-Based Care

The Pharmacy Quality Alliance was introduced 15 years ago on April 24, 2006, with a vision declaring the direct influence of medication optimization on value-based care.

Mark McClellan, then the administrator of Centers for Medicare & Medicaid Services, said “the launch of PQA is an important step toward a pharmacy business model that reports real value delivered rather than just the volume of prescriptions dispensed.” It aligned the future of medication use and services with our health care system’s transition to pay-for-performance models in which quality, value, and patient outcomes are measured and incentivized.

Today’s rapid evolution of pharmacy practice and pharmacy system data is allowing that vision to be realized, and a January 2021 CMS final rule is spurring momentum. Pharmacy performance measures in development will demonstrate the value pharmacist-provided care delivers to payers, patients and our health care system.

As PQA began work to develop performance measures in 2006, there was broad consensus among our members to focus on aspects of medication use quality that can be measured efficiently and with a low burden on pharmacies and health plans. As a result, PQA’s foundational measures rely on prescription claims data. The broad availability and consistency of these data fueled the development of health plan measures that are important, feasible, scientifically sound and useable in the marketplace.

Today, PQA stewards 41 measures and quality improvement indicators.  Fifteen PQA measures are used across CMS’ quality programs and more are used in state and regional quality programs. Five PQA measures are included in the Medicare Part D Star Ratings program, and PQA measures are a large portion of a health plan’s Part D Summary Star Rating.

Over the last 15 years, Medicare Part D has been a resounding success for patients and our health care system by increasing access to needed medicines and reducing out-of-pocket costs for millions of beneficiaries. PQA measures have played an important role in Part D’s success. A CMS report showed the economic benefits of PQA’s three adherence measures in Medicare Part D, with an estimated $4.2-$26.9 billion health care costs avoided over a five-year period.

Complementing the success of health plan measures, pharmacy-specific measures are expanding our ability to measure the quality of medication use. Thanks to the expansion and growing standardization of pharmacist-provided care, opportunities have emerged to develop performance measures based on pharmacy data that goes beyond dispensing and claims data. It is a natural progression in the shift to value-based care.

PQA is developing a set of standard pharmacy performance measures that would be appropriate for use in value-based plan-pharmacy agreements. This work accelerated in 2019 at the request of community and specialty pharmacies and in response to growing interest in Congress and the Administration.

In Congress, the Prescription Drug Pricing Reduction Act, which is expected to be reintroduced this year, proposed the creation of “standard pharmacy quality measures.” CMS, through the “Contract Year 2022 Medicare Advantage and Part D Final Rule (CMS-4190-F2),” has established pharmacy performance measures reporting requirements. In proposing that rule, CMS acknowledged PQA’s work, noted our progress, and encouraged the industry to continue to work together on developing a set of pharmacy performance measures through a consensus process and Part D sponsors to adopt such measures to ensure standardization, transparency and fairness.

Guided by our Pharmacy Measure Development Action Plan, PQA has launched three Technical Expert Panels that are working now to develop pharmacy measures for hemoglobin A1c reporting and blood pressure reporting; adherence to medications for cardiovascular disease, high cholesterol and diabetes; and antidepressant medication management. These are important measures that address chronic, high-cost and high-burden diseases.

PQA aims to complete development and have these measures available for use in early 2022 and 2023. More pharmacy measure development panels will be launched in the future. PQA also is working with the Community Pharmacy Foundation to identify and prioritize additional pharmacy measure concepts that are responsive to the needs of all participants in value-based arrangements – including private sector agreements beyond Medicare and other public programs.

Parallel to this pharmacy measure effort, PQA continues to develop and steward health plan measures. In all our work, PQA is committed to including the perspectives of patients, including those affected by disparities, to ensure our measures are informed by individuals with lived experience.

Our continued success – and that of pharmacy quality itself – depends on the value that payers see in pharmacy services and the greater integration of pharmacy in team-based care. Equally, the collection, standardization and availability of data will determine our ability to build and to implement meaningful performance measures.

By developing performance measures that demonstrate the value pharmacy delivers to payers, patients and our health care system, we are realizing the vision McClellan articulated 15 years ago. As a multi-stakeholder organization, we are well positioned to bring the industry together to create successful, consensus-based measures – and we see a bright future for medication use quality.

 

Micah Cost, PharmD, MS, is the CEO of the Pharmacy Quality Alliance. Richard Schmitz, MA, is senior director of communications for PQA.

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