1 David Nau, Ph.D., R.Ph., CPHQ Improving the Quality of Medication Use Medication Use in Rural America NHRA 2010 Building a High-Value Healthcare System

2 Value – Based Competition “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.

Value-Driven Health Care The U.S. health care system is moving towards value-based purchasing Value is the balance of quality and costs, thus we can optimize value by improving quality while reducing costs One of the biggest challenges in driving better quality is that we can’t always agree on how to define and measure quality

Performance Reporting: A Growing Reality in Healthcare Who is currently measured? Physicians, physician groups, hospitals, nursing homes, home healthcare agencies. Common elements of performance improvement programs: Based on a set of metrics representative of quality performance in a given discipline Public reporting on performance to increase transparency Financial incentives (or disincentives) based on measured quality 4

Alphabet Soup of Quality 5 NCQA URAC NQF PQRI AHRQ PCPI NABP PQA QIO CMS TJC

NCQA HEDIS contains numerous measures that focus on medications. This is expected to increase. NCQA may move towards “measure sets” that focus on diseases or other groupings QualityCompass provides detailed comparative information on health plans (for a fee) Consumers can get broad comparisons for free 6

7 NCQA Health Plan Comparison Tool

URAC PBM/DTM currently include “quality” metrics such as adherence and high-risk medications Number of PBM/DTM measures will likely expand for every accreditation cycle Exploring new accreditation programs for pharmacies 8

9 CMS Hospital Compare Website

10 CMS Nursing Home Compare Website

11 Massachusetts Health Care Partners

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CMS – Star Ratings for Drug Plans Plans receive an overall rating on quality as well as four domain scores Drug Pricing & Patient Safety are combined within 1 domain (separate domains someday?) Patient Safety measures: –High-risk drugs in the elderly –Appropriate blood pressure treatment in persons with diabetes (ACEI/ARBs used in patients with diabetes) 13

CMS – Part D Display Measures Launched in November 2009 Includes 10 measures that are not in Star Ratings but that may be useful for Quality Improvement Patient Safety measures: –Drug-Drug Interactions –Excessive doses of oral diabetes medications –New measures may be announced in May 14

What about pharmacies? Until recently, pharmacies were not included in quality/performance reporting programs Scant efforts to assess pharmacies focused on: –Patient satisfaction using a variety of surveys –Costs –Errors ? 15

Do pharmacies matter? Numerous studies have shown the effect of pharmacists on quality of medication use If pharmacists in the community can affect quality, then why not assess whether they are improving quality and value PQA’s efforts have focused on ways to measure pharmacist/pharmacy quality and how to encourage quality improvement in pharmacies 16

The Pharmacy Quality Alliance  Established in April 2006, as a public-private partnership Drs. Mark McClellan & Carolyn Clancy - Inaugural PQA Steering Committee members  Consensus-based, membership alliance with over 50 members  Now, PQA is an independent, nonprofit organization  Mission: Improve the quality of medication use across health care settings through a collaborative process in which key stakeholders agree on a strategy for measuring and reporting performance information related to medications. 17

18 The PQA Board of Directors Bruce Roberts, NCPA (Chair) Judy Cahill, AMCP (Vice Chair) William Fleming, Humana Mark McClellan, MD, PhD, Brookings Institution Karen Ignagni, AHIP Woody Eisenberg, MD, Medco Thomas Menighan, APhA Jeffrey Kelman, MD, CMS Eleanor Perfetto, Pfizer Bruce Sherman, MD, Whirlpool Becky Snead, NASPA Steven Anderson, NACDS Lee Rucker, AARP David Marshall, Teva USA Laura Cranston, PQA, Inc.

19 Who’s at the PQA Table? Pharmacy Practitioner Groups Pharmacy Trade Groups Managed Care Organizations Health Plans AARP Consumer Advocacy Groups PBMs Employer Coalitions Pharm. Manufacturers Health IT Vendors MTM Vendors Chain Drug Companies Independent Pharm Owners Outcomes Researchers

Steps Towards Improved Quality 1.Identify potential measures of medication-use quality 2.Test the measure concepts using real-world data 3.Endorse and promote uptake of valid measures by plans and pharmacies 4.Identify and test ways to improve the quality of medication use 5.Identify and test ways to incentivize improvements in medication-use quality 20

The Pharmacy Quality Alliance PQA Formed Starter Set of Measures Tested Phase I Demo Projects Launched Phase I Demo Projects Completion Phase II Demo Projects Phase I Data Aggregation Pharmacy Reports Feedback for QI Phase II More demo partners Intervention strategies P4P modeling 21

PQA measures of pharmacy quality Safety –High-risk drugs in the elderly –Drug-drug interactions –Excessive doses of oral diabetes medications Adherence –CVD (beta blockers, ACEI/ARB, lipid-modifiers) –Diabetes oral drugs Appropriateness / Effectiveness –ACEI/ARBs in patients with diabetes and hypertension –Asthma controllers in patients with high use of relievers 22 Examples

Testing the PQA Measures 23

Uses of Performance Measures Quality/Performance Improvement Public Reporting / Consumer Empowerment Contract & Network Decisions Pay for Performance (P4P) 24

Quality Improvement Plans and pharmacies can self-assess quality to identify opportunities for improvement The quality measures can be used to track the impact of interventions or system changes

26 Arrow indicates direction of change from previous period. Color indicates if the change occurred in the recommended direction. Arrow indicates direction of change from previous period. Color indicates if the change occurred in the recommended direction. Measure value and # of patients

27 Additional information on peers Detailed analysis over time Measure Definition

Public Reports Information on hospital and physician quality is increasingly available to the public. CMS began provide public reports on drug plan quality in 2008 Drug plans, or regional coalitions, may start providing pharmacy reports in near future.

Public reports on pharmacy quality? 29

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 –Will this adversely affect pharmacies that serve lower-income populations?

P4P models for Pharmacy The Institute of Medicine has studied P4P models and recommends that financial incentives be based on a combination of “improvement” and “current performance.” No one has identified the perfect system for P4P, and various models will be tested in the near future. So… get used to change.

P4P models Improvement models are good for providers that are initially far below the threshold for “good” performance, but provide little incentive for top performers. Models based on current performance are good for top performers, but may not motivate low performers to do better.

Pharmacy P4P Example: Current Performance Medication Adherence Medication Safety Appropriateness: Asthma / Diabetes # of patients # Quality measures 734 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 Medication Adherence Medication Safety Appropriateness: Asthma / Diabetes # of patients Score in %90%93% Score in %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

PQA Demonstrations: Phase I June 2008 – Nov Determine resources requirements for collecting/aggregating prescription claims data and calculating the quality measure scores Collection of patient experiences with pharmacy services using the PQA consumer survey Generate/test models of providing pharmacy performance reports Get feedback from pharmacists on the reports’ accuracy, user-friendliness and value in improving quality 35

Demo TypeProject Leader Partners Health PlanHighmark BCBS CE City Rite Aid Corporation Community Pharmacy Corporation Outcomes Pharmaceutical Health Care Kerr Drug University of NC Coalition of Health Plans Pharmacy Society of Wisconsin and Wisconsin Pharmacy Quality Collaborative State of Wisconsin Dept of Health and Family Services United Healthcare of Wisconsin Unity Health Insurance and Group Health Cooperative of South Central Wisconsin Coalition of Health Plans Purdue University School of Pharmacy Indiana Pharmacists Alliance Indiana Health Information Exchange Regenstrief Institute Coalition of Health PlansUniversity of Iowa Iowa Foundation for Medical Care, Wellmark Blue Cross and Blue Shield Iowa Medicaid Enterprise PQA Demonstration Projects 36

Lessons learned from Phase I It is feasible to create user-friendly electronic performance reports from drug claims data Pharmacy staff can access the reports and efficiently locate information Pharmacists found the reports to be interesting and believable, but were not yet sure how to use the information to improve quality 37

Test the effectiveness of 1 or more pharmacist interventions to improve medication use by measuring PQA’s Quality Measures and Pharmacy Consumer Experience Survey Create/refine standardized pharmacy performance quality reports to determine the cost-effectiveness of interventions for pharmacy managers and payors 38 Phase II: Primary Research Objectives

Phase II: Secondary Objectives Develop specifications for P4P actuarial model Determine causes of low PQA quality scores Evaluate the impact of quality scores on health outcomes Measure any negative effects of providing intervention Evaluate the scalability of the use of quality measures in large settings (e.g., multi-site)

Phase II 40 Demo Projects to get started in Summer 2010 Designed to be 24-month studies with integrated medical and pharmacy claims data Top 4 collaborative teams: Team #1: Rite Aid Corporation, Highmark-CECity (as their HIT partner), University of Pittsburgh Team #2: SuperValu Corporation, Humana, Univ of Illinois – Chicago Team #3: PharmMD, HealthSpring, University of Tennessee Team #4: Wisconsin Pharmacy Quality Collaborative (in conjunction with Pharm. Society of Wisconsin and Univ. of Wisconsin (a collaborative of 50 plus community independent pharmacies and four health plans)

More public reports on plan/pharmacy quality Accreditation program for community pharmacy? Payment linked to quality measures (P4P)? Public reports on quality may lead to pharmacies trying to differentiate themselves on quality within crowded markets – does it matter in rural areas? Future of Performance Measurement 41

David Nau Senior Director Research & Performance Measurement Pharmacy Quality Alliance 42