1 The Pharmacy Quality Alliance: Promoting High-Value Health Care via Transparency in Pharmacy Performance Dave Domann, MS, R.Ph Johnson & Johnson

2 : 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

3 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.

4 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.

5 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 6

7 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

8 Pharmacy Quality Alliance’s Four Primary Groups Director Quality Metrics Research Coordinating Council Data Aggregation and Reporting Education & Communications Director of Practice Improvement

9 PQA Activities 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

10 PQA Activities 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 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

12 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.

13 Single Gap Index FillRefill Due Actual Refill Date Single Gap = 37 days 90 day supply Jan 15Apr 15May 22

14 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 TitleMeasure Description/Definition

15 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 – Phase II Selection of Generation II measures Educational programs for pharmacists, students, and other stakeholders Participation in Quality Alliance Steering Committee (QASC) 16

17 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

18 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) 19

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 20

Cluster Groups 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? 23

Potential Uses of PQA measures Quality/Performance Improvement Tested in Phase II demonstrations Public Reporting / Consumer Empowerment Contract & Network Decisions Pay for Performance (P4P) 24

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. 25

26 Public reports could be embedded in drug plan websites…

27 PharmacyQuality.com Pharmacy Performance: What’s Your Grade?

28 Compare Pharmacies

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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). 37

38 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 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

41 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?

42 Questions??....Always welcomed! For more information: