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Medication Adherence: The Quality Bullet
Suboptimal Medication Use and Adherence: The Intersection of Research, Implementation and Policy December 5, 2016
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What is the Pharmacy Quality Alliance?
PQA Timeline What is the Pharmacy Quality Alliance? Pharmacy Quality Alliance’s Mission Statement: Improve the quality of medication management and use across health care settings with the goal of improving patients’ health through a collaborative process to develop and implement performance measures and recognize examples of exceptional pharmacy quality. Measure Development & Maintenance Implementation of PQA Measures Infrastructure & Engagement Communication & Education -Created in 2006 as a public-private partnership -Multi-Stakeholder Member-Based Non-Profit -Transparent & Consensus Based Process -Nation-wide Measure Developer Research and Demonstration Projects
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2016 Medicare Part D Star Ratings
Measure ID Measure Name Part D Summary MA-PD Overall D01 Call Center—Foreign Language Interpreter and TTY 1.5 D02 Appeals Auto– Forward D03 Appeals Upheld D04 Complaints about the Drug Plan D05 Members Choosing to Leave the Plan D06 Beneficiary Access and Performance Problems 1 D07 Drug Plan Quality Improvement 5 D08 Rating of Drug Plan D09 Getting Needed Prescription Drugs D10 MPF Price Accuracy D11 High Risk Medication 3 D12 Medication Adherence for Diabetes Medications D13 Medication Adherence for Hypertension (RAS antagonists) D14 Medication Adherence for Cholesterol (Statins) D15 Comprehensive Medication Review Completion Adapted from CMS - “Medicare 2016 Part C & D Star Rating Technical Notes”. Accessed July 2016.
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2016 Medicare Part D Star Ratings
Measure ID Measure Name Part D Summary MA-PD Overall D01 Call Center—Foreign Language Interpreter and TTY 1.5 D02 Appeals Auto– Forward D03 Appeals Upheld D04 Complaints about the Drug Plan D05 Members Choosing to Leave the Plan D06 Beneficiary Access and Performance Problems 1 D07 Drug Plan Quality Improvement 5 D08 Rating of Drug Plan D09 Getting Needed Prescription Drugs D10 MPF Price Accuracy D11 High Risk Medication 3 D12 Medication Adherence for Diabetes Medications D13 Medication Adherence for Hypertension (RAS antagonists) D14 Medication Adherence for Cholesterol (Statins) D15 Comprehensive Medication Review Completion Due to heavy weighting by CMS on PQA measures, PQA measures make up almost half of a plan’s Star rating Currently, process measures receive a weight of 1.0, as do new measures. Patient experience measures receive a weight of 1.5; outcomes and intermediate outcomes, a weight of 3. Quality improvement measures were raised from a weighting of 3 to 5 beginning in 2015 Adapted from CMS - “Medicare 2016 Part C & D Star Rating Technical Notes”. Accessed July 2016.
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If you build it…do they care?
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Adapted from “CMS 2016 Star Ratings Fact Sheet”
Adapted from “CMS 2016 Star Ratings Fact Sheet”. Atlantic Information Services, Inc. Accessed Jul 2016 at:
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MA-PD Star Ratings Distribution
Key Points Number of contracts decreased by 26 Average star rating increased Adapted from “CMS 2016 Star Ratings Fact Sheet”. Atlantic Information Services, Inc. Accessed Jul 2016 at:
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Are you down with PDP?
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Adapted from “CMS 2016 Star Ratings Fact Sheet”
Adapted from “CMS 2016 Star Ratings Fact Sheet”. Atlantic Information Services, Inc. Accessed Jul 2016 at:
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PDP Star Ratings Distribution
Key Points Number of contracts decreased by 2 Average star rating decreased Adapted from “CMS 2016 Star Ratings Fact Sheet”. Atlantic Information Services, Inc. Accessed Jul 2016 at:
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Calculation Example Benchmark is $750 Bid is $700
Plan has 10,000 members and scores a 4-Star rating (provides plans with 5% bonus and 65% rebate of the difference) Plan receives over $6.5M in rebate/bonus payment
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The New Healthcare System
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Patient-reported Outcomes in Quality Measurement
PRO PROM PRO-PM patient-reported outcomes instrument, tool, single-item measure PRO-based performance measure Information on the patient, told by the patient, without interpretation Means to collect information told by the patient without interpretation Means to aggregate information shared by the patient and collected into a reliable, valid measure of performance EXAMPLE: Patient with Clinical Depression Symptom: depression Patient Health Questionnaire (PHQ-9©), a standardized tool to assess depression Percentage of patients with diagnosis of major depression or dysthymia and initial PHQ-9 score >9 with a follow-up PHQ-9 score <5 at 6 months (NQF #0711) In recent years, there is a new emphasis on patient centeredness and empowerment. Patients’ experiences, including symptoms of a disease and its impact on their lives, provide valuable information. Outcomes reported directly by the patient, are referred to as patient-reported outcomes, or PROs. PRO data are captured through the use of tested, validated instruments called patient-reported outcome measures, or PROMs. In Module 1, we discussed the example of a PRO and a PROM; the symptom of depression, being the PRO, and tool for detection, or PROM, being the PHQ-9 questionnaire. The data collected by a PRO measure at an individual patient level needs to be aggregated for the purposes of performance improvement and accountability. For the example of depression, the PRO-based Performance Measure, or PRO-PM, is the percentage of patients at a site with diagnosis of major depression and an initial PHQ-9 score greater than 9 who have a follow-up PHQ-9 score of less than 5 at 6 months. Clinical trials often use patient-reported outcome measures as a means for assessing the patient’s perspective on how a treatment impacts their well being. As discussed earlier, this integration is being supported by new and existing policies, such as the proposed 21st Century Cures Act, and through guidance by the Food and Drug Administration to ensure adequate and meaningful measurement of PROs. Adapted from: National Quality Forum. (2013). Creating Valid and Reliable Patient-Reported Outcome Measures. Accessed March 2015 at:
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Medication Adherence: The Quality Bullet
Suboptimal Medication Use and Adherence: The Intersection of Research, Implementation and Policy December 5, 2016
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