Medication Management Measures: NQF and Beyond

1. Medication Management Measures: NQF and Beyond Harold Alan Pincus, MD Professor and Vice Chair, Department of Psychiatry Associate Director, Irving Institute for Clinical and Translational Research Columbia University Director of Quality and Outcomes Research NewYork-Presbyterian Hospital Senior Scientist, RAND Corporation AHRQ's Annual Research Conference Panel Session September 16, 2009

2. Medication Management Measures: NQF and Beyond • Background/Context • NQF Process • Steering Committee Consensus • conclusions • concerns • Issues/Questions in Measuring Medication Management Quality AHRQ's Annual Research Conference Panel Session September 16, 2009

3. PracticePolicy Research Linking Policy, Practice and Research AHRQ's Annual Research Conference Panel Session September 16, 2009

4. Policy Context • Rising costs •  proportion of GDP • Disparities in care • regional, populations • Growth in HIT • stimulus, “meaningful use”, RHIO’s • Translational science • T1, T2, T3, T4/CER • Alphabet soup of managers/regulators • NCQA, NQF, Joint Commission, PBM, PQRI, NICE • Quality and safety problems • Crossing the Quality Chasm/IOM • Health care reform? AHRQ's Annual Research Conference Panel Session September 16, 2009

5. To Err Is Human: Building A Safer Health System First Report Committee on Quality of Health Care in America To order: http://www.nap.edu AHRQ's Annual Research Conference Panel Session September 16, 2009

6. Crossing the Quality Chasm “Quality problems occur typically not because of failure of goodwill, knowledge, effort or resources devoted to health care, but because of fundamental shortcomings in the ways care is organized” The American health care delivery system is in need of fundamental change. The current care systems cannot do the job. Trying harder will not work: Changing systems of care will! AHRQ's Annual Research Conference Panel Session September 16, 2009

7. Image: Institute of Medicine Quality Chasm Series AHRQ's Annual Research Conference Panel Session September 16, 2009

8. Image: “Crossing the Quality Chasm” “Crossing the Quality Chasm” AHRQ's Annual Research Conference Panel Session September 16, 2009

9. Preparing for the Future Consumer Participation Standardize Practice Elements • Clinical assessment • Interventions • IT infrastructure Develop Guidelines • Evidence-based medicine • Shared decision making Measure Performance • For each “6P” level • Across silos Improve Performance • Learn • Reward Strengthen Evidence Base • Evaluate effective strategies • Translate from bench to bedside to community Leadership Support Clinical Perspectives Integrative Processes AHRQ's Annual Research Conference Panel Session September 16, 2009

10. Measure Performance • “You can’t improve what you don’t measure” • Develop quality metrics - structure - process - outcomes • Across silos of data sources • MCO/MBHO/PBM • claims/EHR, etc. • At each “P” level AHRQ's Annual Research Conference Panel Session September 16, 2009

11. Organizational Chart: “6P” Conceptual Framework Patient/ Consumer • Enhance self-management/participation • Link with community resources • Evaluate preferences and change behaviors • Improve knowledge/skills • Provide decision support • Link to specialty expertise and change behaviors Providers • Establish chronic care model and reorganize practice • Link with improved information systems • Adapt to varying organizational contexts Practice/ Delivery Systems • Enhance monitoring capacity for quality/outliers • Develop provider/system incentives • Link with improved information systems Plans Purchasers (Public/Private) • Educate regarding importance/impact of depression • Develop plan incentives/monitoring capacity • Use quality/value measures in purchasing decisions Populations and Policies • Engage community stakeholders; adapt models to local needs • Develop community capacities • Increase demand for quality care enhance policy advocacy “6 P” Conceptual Framework AHRQ's Annual Research Conference Panel Session September 16, 2009

12. Strategies for Influencing Quality of Medication Care • Guidelines/”Black Boxes” • Provider Training/Education/CME • Academic Detailing • Pharmacist-based Interventions • Preferred lists/Prior auth/Second opinion • Certification/Accreditation/Licensure • Provider Reminder System/Decision Support • Patient Education/Reminders • Quality Measurement/Improvement • Public Reporting/Profiling/Feedback • Financial Incentives/P4P AHRQ's Annual Research Conference Panel Session September 16, 2009

13. Medication Management • 81% of adults take at least 1 med • 90% of Medicare beneficiaries report taking prescription meds (nearly half use 5 or more) • Between 14 and 23% of elderly receive inappropriate meds • Up to 40% of patients do not take meds as prescribed • Adverse drug events 2.5% of ER visits for unintentional injuries AHRQ's Annual Research Conference Panel Session September 16, 2009

14. NQF Process • Open call for measures • Augmented by lit review/National Quality Measures Clearinghouse • Conditions for consideration • public domain or IP agreement • responsible entity to maintain • public reporting and QI • complete info (provisional if not tested) • Criteria for evaluation- PH/Improvement • importance- PH and improvement • scientific acceptability-reliable/valid • useability- decision making/6P’s • feasibility- data available/burden • Steering Committee- open consensus/interactive • Member and public comment AHRQ's Annual Research Conference Panel Session September 16, 2009

15. Steering Committee Consensus • Other NQF projects include medication management measures • 35 submitted measures were considered • Measure categories: • prescribing/selection • dispensing/adherence • monitoring • outcomes • 19 measures recommended (7 time limited) • 3 measures combined with other submitted measures • Considerable interaction with measure developers to improve/modify measures • Range of clinical topics spanned CAD, asthma, schizophrenia, COPD, INR monitoring, generic adherence/monitoring AHRQ's Annual Research Conference Panel Session September 16, 2009

16. Recommended Measures AHRQ's Annual Research Conference Panel Session September 16, 2009

17. Recommended Measures (cont’d) AHRQ's Annual Research Conference Panel Session September 16, 2009

18. Steering Committee Concerns Submitted (and recommended) measures do not represent full array needed to assess/improve quality Measures not linked or harmonized across multiple developers Single prescription for chronic diseases Multiple, conflicting, confusing ways to measure similar concepts (i.e. adherence) Limited testing of measures Need for continual updating Significant R and D needed for measures addressed/linked to outcomes, are patient-centered and cover a broader array of conditions, settings, populations AHRQ's Annual Research Conference Panel Session September 16, 2009

19. Proposed Standard Specifications for Adherence Measurement AHRQ's Annual Research Conference Panel Session September 16, 2009

20. Research Recommendations • Adherence Measures • appropriate use/reasons for non-adherence • Plan of care measures • expand patient/caregiver communication • Medication review/reconciliation • content/accountability • COPD management • lower risk patients • Outpatient psychiatry • adherence/monitoring/polypharmacy • Migraine • Use of technology • bar coding/decision support/dose calc. • Medication validation • steps from order to patient/monitoring over time AHRQ's Annual Research Conference Panel Session September 16, 2009

21. Issues in Measuring Medication Management Quality • Measurement v. Improvement • Information lag/real time v. delayed • Use of measures- POC v. external • Accountability- pt/prescriber/pharmacist/plan • Patient-centered measures- $/values/preferences • Clinical exceptions v. “cookie cutter” medicine • Adequacy of data bases • include Dx/Indication on Rx • Does measurement lead to improvement? • MH HEDIS • Does improvement lead to enhanced health status? • Diabetes and ACCORD AHRQ's Annual Research Conference Panel Session September 16, 2009

22. The State of Health Care Quality 2006, NCQA There are, however, disturbing exceptions to this pattern of [overall health care quality] improvement. The quality of care for Americans with mental health problems remains as poor today as it was several years ago. Patients on antidepressant medication are about as likely to receive appropriate care today as they were in 1999. http://www.ncqa.org AHRQ's Annual Research Conference Panel Session September 16, 2009

23. 100% 80% Commercial 60% Medicaid Medicare 40% 20% 0% ‘98 ‘99 ‘00 ‘01 ‘02 ‘03 ‘04 ‘05 Antidepressant Medication Management:Optimal Practitioner ContactsTrends, 1998-2005 AHRQ's Annual Research Conference Panel Session September 16, 2009

24. 100% 80% Commercial 60% Medicaid Medicare 40% 20% 0% ‘98 ‘99 ‘00 ‘01 ‘02 ‘03 ‘04 ‘05 Antidepressant Medication Management: Effective Continuation Phase TreatmentTrends, 1998-2005 AHRQ's Annual Research Conference Panel Session September 16, 2009

25. Image: “Crossing the Quality Chasm” “Crossing the Quality Chasm” AHRQ's Annual Research Conference Panel Session September 16, 2009

26. Image: San Francisco Bay Bridge AHRQ's Annual Research Conference Panel Session September 16, 2009 26