ncqa

1. Donna Pillittere Dugan, MS, Director, Performance Measurement, NCQA Kimberly McDonough, PharmD, President, APC November 30, 2007

3. Process and Timeline April 2007 Project Kick-Off Technical Expert Panel (TEP) Assembled May-September Measure Specification Development Testing Plan Development Institutional Review Board (IRB) Approval August-November Measure Testing Report Preparation

4. NCQA/APC Team National Committee for Quality Assurance (NCQA): Assembled and facilitated technical expert panel (TEP) Developed detailed technical specifications Prepared final report Advanced Pharmacy Concepts (APC) Offered technical expertise in the development of measures and medication lists based on experience with pharmacy databases and pharmaceutical claims Conducted field test

5. Technical Expert Panel (TEP) Diverse expertise benefited performance measure development activities Clinical Data sources Measurement Provided input on the development of measure specifications and testing plan and on interpretation of pilot test results on behalf of PQA membership

6. Technical Expert Panel (TEP) Membership Co-chair: Julie Kuhle, PharmD, IFMC Co-chair: Brad Tice, PharmD, Chief Clinical Officer, PharmMD Emily Cox, PhD, Express Scripts Ajit Dhavle, PharmD, MBA, SureScripts Systems Debra Dullinger, PharmD, Medco Health Solutions Cathy Graeff, RPh, Vice President, NCPDP David Medvedeff, PharmD, MBA, Informed Decisions Jay Nadas, PharmD, Walgreens David Nau, Ph.D., R.Ph., CPHQ, University of Kentucky Matt Palmgren, PharmD, Humana Darren Triller, PharmD, IPRO Alan Zillich, PharmD, Purdue University

7. Measure Specification Development Developed detailed technical specifications Description Eligible Population (Denominator) Numerator Exclusions Calculation algorithms Comprehensive medication lists Measurement areas identified by PQA: Adherence/Persistence Efficiency Safety Diabetes Respiratory Cardiovascular

8. Measure Specification Development Limited to the use of pharmacy data only No centralized Rx dispensing file Limitations based on source Although quality goals are focused on individual pharmacy/pharmacist performance, claims data does not always contain necessary fields

9. The pros and cons of Rx claim data Advantages Standardized format for claims Broad range of fields Drug, patient, pharmacy, pricing, clinical Electronic controls verifying data integrity with claim submission Timely

10. The pros and cons of Rx claim data Disadvantages Sources impact scope of analysis PBM, Health Plan, pharmacy, other Diagnosis, eligibility must be inferred Data inconsistently populated, retained or may be modified by sources depending on business needs May not represent valid claim history for population: OTC, samples, medical claims, pets, etc

11. Considerations when using data Source of data affects scope of evaluation Pharmacy Comprehensive reflection of internal operations May not reflect comprehensive patient Rx activity Health plan Eligibility system can affect patient identification Benefit limitations impact drug processing Unique member ID, member plus dependent factors PBM Provides access across multiple benefit programs FDB vs Medispan Generic status, therapeutic class Data fields limitations

12. Deferred Measures Initial measure development revealed that some measures were not feasible or presented conceptual challenges that required refinement. Speed to Uptake of New Generic Opportunities Date of availability highly variable; not comparable across years as list of available generics changes regularly; ability to use a new generic depends on factors outside the pharmacist�s control. Medication Therapy Management, Comprehensive Medication Review no standardized definition of MTM

13. Deferred Measures (cont.) Drug-Drug Interactions (severity level 1 DUE alerts) DUE and DUR information in most claims databases is of questionable validity Potentially Contra-indicated Medicine in Heart Failure Patient: NSAID & Warafrin Measure not supported by solid clinical evidence at this time. Dosing of ACEI/ARB in Heart Failure Guidelines refer only to LVSD, not all heart failure. Not well supported given lack of clear diagnostic data or other factors.

14. Measure Testing Data Sources Pharmaceutical claims (retail and mail order) 3 heath plans and 1 national prescription drug plan Enrollment ranged from approximately 3,330 to nearly 1.7 million members across plans Commercial, Medicaid and Medicare populations included

15. Measure Testing Examples of Research Questions How do we verify continuous member eligibility in the absence of eligibility files? How many pharmacies per plan have enough eligible patients per measure? Distribution of rates across pharmacies per plan and across plans? Evidence of Variation Potential for improvement

16. Proportion of Days Covered-ACEI/ARB Measure Description Denominator: All patients who filled a prescription for a ACEI/ARB or ACEI/ARB combination any time during the measurement period. Numerator: The number of patients who met the PDC threshold (80%) during the measurement period.

17. Proportion of Days Covered-ACEI/ARB

18. Adjusted Generic Efficiency Measure Description Denominator: Any generic medication or brand name medication available as a generic dispensed to a patient in the measurement period. Numerator: Any generic medication dispensed to a patient Exclusions: Patients with prescriptions that are indicated to be dispensed as written.

19. Adjusted Generic Efficiency

20. Measure Readiness Pilot test results looked promising for: Proportion of Days Covered (80%) Gap in Therapy (30 days) Use of High-Risk Medications in the Elderly Diabetes Medication Dosing Diabetes Suboptimal Treatment Suboptimal Asthma Control Absence of Controller Therapy

21. Measure Readiness Pilot test results show the following may not yet be ready for prime time: Lack of variation and potential for improvement Generic Efficiency & Adjusted Generic Efficiency Drug-Drug Interactions Therapeutic Duplication

22. Measure Readiness Pilot test results show the following may not yet be ready for prime time Current lack of data to support medication based algorithm for Heart Failure Potentially Contraindicated CCBs in Patients w/HF Not an good indicator of poor quality prescribing, counseling or adherence Adverse Events due to Inhaled Corticosteroids Data interpretation difficult; lack of meaningfulness Use of High Risk Medications in the Elderly-Intensity of Exposure

23. NQF Endorsement Therapeutic Drug Management Initiative Expected timeline: Open call for measures- early December-Jan Submission: 14 measure recommended for submission Completion of measure submission/rationale forms by NCQA Documentation of Meaningfulness, Scientific Soundness and Feasibility.

24. Process for inclusion in HEDIS� Evaluation by NCQA panels Meaningfulness, scientific soundness and feasibility at the health plan level Quality gap, evidence base, opportunity for improvement, variation, field-test results 30-day public comment for approved measures NCQA Committee on Performance Measurement (CPM) vote Implementation into HEDIS First-year measure status Public reporting

25. Potential Uses for Measures Medicare comparison of PDP plan quality Health plan evaluation of pharmacy performance Pharmacy internal quality improvement programs Identification of patient education/intervention opportunities

26. Insights/Next Steps/Key Considerations Reporting of data testing: what worked, what didn�t and why How to increase scope of pharmacies for whom valid testing can be achieved Data aggregation across pharmacies and plan sponsors Improving methods to determine patient diagnosis

27. Questions