The Pharmacy Quality Alliance: Promoting High-Value Health Care via Transparency in Pharmacy Performance

1. The Pharmacy Quality Alliance:Promoting High-Value Health Carevia 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?

6. 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

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

9. PQA Activities - 2006 • 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 - 2007 • 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)

11. 1. 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   PQA’s Starter Set of Measures - 2007

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)

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

14. PQA Appropriateness Measure: Suboptimal Treatment of HT in Diabetes

15. CAHPS Pharmacy Survey • Consumer • Assessment of • Healthcare • Providers and • Systems • Developed by American Institutes for Research – University of North Carolina 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.

16. What’s Next for PQA ? • Demonstration Projects • Phase I 2008-09 • Phase II 2009-11 • Selection of Generation II measures • Educational programs for pharmacists, students, and other stakeholders • Participation in Quality Alliance Steering Committee (QASC)

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

19. 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)

20. 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

21. 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 Cluster Groups - 2008

22. 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

23. How will PQA measures be used?

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

25. 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.

26. Public reports could be embedded in drug plan websites…

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

28. Compare Pharmacies

31. Find My Pharmacy

37. 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).

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.

39. Pharmacy P4P Example: Current Performance This example is presented for illustration only! PQA has not endorsed any model for pharmacy P4P

40. Pharmacy P4P Example:Improvement Model 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: www.pqaalliance.org