Micah Cost, PharmD, MS, Chief Executive Officer, Pharmacy Quality Alliance

The Pharmacy Quality Alliance (PQA) has a new pharmacy performance measure that evaluates adherence to medications for diabetes, renin angiotensin system antagonists for hypertension, and statins for high cholesterol through a single composite measure.

 Although many might think the PQA already had member-endorsed adherence measures for these medications, the situation is a bit nuanced.

There are 3 similar PQA adherence measures used in the Medicare Part D Star Ratings that were developed, tested, and specified for health plan performance measurement.

 There are notable differences between those health plan measures and the PQA’s new pharmacy measure. Endorsed by PQA members after rigorous development and testing, the new composite pharmacy adherence measure is a major step forward in the PQA’s work to develop standard pharmacy performance measures focused on improving patient care.

Addressing Pharmacy and Stakeholder Interests

This measure addresses 3 key interests expressed by pharmacy stakeholders, including some communicated by the National Association of Chain Drug Stores and the National Community Pharmacists Association to the Centers for Medicare & Medicaid Services.

 First, it measures the performance of individual pharmacies and provides a basis for evaluating and rewarding them for the patients under their care.

Second, the measure’s composite approach is important when evaluating pharmacies, many of which have small numbers of patients on certain medications. As endorsed and specified, each pharmacy must have at least 30 eligible patients to be reliably evaluated by this measure. This minimum number for reliability is easier to reach with the composite measure.

Third, this measure is aligned with the PQA health plan adherence measures used in the Medicare Part D Star Ratings program. Therefore, it should be considered as a solution to align incentives between health plans and pharmacies that are working together to improve adherence.

Multiple pharmacy stakeholders have told the PQA that the quality measures often used in their Part D agreements are health plan measures and do not accurately evaluate their contributions to adherence. This measure addresses that issue and provides an appropriate measure for individual pharmacy performance.

The PQA composite pharmacy performance measure was prioritized by its members and developed with input from a technical expert panel that included 6 health plan and 6 pharmacy representatives. It was then successfully tested for use in value-based plan-pharmacy agreements. The collaborative, consensus-based, transparent process has consistently produced high-quality measures that balance the needs of relevant industry stakeholders.

Medication adherence continues to be an important part of evaluating and supporting high-value care. With the endorsement of this new pharmacy adherence measure, now is the time for pharmacies to advocate for its inclusion in agreements with health plans for 2023, which from an implementation standpoint is just around the corner.

The PQA also endorsed a specialty pharmacy turnaround time measure that evaluates the average number of days between a specialty pharmacy receiving a new prescription for a specialty medication and the prescription being ready for pickup or scheduled for delivery.

The PQA is working to develop and pilot pharmacy measure concepts for control, improvement, and reporting of blood pressure and hemoglobin A

 The PQA also will begin work this year to develop a specialty pharmacy prescription abandonment rate measure.

Each of these pharmacy measures in development is aligned with pharmacy services that improve patient health outcomes. Collectively, they will form a set of standardized pharmacy performance measures that can be used across the care system.

Ultimately, the success of pharmacy measures depends on whether they are effectively used in the market. The composite adherence measure provides a timely opportunity for health plans and pharmacies to pursue shared goals in value-based care, while laying the groundwork for the implementation of future outcomes-focused measures that require time, relevant data sources, and testing to develop. From adherence to outcomes, the PQA will continue to provide tools that evaluate care, help close gaps, and improve patient health.

, is CEO of the Pharmacy Quality Alliance in Alexandria, Virginia.

1. PQA endorses pharmacy performance measures for medication adherence and specialty turnaround time. News release. Pharmacy Quality Alliance. December 20, 2021. Accessed February 2, 2022. https://www.pqaalliance.org/pqa-endorses-pharmacy-performance-measures-for-medication-adherence-and-specialty-turnaround-time

2. PQA measure use in CMS’ Part D quality programs. Pharmacy Quality Alliance. Accessed February 2, 2022. https://www. pqaalliance.org/medicare-part-d

3. NCPA and NACDS discuss drug pricing with HHS officials. Indiana Pharmacists Association. August 3, 2018. Accessed February 2, 2022. https://www.indianapharmacists.org/news/ community-pharmacy-recommendations-for-measuring-quality-in-the-medicare-part-d-program/

4. PQA pharmacy performance measures in development. Pharmacy Quality Alliance. Accessed February 2, 2022. https://www. pqaalliance.org/pharmacy-measures#:~:text=Pharmacy%20performance%20measures%20evaluate%20quality,quality%2C%20 patient%2Dcentered%20care

Articles

Pharmacy Quality Alliance's new benchmark evaluates adherence to medications for diabetes, high cholesterol, and hypertension.

Implement Pharmacy Performance Measures for Value-Based Care

The Pharmacy Quality Alliance (PQA) has a 

 that evaluates adherence to medications for diabetes, hypertension (renin angiotensin system antagonists) and high cholesterol (statins), through a single composite measure.

You may be thinking, “I thought PQA already had member-endorsed adherence measures for these medications.” The answer is a bit nuanced.

There are 3 similar PQA adherence measures used in the 

 that were specifically developed, tested and specified for health plan performance measurement.

 There are notable differences between those health plan measures and our new pharmacy measure.

Endorsed by PQA members in December after a rigorous development and testing process, the new composite pharmacy adherence measure is a major step forward in our work to develop standard pharmacy performance measures focused on improving patient care.

 expressed by pharmacy stakeholders, including some communicated by the National Community Pharmacists Association and the National Association of Chain Drug Stores to the Centers for Medicare & Medicaid Services (CMS).

First, it measures the performance of individual pharmacies and provides a basis for evaluating and rewarding pharmacies for the patients under their care.

Second, the measure’s composite approach is important when you’re evaluating pharmacies, many of which have small numbers of patients on certain medications (i.e., small denominators). As specified and endorsed, each pharmacy must have at least 30 eligible patients to be reliably evaluated by this measure. This minimum number for reliability is easier to reach with the composite measure.

Third, this measure is aligned with the PQA health plan adherence measures used in the Medicare Part D Star Ratings program. Therefore, it should be considered as a solution to align incentives between health plans and pharmacies who are working together to improve adherence.

Multiple pharmacy stakeholders have told PQA that the quality measures often used in their Part D agreements are health plan measures and do not accurately evaluate their contributions to adherence. This measure directly addresses that issue and provides an appropriate measure for individual pharmacy performance.

The PQA composite pharmacy performance measure was prioritized by our members and developed with input from a Technical Expert Panel that included 6 pharmacy and 6 health plan representatives. It was then successfully tested for pharmacy attribution for use in value-based plan-pharmacy agreements. Our collaborative, transparent and consensus-based process has consistently produced high-quality measures that balance the needs of relevant industry stakeholders.

PQA also endorsed in December a specialty pharmacy turnaround time measure that evaluates the average number of days between a specialty pharmacy receiving a new prescription for a specialty medication and the prescription being ready for pick-up or scheduled for delivery.

Work to Develop New Pharmacy Measures Continues

 for reporting, improvement and control of hemoglobin A1c and blood pressure.

 We also will begin work this year to develop a specialty pharmacy prescription abandonment rate measure.

Each of these pharmacy measures in development is aligned with pharmacy services that improve patient health outcomes. Collectively, they will form a set of standardized pharmacy performance measures that can be used across our care system.

Ultimately, the success of pharmacy measures depends on whether they are effectively used in the market. The composite adherence measure provides a tremendous and timely opportunity for pharmacies and health plans to pursue shared goals in value-based care, while laying the groundwork for the implementation of future outcomes-focused measures, which require time, relevant data sources and testing to develop.

From adherence to outcomes, PQA will continue to provide tools that evaluate care, help close gaps and improve patient health.

Pharmacy Quality Alliance. PQA Endorses Pharmacy Performance Measures for Medication Adherence and Specialty Turnaround Time. PQA website. 

pqaalliance.org/pqa-endorses-pharmacy-performance-measures-for-medication-adherence-and-specialty-turnaround-time

. December 20, 2021. Accessed February 2, 2022.

Pharmacy Quality Alliance. PQA Measure Use in CMS’ Part D Quality Programs. PQA website. 

National Community Pharmacists Association and National Association of Chain Drug Stores.NCPA and NACDS Discuss Drug Pricing with HHS Officials. Indiana Pharmacists Association website. 

indianapharmacists.org/news/community-pharmacy-recommendations-for-measuring-quality-in-the-medicare-part-d-program/

. August 3, 2018. Accessed February 2, 2022.

Pharmacy Quality Alliance. PQA Pharmacy Performance Measures in Development. PQA website. 

Micah Cost, PharmD, MS, is chief executive officer of the Pharmacy Quality Alliance, the national quality organization dedicated to improving medication safety, adherence and appropriate use. A non-profit, consensus-based organization, PQA has 250 diverse member organizations from across health care.

New composite pharmacy adherence measure is a major step in developing standard pharmacy performance measures focused on improving patient care.

Implementing Pharmacy Performance Measures for Value-Based Care

The Pharmacy Quality Alliance (PQA) continues to forge ahead with our work to develop a 

set of standard pharmacy performance measures

 that would be appropriate for use in value-based plan-pharmacy agreements. Over the past 3 years, we have convened and worked with a broad base of industry leaders to identify and vet pharmacy performance measures that meet the needs of pharmacies, payers, and patients—while balancing feasibility and probability for success.

You may wonder where this project originated and how pharmacy performance measures could be used to support person-centered care. Going back to the early days of PQA in 2006, the 

 was to usher in a quality-focused framework to support a new pharmacy payment system focused on enhancing value within the health care system. Developing pharmacy performance measures directly aligns with that vision. It wasn’t until recently that pharmacy practice and our health care system was ready to realize this vision.

Today’s effort is responsive to requests from our members, as well as 

proposed rules from the Centers for Medicare and Medicaid Services (CMS)

 and proposed federal legislation, all of which have signaled growing interest in pharmacy performance measures. Further, PQA believes that pharmacy performance measures can support greater patient access to care and services through team-based care and to facilitate value-based contracts between pharmacists and payers.

Although patients view pharmacists among their most trusted health care allies, the pharmacy profession continues to seek a more meaningful model of care that displays their value as providers to payers, health plans, and fellow providers. The gradual progression of our health care system away from the traditional fee-for-service model and toward a more performance-driven and value-based care framework, both in public payer programs such as Medicare and Medicaid, as well as patient-centered medical homes and accountable care organizations, presents the pharmacy profession with a great opportunity to do just that.

This shift to pay-for-value programs has shown the importance of performance measurement in monitoring and improving the quality of care in a variety of patient care settings, such as hospitals, long-term care facilities, medical group practices, and other settings. However, a standardized performance program for pharmacy practice does not currently exist, which reflects the product-based reimbursement infrastructure that continues to confine pharmacists. 

With the focus now more narrowed on increasing value, pharmacists have an opportunity today, and in the future, to play a more direct and measurable role in the delivery of patient care services.

Much like the MIPS program for physician-delivered care, a standard set of pharmacy performance measures could be used to lay the foundation for meaningful and measurable improvements in patient access and quality of pharmacist-provided care. 

It’s important to note that pharmacy measures are different than, but can be complimentary to, other performance measurement programs for physicians and other providers, especially in relation to medication-related outcomes of care. Pharmacy measures are also a tangible mechanism that can aid in quantifying the clinical and fiscal impact of pharmacist-provided care to payers and health plans.

Medication adherence is a prime example of the ability to leverage pharmacy performance measures to support value-based contracts between payers and pharmacies. For instance, CMS, in its 

, identified that improving medication adherence for PQA’s 3 primary proportion of days covered (PDC) measures 

resulted in $46.6 billion in estimated health care costs avoided

. PDC is the preferred method to measure medication adherence.

While the positive impact of optimizing medication use quality through improved medication adherence is clear, there is an opportunity to take medication adherence a step further. Existing adherence measures focus on patients’ access to medications, but pharmacy performance measures have the potential to draw a correlative link between optimized adherence and improved patient outcomes.

How can pharmacy performance measures evaluating clinical endpoints and biomarkers further drive home quality of care? Our initial prioritized pharmacy performance measure set will focus on services that pharmacists have the most opportunities to impact on a broad scale, such as hemoglobin A1C, blood pressure, immunizations, and a PDC composite adherence measure.

Pharmacy performance measures, which incorporate clinical biometrics such as hemoglobin A1C and blood pressure, and guideline-based preventive care interventions such as immunizations, support the delivery of clinical care and services by pharmacists and provide essential health information to plans, payers, and providers.

There are some important next steps needed to generate the lift and thrust necessary to get pharmacy performance measures off the ground. 

Pharmacists and the pharmacy community must continue to advance the practice of pharmacy and ensure that the needs and expectations of patients, providers, and payers are being met. Pharmacists must continue to elevate the standard of care and delivery of services beyond refill histories, medication profiles, and 

-required medication counseling. The COVID-19 pandemic has accelerated the prevalence of medical care and services provided by pharmacists, such as chronic disease management services, immunizations, and biometric assessment of clinical status through point-of-care testing and patient monitoring services. Once considered innovative and isolated, patient access to these services must become the standard expectation at all pharmacies.

Health plans and payers must be committed to building pharmacy performance programs that reward and incentivize high-quality, pharmacist-provided care. It’s no secret that new medication therapies and chronic disease care are increasingly complex and costly, creating the need to ensure the optimization of medication use quality. Pharmacy performance measures can serve as the bridge between care delivery and optimized quality. As the pandemic has shown, pharmacists are in an ideal position to improve patient access to care.

Technology vendors must develop and fine-tune pharmacist-provided care documentation platforms to capture and communicate the critical information needed to inform the provider community and support payer-driven performance on quality. Pharmacist-provided clinical information is a missing piece in the care delivery puzzle. Documenting pharmacist-provided care and services and sharing that information fills in gaps in care, repairs holes in data, and closes the feedback loop between providers, plans, and payers.

There are other factors that must be addressed to ensure the success of this effort. The pharmacy profession must continue its pursuit of a re-envisioned practice environment that supports pharmacist-provided care. The physical pharmacy practice setting must be patient-focused and supportive of pharmacists as providers.

Practice models must ensure that pharmacists and pharmacy personnel are empowered to practice at the top of their training. Organizations must continue to push for the inclusion of pharmacists as members in team-based care. The first step is aligning incentives and laying out the path forward, and PQA is committed to playing its part by developing pharmacy performance measures.

As the stars continue to align, pharmacists will have an opportunity to establish their role as providers in the value-based care environment of the future. PQA remains committed to working alongside our forward-thinking members and diverse stakeholders to finish the job we started on pharmacy performance measures.

We’re building a program that our members have asked for and that doesn’t currently exist, but the time has come to identify and engage early adopters. We are seeking innovators and champions from the pharmacy, payer, and technology communities to come together and lead the implementation of standardized pharmacy performance measures. Together, we will work together to transform this concept into reality.

Pharmacy performance measures can support greater patient access to care and services through team-based care and to facilitate value-based contracts between pharmacists and payers. 