More Than Ever, Quality Is the Name of the Game

Nearly 10 years ago, the Institute of Medicine made a statement that could have been read as a call to action for pharmacists. Today, the statement encapsulates a health care system that is evolving to focus on the value delivered rather than the volume produced:

"Pharmaceuticals are the most common medical intervention and their potential for both help and harm is enormous. Ensuring that the American people get the most benefit from advances in pharmacology is a critical component of improving the national health care system."¹

Optimizing the benefit that can come from the remarkable technology represented in medications has been an elusive proposition. In 2012, it was estimated that $213 billion in avoidable costs were due to medication-related problems.² Between 2007 and 2010, only 18.8% of patients with diabetes had glycated hemoglobin (A1C) less than 7%, blood pressure under 130/80 mm Hg, and low-density lipoprotein level below 100 mg/dl (achievement of each these clinical measures is primarily pursued via medication use).³ Of all adverse events experienced by patients within 5 weeks of hospital discharge, 66% are related to medications.⁴

The list of sobering statistics could continue, as readers are no doubt aware. When numbers such as $213 billion are presented, the problem seems large and impersonal and can appear insurmountable. The frequency with which these statistics are cited and the offhand manner in which they are used have failed to establish a sense of urgency among health care practitioners and leaders.

With the move to value-focused payment strategies in health care, however, a sense of urgency is emerging from health care stakeholders external to pharmacy. The importance of managing medication use has never been greater at any time in our history than right now, and this awareness is represented in programs that are directed specifically toward the work of pharmacists. This includes development of medication therapy management programs within the Centers for Medicare & Medicaid Services (CMS) and the quality measurement work of the Pharmacy Quality Alliance. More frequently, this awareness is reflected in programs that seek to measure or improve broad health outcomes but can’t succeed unless program design includes a specific focus on improving medication use. Examples include the breadth of chronic disease measures promoted by the National Quality Forum, the CMS Partnership for Patients (which includes several initiatives focused on improving medication effectiveness and safety), and the National Action Plan for Adverse Drug Event Prevention.

The first examples continue to evolve and provide an important forum for pharmacists to increase their contributions to improving patient care. However, the latter examples, in which programmatic development is not focused specifically on the work of pharmacists but in which optimal medication use will help achieve success, provide the profession its greatest opportunities to increase its influence and be recognized in meaningful ways. But how will that occur?

Proactively Propose to be Part of the Solution

A physician colleague of mine who leads a state quality improvement organization shared a story of traveling around his state speaking to pharmacists about the state’s overarching quality improvement plan. This plan includes a specific focus on improving medication effectiveness and safety. After speaking to local pharmacists at several events, he walked away from his experience disillusioned regarding the ability of practicing pharmacists to see how they could contribute meaningfully to the state’s quality agenda. His perception was that pharmacists were too often interested in preserving the care and business models of the present rather than collaborating on solutions to produce a system of care to help communities achieve the quality improvement goals established for their state. The experience of this physician highlights the need for pharmacists to proactively describe a vision for being part of the global agenda for improving health and limiting unnecessary costs to those who are in a position to create opportunities to make the vision a reality.

The focus of those who are most influential in the health care system—federal and state governments, health plans, and large health systems forming accountable care organizations—is on producing and measuring quality and then building payment systems around this focus. When medications are “the most common medical intervention,”¹ these groups focus on optimizing medication use as part of a much broader quality agenda. They may not consider the contribution pharmacists could bring to their value equation, however. Pharmacists must therefore understand their local landscapes, identify individuals in influential positions within influential organizations, and proactively bring forward solutions for enhancing the value generated by medication use. They must see themselves and their services as an integral component of the value equation that policy and payer groups are developing.

Medication use by patients is not an isolated intervention but is embedded in and influences many aspects of the health care experience. As a result, pharmacists must help show decision makers focused on producing value in health care how they can be integrated into new systems of care rather than continuing to be largely separated from primary and specialty care services.

Seek to Integrate

In the Harvard Business Review article, “The Strategy That Will Fix Health Care,” Porter and Lee cite the importance of developing “integrated practice units” to improve patient outcomes.⁵ The authors specifically refer to the potential value of engaging pharmacists in this model, referencing the experience of Geisinger Health System in Pennsylvania, where “the inclusion of pharmacists on teams has resulted in fewer strokes, amputations, emergency department visits, and hospitalizations, and in better performance on other outcomes that matter to patients.”

This integration could be designed many different ways; the Geisinger example is only one model. The key point to take away is that utilizing teams and coordinating care among practitioners with different skill sets is critical for achieving quality health care. Several evaluations have demonstrated that systematic integration of pharmacists into teams has a positive impact on patient health.^6-9 Therefore, there is a need to rapidly produce care models that integrate the unique skills and expertise of pharmacists to improve patient outcomes. This leads to a third strategy for success: once the pharmacy community brings forward solutions that will address broader quality issues and seeks to integrate their services in team-based approaches to care, then the community must commit to establish measurement and reporting strategies that truly communicate value to decision makers.

Measure What Matters

The movement of compensation systems to align with performance has ushered in the era of measurement in health care. The number of entities promoting quality metrics has increased and the diversity of measures promoted has dramatically expanded, creating an administrative burden for health care providers. This trend brings to mind the old saying that not everything that can be counted counts and not everything that counts can be counted. In response to this emerging measurement burden, the Core Quality Measures Collaborative (CQMC) was convened in 2014. The goals of CQMC are to “reduce the total number of measures by eliminating low-value metrics and introducing consistency across payers… refine the measures that remain to further ease the burden of collection… [and] relate measures to patient health outcomes, focusing on ‘measures that matter.’”¹⁰

Pharmacy providers must keep these principles in mind as they seek to establish metrics that measure the quality of their services. In focusing on “measures that matter,” CQMC aims to relate measures to patient health. How will this principle look when applied to pharmacy? The following scenarios highlight common metrics applied to pharmacy today and how they fall short of meeting the “measures that matter” principle:

• A patient meets the threshold of adherence (proportion of days covered [PDC]) for a prescribed angiotensin-converting enzyme inhibitor, but does not achieve their blood pressure goal because the dose is too low. The opportunity to reduce the patient’s risk of cardiovascular disease is not achieved.
• A pharmacist conducts a comprehensive medication review (CMR) (number of CMRs completed) with a patient and identifies 3 problems with the medication regimen. Recommendations for resolution are faxed to the patient’s primary care physician, but no change is made because there is no relationship between the 2 practitioners.
• A patient who has diabetes achieves A1C <7% partly because of the clinical efforts of a pharmacist through a diabetes disease state management program (metric: isolated disease measure). However, the patient continues to frequently miss work because management of lower back pain is insufficient.

A Call to Action on Quality

Earlier this year, Department of Health and Human Services Secretary Sylvia Burwell set the stage for rapid expansion of value-based payment models when she announced that by 2016, CMS aims to tie 30% of its payments to quality and value by using alternative payment models; the goal is to reach 50% by 2018.¹¹ It’s clear that the focus on producing quality will increase significantly over the next few years. Payers and organizations that provide health care are realizing what the Institute of Medicine declared 8 years ago: medications are the most common medical interventions and high-quality care cannot be achieved without optimizing medication use. Pharmacy services thus have an unprecedented opportunity to be a critical part of improving health care quality. This opportunity can be realized if the profession collectively engages in leadership efforts that bring creative solutions to stakeholders with a health care system—wide view of quality, integrates services with teams of practitioners, and defines and advocates for a measurement agenda that focuses on metrics that truly represent value to patients and payers.

Todd D. Sorensen, PharmD, is professor and associate head, Department of Pharmaceutical Care and Health Systems, at the College of Pharmacy, University of Minnesota. He also serves as the executive director of the Alliance for Integrated Medication Management, a nonprofit organization that engages health care institutions in practice-transformation activities that support improved medication use. Dr. Sorensen’s work over his career has focused on leading practice change and the development of future pharmacy leaders. He has worked with numerous health care organizations focused on identifying ways in which pharmacists can better meet the needs of patients. His research and service activities, focused on identifying strategies and leadership activities, have led organizations to successfully integrate and sustain medication management services. This work has been greatly influenced by 7 years of experience participating in and leading a national quality improvement collaborative for health systems seeking to optimize medication use in outpatient settings.

References

• Institute of Medicine. Informing the Future: Critical Issues in Health. 4th ed. Washington, DC: The National Academies Press; 2007.
• Aitken M, Valkova S. Avoidable costs in U.S. healthcare: the $200 billion opportunity from using medicines more responsibly. IMS Health website. http://www.imshealth.com/en/thought-leadership/ims-institute/reports/avoidable-costs. Published June 2013. Accessed December 9, 2015
• Stark Casagrande S, Fradkin JE, Saydah SH, Rust KF, Cowie CC. The prevalence of meeting A1c, blood pressure, and LDL goals among people with diabetes, 1988-2010. Diabetes Care. 2013;36(8):2271-2279. doi: 10.2337/dc12-2258.
• Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138(3):161-167.
• Porter ME, Lee TH. The strategy that will fix health care. Harvard Business Review website. www.hbr.org/2013/10/the-strategy-that-will-fix-health-care. Published October 2013. Accessed December 1, 2015.
• Bogden PE, Abbott RD, Williamson P, Onopa JK, Koontz LM. Comparing standard care with a physician and pharmacist team approach for uncontrolled hypertension. J Gen Intern Med. 1998;13(11):740-745.
• Borenstein JE, Graber G, Saltiel E, et al. Physician-pharmacist comanagement of hypertension: a randomized, comparative trial. Pharmacotherapy. 2003;23(2):209-216.
• McLean DL, McAlister FA, Johnson JA, et al. A randomized trial of the effect of community pharmacist and nurse care on improving blood pressure management in patients with diabetes mellitus: study of cardiovascular risk intervention by pharmacists-hypertension (SCRIP-HTN). Arch Intern Med. 2008;168(21):2355-2361. doi: 10.1001/archinte.168.21.2355.
• Schneider PJ, Larrimer JN, Visconti JA, Miller WA. Role effectiveness of a pharmacist in the maintenance of patients with hypertension and congestive heart failure. Contemp Pharm Pract. 1982;5(2):74-79.
• Conway PH; Core Quality Measures Collaborative Workgroup. The Core Quality Measures Collaborative: a rationale and framework for public-private quality measure alignment. Health Affairs Blog website. www.healthaffairs.org/blog/2015/06/23/the-core-quality-measures-collaborative-a-rationale-and-framework-for-public-private-quality-measure-alignment/. Published June 23, 2015. Accessed December 1, 2015.
• Better, smarter, healthier: Health Care Payment Learning and Action Network kick off to advance value and quality in health care [news release]. Washington, DC: US Department of Health and Human Services; March 25, 2015. www.hhs.gov/about/news/2015/03/25/better-smarter-healthier-health-care-payment-learning-and-action-network-kick-off-to-advance-value-and-quality-in-health-care.html. Accessed December 1, 2015.