Pharmacy Quality Alliance Meeting Overview

This past week I attended the Pharmacy Quality Alliance’s (PQA) annual meeting.  The impact that PQA is having on the practice of pharmacy in virtually all respects, but especially with regard to medication management and clinical pharmacy warrants a review of meeting highlights.

Note: I write this overview from a personal perspective and not as an authorized representative of PQA.  All thoughts and comments are my personal impressions.

One of the most interesting aspects of the meeting was an overview of PQA’s focus.  PQA’s focus has historically been to provide stewardship of plan level quality measures.  Moving forward PQA will be evolving its focus to include:

  • Electronic Clinical Quality Measures (eCQMs).  PQA has traditionally focused on quality metrics in which the data elements are claims based.  eCQMs are next generation measures requiring clinical or social data elements.  This change has been stimulated by market changes such as MACRA and Value Based Reimbursement requiring providers to report on quality metrics.  A good portion of the PQA annual meeting provided insight into MACRA, Value Based Reimbursement and eCQMs.  Kate Goodrich, Director of the Center for Clinical Standards provided and excellent overview of MACRA and the Value Based Reimbursement structure proposed for providers, and Kendra Hanley, Director of Measure Specification Operations for the Physician Consortium for Performance Improvement provided an in-depth  review of eCQMs.  For a more in-depth view of MACRA see Kate Goodrich’s presentation (http://pqaalliance.org/images/uploads/files/2016%20PQA%20Annual_Advancing%20Healthcare%20Delivery_Kate%20Goodrich.pdf)
  • Immunization.  Immunization will become a more integral part of quality reporting and medication management.  For example, a new CMR quality metric under development proposes evaluating the inclusion of a vaccine assessment as a measure of CMR quality (see below for more).  Consequently, PQA will be evolving its focus to include reporting immunizations to public registries and assessment of immunization status. 
  • Enhanced MTM models.  As the new Enhanced PDP MTM models are rolled out, they will require a standard set of evaluation parameters to allow for “apples to apples” comparison and the identification of MTM best practices.  PQA will be at the forefront of designing and testing this standard set of measures.
  • Specialty measures.  PQA will be expanding it’s measure focus to include drug related specialty measures.  Currently measures under development include – Multiple Sclerosis, Hepatitis C, Rheumatoid Arthritis and Immunosuppression in kidney transplant (more below).

In addition, PQA will be exploring new territory and augmenting existing efforts.  Some examples include:

  • Capturing the View of the Patient.  PQA held a reactor panel titled – Cost-Effectiveness Data: Does it Have a Place in Performance Measure Development.  The panelists debated the issue of including patient utility (i.e. quality of life or health status) as a component of performance success. 
  • Implementation Advisory Panel.  PQA has formed an Implementation Advisory Panel to explore the practical / operations aspects of implementing a quality measure. 
  • Educating Pharmacists in Quality (EPIQ).  The PQA meeting opened with a series of podium presentations which explored the inclusion of quality metrics in pharmacy education.  These presentations highlighted that while there is wide variation in how pharmacy schools cover the topic of quality metrics, there was a general concensus regarding the fact that all pharmacy students require some foundational knowledge of performance measurement.  To this end, PQA has announced a new scholars program in conjunction with the CVS foundation.

Finally, while many PQA success were highlighted during the meeting the one that stood out for me was the conditional approval  of PQA’s three opioid measures (approved by PQA in 2015) for inclusion the Adult Core measures set.  These three opioid measures are currently being reviewed by NQF for endorsement.  To my mind this demonstrates how PQA’s efforts are being adopted across the health care continuum  and providing an expanded role for pharmacist in care quality improvement.

I provide below a synopsis of PQA measure approval and development activity.  Again I feel compelled to note that I provide this overview from my personal perspective and not as a representative of PQA – the “world according to Jim” to be sure.  I provide this personal perspective as I believe that an intimate knowledge of quality metrics (past, present and future) are required for any pharmacist involved in clinical program design or medication management delivery who hopes to develop and / or operate a program with an accepted value proposition. 

Measures Adoption

Pharmacy Quality Alliance (PQA) members approved four new quality improvement indicators (QIIs).  QIIs differ from performance measures in that they are not used for public reporting. They are intended only for internal use within an organization or pharmacy to better understand and improve the efficiency and outcomes of internal processes.  All four QIIs were focused  on the pharmacy based medication synchronization process and were developed to assist pharmacists improve medication synchronization programs.  Medication synchronization is the process of aligning refill dates of patients’ chronic medications and regularly connect with patients.  A relatively large body of evidence suggests that  medication synchronization promotes active medication reconciliation and adherence.

  • Program Acceptance and Initial Synchronization Rate.  The percentage of patients or their caregivers who have met the pharmacy criteria for medication synchronization who are contacted by the program, agree to participate and whose medications are initially synchronized
  • Patient Contact Rate.  The percentage of patients or their caregivers participating in the medication synchronization program who are scheduled for contact and who are contacted prior to the patient’s appointment date (usually 5 to 7 days prior).
  • Medication Synchronization Completeness.  The percentage of patients in the medication synchronization program who have all of their chronic medications included in the synchronization.
  • Medication Synchronization Continuation (2 Measures)
    • The percentage of patients enrolled in the medication synchronization program who have their chronic medications synchronized after 6 months (after 12 months).
    • The Number of patients who are enrolled in the medication synchronization program on the first day of the measurement period.

The four medication synchronization QIIs were each tested by two PQA member organizations.  The results demonstrated that QII implementation was feasible and measure results useful.  Community pharmacies now have an objective approach for demonstrating that their activities are focused on achieving community standard goals of  medication adherence.  For a more in-depth review of the new QIIs see Woody Eisenberg and Julie Kuhle’s presentation (http://pqaalliance.org/images/uploads/files/2016%20PQA%20Annual_Msr%20Development%20Update%20and%20Vote_Eisenberg%20and%20Kuhle.pdf)

Measures Development Activity

During the annual meeting all Stakeholder Advisory Panels (SAPs) were able to meet and review measure development activity.  Each SAP is composed of  a number of Measurement Development Teams (MDTs) or Task Forces.  These teams are engaged in the next generation of measures that will appear in STARS, HEDIS and Value Based Payment programs.  A key tenant of developing a clinical program is to “begin with the end in mind”.  That is, begin with an understanding of the value that you would like to create.  To that end, the work of these teams provides a bit of a “crystal ball” for pharmacists in understanding how to develop or evolve a clinical program.

  • SAP A is focused primarily on the work of developing specialty quality metrics. 
    • Adherence to Immunosuppressants Post Kidney Transplant  (MDT 2).  This is a health plan level performance measure that is intended to include the adult population.   It is anticipated that data sources will include prescription claims data; medical claims (diagnosis) data and the Medicare Transaction Reply Report (TRR)
      • Denominator.  The denominator would include patients with diagnosis code (or TRR) for kidney transplant and two or more prescription claims for an immunosuppressant medication
      • Numerator:  The denominator would include a PDC calculation with 80% threshold
      • Exclusions: The measure would exclude patients in hospice

The next step will be to convene an expert panel of transplant physicians, transplant pharmacists and transplant nurses to assess the face validity of the measure
 

    • Treatment of Chronic Hepatitis C: Completion of Therapy (MDT 10).  Also a health plan level performance measure that is intended to include the adult populations.  It is intended that the data source would include prescription claims.
      • Measure Objective.  The measure is intended to assess the degree to which a patient completed a minimum duration of therapy with no significant gap(s).  Significant gaps is being defined as no greater than a 15-day cumulative gap between the first and last fills of the direct acting anti-viral medication
      • Exclusions.  The measure would exclude individuals with a prescription claim where the days’ supply is 56 or greater

It is interesting to note that this measure could be used as a QII by any pharmacy providing direct acting antiviral medication to patients, by simply substituting dispensing for prescription claims data.

  • Multiple Sclerosis Treatment and Monitoring Task Force.  This task force has been charged with initiating the development of MS related quality metrics.  The objectives of the task force are to conceptualize measures that:
    • Drive meaningful and measureable improvements in care for patients with MS
    • Are appropriate for quality improvement and accountability purposes; and
    • Are implemented as performance measures within the clinical community and in national programs (e.g., CMS Physician Quality Reporting System [PQRS], Merit-Based Incentive Payment System [MIPS]).

To date Measure Concept Ideas include (in priority order) – 1) Treatment with Disease Modifying Therapy (DMT) in Patients with Relapsing forms of Multiple Sclerosis 2) Reassessment of Drug Efficacy 3) Screening for Relapse 4) Shared decision-making when selecting DMT
 

  • SAP B is primarily focused on the delivery of MTM
    • MTM Patient Survey (MDT 3).  The patient survey will initially be developed as a QII to allow health plans to assess the experience / satisfaction of member’s participated in a CMR.  The survey will provide a common tool to be used by all providers of MTM services to assess satisfaction and user experience of patients who have engaged in a CMR.   The proposed tool is the Health-Systems Alliance for Integrated Medication Management (HAIMM) Survey Tool, a 10 question survey that has completed initial validation.  Future  work will focus on psychometric testing and scoring.
    • MTM DPT Resolution (MDT 9).  The Enhanced PDP MTM Program will include enhanced MTM encounter reporting.  The MTM encounter report will use 17 unique data elements to describe a medication management encounter.  Each data element will be describable using a community standard code set and introduce the use of SNOMED CT codes.  The clinical portion of the MTM encounter will be described using 4 categories:
      • Referral.  Who notified or who referred the beneficiary to receive MTM (e.g., transition from acute to self-care)
      • Procedure. What service or intervention did the beneficiary received (e.g., medication regimen review)
      • Issue.  The beneficiary’s medication therapy issue  (i.e., DTP, medication therapy unnecessary)
      • Outcome: What happened following an MTM procedure (e.g. medication stopped)

While referral (e.g. 309014007 – referred by doctor) and procedure (e.g. 435441000124107 – Medication reminder device set up)  are more readily documented using SNOMED codes.  There currently exists no community standard framework for documenting drug therapy problems (DTPs).  The charge of MDT 9 is provide a common framework for DTPs and map these DTPs to available SNOMED codes.  The framework will provide a common rubric for articulating the texture of a medication management interaction moving us closer to outcomes based evaluation of medication management program.  The MDT has proposed a DTP framework illustrated below

DTP Framework

In addition, MDT 9 has proposed three measures – 1) Beneficiaries Discharged from Hospital who Received MTM 2) Targeted Beneficiaries with at least One DTP 3) MTM Recommendations that were Implemented

While this work has initially being conducted for the Innovation Center’s Enhanced MTM Model,  but obviously can be extended to all medication management programs Medicare or otherwise

  • SAP C is primarily focused on quality metrics which describe the quality of a medication regimen. 
    • Duplicate Therapy (MDT 12).  This measure is intended to quantify the percentage of individuals with prescriptions for one or more duplicate therapies that are generally considered clinically inappropriate and whose elimination would contribute to a reduction in cost or adverse events. Currently, MDT 12 is collecting clinical evidence of therapeutic classes of drugs which meet these criteria.
       
    • Poly-Pharmacy, Inappropriate or Unnecessary Therapy (MDT 11).  This measure is intended to quantify the percentage of individuals who are older than 65 and using concurrent medications which pose a safety concern.   The MDT 11 is proposing that targets for concurrent medications are derived from the AGS 2015 Beers Criteria Update .  For example – Greater than 3 CNS active medications (e.g. antipsychotics, benzodiazepine, nonbenzodiazepine sedative / hypnotics,  opioids, TCAs and SSRIs) and Greater than 2 medications with strong anticholinergic properties

      It is worthy to note that as the high risk medication measure are returned to a Display measure for re-evaluation, it is feasible to think that the Poly-pharmacy measure might be its replacement, at least initially.

    • Concurrent Use of Opioids and Benzodiazapines (MDT 13).  This measure is intended to quantify the percentage of the percentage of individuals with concurrent prescriptions for opioids and benzodiazepines.  Currently the proposal of the MDT 13 is to consider only non-acute opioid prescriptions (i.e. Individuals with 2 or more prescription claims for opioids filled on 2 or more separate days, for which the sum of the days supply is 15 or more days during the measurement year) and all benzodiazepine products.  In addition, patients in hospice and with cancer would be excluded.  
  • SAP D has a two pronged charge.  The development of drug related outcome measures and immunization measures.  For the development of the immunization measures two task forces have been created Immunization Task Force 1 (IZTF 1) and 2 (IZTF2).     The second, continues to define the quality of a MTM encounter. 
    • Medication Related Urgent, Emergent or Hospital Care.   These outcome measures evolve from the National Action Plan for Drug Adverse Event Prevention.  There are three measures and in general measure the degree to which medication use may have contributed to urgent, emergent or hospital care. 
      • Hospital, Emergency Department, and/or Urgent Care Utilization Related to Prescription Opioids.  This measure quantifies the rate of events among individuals receiving prescription opioid medications that have evidence of opioid-related hospitalizations, ED visits, and/or urgent care visits.  The denominator is the number of member months and the numerator is the number of prescription opioid-related hospitalizations, ED visits, or urgent care visits.  Individuals with diagnoses for opioid poisoning that is intentional (self harm) or heroin poisoning would be excluded from the numerator.  This measure has been approved to move forward with testing
         
      • Serious Hypoglycemic Events Requiring Hospital Admission or ED Visit Associated with Anti-Diabetic Medications.  This measure quantifies the rate of events among individuals receiving anti-diabetic medications that have evidence of hospitalizations, ED visits, and/or urgent care visits related to a serious hypoglycemic event.  The denominator is the number of member months and the numerator is the number of hypoglycemic events that result in a hospitalization, ED visit, or urgent care visit.  This measure has undergone it’s first round of testing, but will require testing in additional environments.
         
      • Hospital Admission or ED Visit for Bleeding Events Associated with Anticoagulant Medications.  This measure quantifies the rate of events among individuals receiving anticoagulant medications that have evidence of a hospitalization or emergency department visit related to a bleeding event. The denominator will be the number of member months and the numerator will be the number of bleeding events that result in a hospitalization (including admissions and observation stays) or ED visit.
         
    • Immunization.  The immunization measures measure two different aspects of immunization delivery
      • MTM Immunization Status Assessment  (IZ TF 2) .  This is another quality metric which seeks to assess the quality of a CMR by quantifying the percent of adult health plan members who met eligibility criteria for medication therapy management (MTM) services and who receive an immunization status assessment within the eligibility period.  The measure will focus on the assessment of influenza, pneumococcal (both PCV 13 and PPSV 23), adult herpes zoster, pertussis and Hepatitis B vaccines.  The data source for this measure will be the MTM vendors’ documentation/billing platform data and/or SNOMED CT data
         
      • Immunization Information System Reporting (IZTF 1).  This is a health plan (or PBM) level measure that seeks to understand the percentage of medical and/or prescription claims for an immunization which contain a matching record in a public vaccination record.

While the final specifications for many of these measures have not been decided, enough information is available for many of these measures for plans to take measure of where they stand.  Moreover, it is never to early to prepare your strategy for incorporating new measure monitoring and improvement in your quality and medication management programs.

I would be happy to discuss any of these thoughts in greater detail. Feel free to reach out by phone or e-mail.

Jim Notaro
716.541.0273 x101
jnotaro@csshealth.com