Record Breaking Attendance at the PQA 6th Annual Meeting

Over 225 healthcare leaders joined together at the Omni Shoreham Hotel in Washington, DC on June 1-2 to kick off the Pharmacy Quality Alliance's celebration of "Five Years of Quality." The full agenda included thought leaders in healthcare, a select number of exhibitors with both high-tech and high-touch services, and the inaugural PQA Quality Awards Program and Dinner. The thought provoking and educational meeting provided tremendous take home value.

Laura Cranston, the PQA Executive Director since its founding in 2006, began the meeting with a review of the Alliance's accomplishments along with a look at the work PQA will undertake in the future. She thanked the PQA members for their dedicated efforts within the Alliance workgroups, for their time spent on developing measure concepts and weighing-in on important issues facing PQA stakeholders. Cranston added that "The enthusiasm and engagement of the PQA members is demonstrated daily and on every workgroup call as they strive to improve the quality of medication use and mediation-related healthcare outcomes."

Opening keynote speaker Dr. Kavita Patel, Managing Director for Clinical Transformation and Delivery, Engelberg Center for Health Care Reform at the Brookings Institution, provided the audience with a look at "Health Care Reform: ACOs, PCMH, HIE & The Role for PQA". Dr. Patel provided a candid and insightful description of the emergence of ACOs (Accountable Care Organizations), their anticipated role in improving overall healthcare outcomes and lowering healthcare costs, and the key challenges and opportunities for pharmacy in engaging with ACOs.

Vikki Oates, Director of the Division of Clinical and Operational Performance, Medicare Drug Benefit, and Part C&D Data Group for CMS, provided a detailed view of the Medicare Plan Ratings, Display Measures and Quality-Based Payments. Her presentation was followed by a panel discussion where top executives from Humana, Kaiser Permanente and Medco commented on how the CMS ratings and payment reform are affecting their business and influencing their strategies to address the key challenges.

Other highlights of the meeting included lessons learned from physicians and hospitals around pay for performance programs. An update was provided about the National Quality Forum's Measure Application Partnership (MAP). The PQA membership also reviewed, discussed and voted on three specific medication measures that were proposed for endorsement.
The PQA workgroup breakout sessions were back for a second year. The sessions brought together members of the various workgroups to share their major objectives for the year. Those in attendance at the meeting who were not part of the 2011 workgroups learned about the PQA Phase II Demonstration Project currently taking place in Pennsylvania. Spokespersons from CECity, Rite Aid and Highmark gave a firsthand look at the goals and accomplishments of this project.

PQA extends special thanks to the sponsors and exhibitors that helped to make the PQA 6th Annual Meeting a great SUCCESS! Back to Top

PQA / URAC Medication Adherence Summit Brings Together Key Stakeholders

The Medication Adherence Summit, jointly convened by PQA and URAC and held on June 2-3 in Washington DC, provided an excellent venue for key stakeholders and recognized experts to share ideas and research on the challenges of improving medication adherence.  Multiple perspectives in the healthcare system, including payers, clinicians and patients were presented to attendees.

The Summit began with a keynote address by Dr. David Cutler, Otto Eckstein Professor of Applied Economics at Harvard University.  Dr. Cutler presented "Medication Adherence and Health Reform" and the provided insights as to the various issues that affect people's adherence habits including cost and the need to get the price right.  Dr. Cutler reviewed several strategies including a bundled approach and a pay for performance program and explained how each affected the overall cost of care.  He also addressed the need for making medication adherence a priority in health IT to facilitate data exchange and track medication use.  In addition, Dr. Cutler felt that one of the biggest challenges was helping the middle income population meet their healthcare needs. He noted that higher income groups have access to more resources such as "concierge physicians", while the low income population may qualify for clinics that offer special services.

Dr. Colleen McHorney, Sr. Director, Outcomes Research Group with Merck, examined the patient's perspective on adherence utilizing extensive research. She stressed the importance of understanding the patient's thoughts and motivations behind medications and medication adherence.  Rebecca Burkholder, Vice President of the National Consumer League and Kellie Murphy, Sr. Vice President of GMMB also discussed this issue in their presentation "Raising Consumer Awareness about Adherence: the National Consumer League's New Multi-Stakeholder Campaign."  They shared with attendees the various marketing vehicles and strategy behind "Script Your Future", which seeks to help patients understand the importance of taking medications properly to ensure they are around to enjoy the future.  

The payer's perspective was highlighted in lively panel discussion that featured: Dr. Jeffrey Kelman, Chief Medical Officer for CMS; Dr. Ed Pezalla, National Medical Director for Pharmacy Policy for Aetna; Dr. Bruce Sherman, Corporate Medical Director with Whirlpool. Together these leaders provided insights on adherence from the perspectives of the government payer, the health plan and the employer.

The perspective of the provider was delivered by Chris DuPaul, Director of Patient Care services with CVS Caremark in a presentation titled "Advancing Adherence & the Science of Pharmacy Care."  A key area of focus was on capabilities of the health care organization to design and support programs that change specific behaviors directly linked to improving overall adherence. According to Dr. DuPaul, critical to this success are people, both pharmacists and technicians, who are willing and able to influence patient behavior and the processes/systems which provide clinical decision support, workflow integration and actionable measures of performance.  He highlighted several CVS programs that are addressing these issues and stated that, in their experience, "When done right, patient care programs create wins for patients, physicians, and pharmacists."

Other highlights of the meeting included a presentation by Joshua Benner, Fellow and Research Director at the Engelberg Center for Health Care Reform at The Brookings Institution, entitled "Interventions for Medication Adherence: An Overview of the Evidence." This session included an informative panel discussion of case studies of interventions to support medication adherence.

Dr. Carolyn Clancy, Director for the Agency for Healthcare Research and Quality, gave the closing keynote address presenting "National Healthcare Quality Strategy: Where Does Medication Adherence Fit?"  Dr. Clancy reviewed AHRQ's resources and priorities, recent legislation, patient centered treatment, and perspectives on healthcare for the 21st Century.   Clancy said that to improve healthcare, we need to "form alliances, partnerships and other strategies that promote collaboration; further integrate quality into the broader health care transformation effort and address the gaps that exist between our ability to generate data and having the capacity to produce actionable information that can be used right now." She added that AHRQs vision is that "as a result of the Agency's efforts, American health care will provide services of the highest quality, with the best possible outcomes, at the lowest cost." Back to Top

PQA Members Endorse Three New Performance Measures

At the PQA Annual Meeting on June 2, 2011, the membership of PQA had the opportunity to consider three new performance measures for endorsement.  After a lively debate, the membership voted in favor of endorsement for the three measures.  The newly-endorsed measures are:

The membership also received information about significant revisions to 2 measures that had previously been endorsed by PQA.  These measures were "Drug-Drug Interactions" and "Medication Therapy for Persons with Asthma."  Additional testing had been done on these revised measures and the testing results supported the appropriateness of the revisions and the measures continue to have PQA endorsement. Three other measures related to MTM services are undergoing further testing by Kaiser Permanente in California. It is hoped that the testing will be completed by the fall of 2011.

The technical specifications for all of the PQA-endorsed measures as well as drug code lists are available to PQA members at no charge provided that the members are using the specifications and drug lists for non-commercial purposes (e.g., performance improvement).   Please contact Dr. David Nau for more information [dnau@PQAalliance.org]. Back to Top

PQA Recognizes Three Health Plans for Excellence in Medication Safety
CalOptima's One Care Plan, Kaiser Permanente Colorado and Kaiser Permanente Hawaii Achieve 5-Star Medication Safety Ratings

CalOptima's One Care Plan, Kaiser Permanente Colorado and Kaiser Permanente Hawaii have received the inaugural PQA Quality Award.  This award recognizes their achievement of a 5-star rating on the PQA measures of medication safety that are included in the CMS Star Rating Program.  The awardees were also required to achieve at least a four-star plan rating overall. The winners were honored at the Awards Recognition Program held June 1st in conjunction with the Pharmacy Quality Alliance's 6th Annual Meeting. This is the first year the consensus-based, multi-stakeholder organization provided this unique recognition to top health plans providing Medicare prescription services across the nation.

The opening keynote speaker during the dinner event was Jonathan Blum, Deputy Administrator and Director of the Center for Medicare.  In his address, Director Blum shared with the attendees that the accomplishments of these three Medicare plans were judged based on their publicly available quality scores.  Blum emphasized that, "The safe use of medications is extremely important to the Medicare program and we commend these award winners for their achievements in ensuring safety for their Medicare members. PQA has set a high standard for excellence in their criteria for this award thereby ensuring that the award recipients are truly outstanding in their protection of patients and promotion of optimal medication outcomes."

Laura Cranston, the PQA Executive Director, offered opening remarks to the attendees and shared that "in an era of increasing focus on the value of healthcare, and the move towards measuring performance of all providers and plans, this award is truly unique because it uses publicly available quality data from CMS.  Therefore, plans don't have to be nominated, they simply have to perform exceptionally well on transparent measures of medication safety." Selections for this inaugural award were made by examining the performance criteria of hundreds of Medicare contracts.

Accepting the awards for the three winners were Kristen Gericke, Director of Clinical Pharmacy Management for CalOptima One Care Plan, Beth Chester, Senior Director of Pharmacy Clinical Operations & Quality for Kaiser Permanente Colorado, and Karen Ching, Chief of Pharmaceutical Services and Barbara Kashiwabara, Director of Pharmaceutical Services for Kaiser Permanente Hawaii. Consistent with the PQA goal of improving quality of care for all patients, these three successful plans have agreed to identify their own internal best practices that enabled them to achieve 5 stars on safety measures and share this information via the PQA Quality Lecture Forum in July. (Editor's note: See related announcement in this newsletter.)

Criteria for the award were set by the PQA Awards Committee and included the top scores - achievement of a 5-star rating - for two PQA-endorsed pharmacy performance measures:

• High Risk Medications: This is a measure of the percentage of patients who receive prescriptions for drugs with a high risk of side effects in the elderly. Beneficiaries on these medications can often be directed toward safer drug choices through the interaction of a physician, the beneficiary's pharmacy and through member education by the plan. 
• Diabetes Treatment: This is a measure of the use of appropriate hypertension medication for diabetic patients.  Clinical research shows that people with diabetes and hypertension respond better to certain types of blood pressure medication. Through education efforts and interventions, a health plan and their team of providers can help patients with diabetes receive the most effective hypertension drugs.

PQA graciously acknowledges the support of Lilly USA for the PQA's Inaugural Quality Awards Recognition Program. Lilly has been a member of PQA since its inception and provides leadership and expertise on a number of PQA workgroups. Back to Top

Hot Off the Press: Rapid Reviews of Key Quality Publications
by David Nau,PhD, RPh, CPHQ,Senior Director, Research & Performance Measurement, PQA

In this edition of Hot Off the Press, we highlight a new report from the Office of Inspector General (OIG) within the Department of Health and Human Services.  The report entitled "Medicare Atypical Antipsychotic Drug Claims for Elderly Nursing Home Residents" was released in May 2011 and was completed at the request of Senator Charles Grassley (R-Iowa).  The report examined whether atypical antipsychotic drugs were being prescribed for off-label conditions (i.e., other than schizophrenia or bipolar disorder) and/or for nursing home residents with the condition specified in the FDA boxed warning (i.e., dementia).  The rationale for the report was that Medicare payment for prescription drugs is supposed to be restricted to drugs that are being used for "medically accepted indications supported by one or more of three compendia."  Medicare Part B & D data from 2007 were used in the analyses.

The key findings of the report were:

• Fourteen percent of elderly nursing home residents had at least one claim for an atypical antipsychotic in the first half of 2007.  Nursing home residents accounted for 20 percent of the 8.5 million claims for atypical antipsychotics across all Medicare beneficiaries during that period. 
• Eighty-three percent of Medicare claims for atypical antipsychotic drugs for elderly nursing home residents were associated with off-label conditions; 88 percent were associated with the condition specified in the FDA boxed warning.
• Fifty-one percent of Medicare atypical antipsychotic drug claims for elderly nursing home residents were erroneous (i.e., the drug was prescribed for an off-label condition or there was no documentation of the drug actually being administered).
• Twenty-two percent of the atypical antipsychotic drugs claimed were not administered in accordance with CMS standards regarding unnecessary drug use in nursing homes.  CMS has established standards for the safety of drug regimens in nursing home residents, and the failure of nursing homes to comply with these standards may affect their future participation in Medicare.

Why This Study is Relevant
PQA has given great attention to the safe use of medications in older adults.  One of performance measures endorsed by PQA is the use of high-risk medications (HRM) in the elderly.  This performance measure has been adopted by CMS to evaluate medication safety in Medicare Part D.  It is also analogous to the NCQA HEDIS measure of "Drugs to be Avoided in the Elderly (DAE)."  An important obligation of PQA is to ensure that the drugs included in this measure are based on evidence of safety in older adults and are updated when new evidence on safety arises. 

The original list of medications within the HRM and DAE measures were derived from the Beer's list of high-risk medications.  The Beer's list has not been updated in several years and the atypical antipsychotics are not currently on this list.  However, we are pleased to announce that the American Geriatrics Society (AGS) is leading an effort to re-examine the Beer's list and potentially provide an updated list of medications that should be used with caution in frail elderly.  We are following the AGS efforts in this area and will consider adopting their recommendations upon their completion of this project.

Another relevant issue is the lack of diagnosis information on prescriptions and drug claims.  As stated in the report, "OIG recognizes that the industry has not developed a standardized way of collecting diagnosis information for prescription drugs. However, without access to diagnosis information, CMS cannot determine the indications for which drugs were used."  Similarly, without access to diagnosis information, pharmacists cannot determine the indication for which the drug was prescribed.  This impedes the ability of the pharmacist to assess the appropriateness of a prescribed medication for a patient.  For decades, pharmacists have sought legislative changes that would require the inclusion of a diagnosis on prescriptions.  The expanded use of e-prescribing should allow the diagnosis to be linked to a prescription by the physician before transmitting the e-prescription to the pharmacy.  It is time for medical and pharmacy societies to re-examine this issue and to find common ground in promoting safe use of medications.

Highlighted Article:
Department of Health and Human Services, Office of Inspector General.  Medicare Atypical Antipsychotic Drug Claims for Elderly Nursing Home Residents.  May 2011.  Available at:  http://oig.hhs.gov/oei/reports/oei-07-08-00150.asp     Back to Top

PQA Welcomes Newest Board Member, Brian Jensen, RPh, FACA

Brian's passion for pharmacy lies in the creation of new opportunities for pharmacists to improve the lives of patients nationally and in the communities he serves in Wisconsin. 

Brian is also a Board member of the Community Pharmacy Foundation where he was responsible for spearheading the development of a web-based pharmacy community of innovators through functional enhancements to the Community Pharmacy Foundation website.

He also developed and integrated a Comprehensive Medication Adherence Assessment Program into the Wisconsin Pharmacy Quality Collaborative, which was one of the PQA Phase I Demonstration Projects. In Brian's role with the Wisconsin Pharmacy Quality Collaborative he continues to oversee and guide the expansion of a quality-based pay-for-performance state-wide pharmacy network.

Brian shares a common commitment to advancing the quality of medication therapy and stands in strong support of the PQA mission and strategic plan.  As a practicing pharmacist and innovator, PQA looks forward to Brian's input on the Board of Directors. Back to Top

PQA Revises Proportion of Days Covered (PDC) Measures

The PQA Quality Metrics Expert Panel met on June 6th to discuss and approve updates to the PQA Diabetes PDC measure specifications.  The following three revisions to improve the PDC measures were made:

An exclusion criterion was added that will eliminate from the measure patients that have received a prescription for insulin at any time during the measurement period.  This additional criterion decreases the possibility of patients being incorrectly identified as non-adherent if they are changed from an oral hypoglycemic agent to insulin.

The diabetes "roll-up" measure was revised and re-instated.  Original testing of the PDC measures included a roll up measure that was specified as an average of the PDC for each individual class of diabetes medications.  The revised rate is not an average but is instead a broad assessment of whether the patient had possession of any oral hypoglycemic agent on any given day during the measurement period.  This overarching measure of adherence to a diabetes regimen is intended to show whether diabetes patients taking oral hypoglycemics remain on any oral medication during the measurement period.

A PDC rate was added for the dipeptidyl peptidase-IV inhibitors (DPP-IV).  Utilization of this class of oral hypoglycemics has surpassed the thiazolidinediones (TZD) and including all commonly used classes of oral hypoglycemic agents was viewed as important to maintaining the integrity of the diabetes roll-up measure. Back to Top

PQA July Quality Forum Lecture Series:
Best Practices AmongThree Health Plans for Excellence in Medication Safety

Please join us for the PQA Quality Forum Lecture on Thursday, July 28th at 1 PM EDT.  This session will feature representatives from CalOptima's One Care Plan, Kaiser Permanente Colorado and Kaiser Permanente Hawaii whom recently received the inaugural PQA Quality Award at PQA's 6th Annual Meeting.  This award recognizes achievement of a 5-star rating on the PQA measures of medication safety that are included in the CMS Star Rating Program.  The awardees were also required to achieve at least a four-star plan rating overall. In the PQA spirit of sharing best practices with the members, leaders from these successful plans will identify their own internal strategies and tactics that enabled them to achieve top scores on safety measures.

Criteria for the award were set by a PQA Awards Committee and included top scores for two PQA-endorsed pharmacy performance measures for High Risk Medications and Diabetes Treatment. The plans optimized care through care coordination and educational efforts and interventions. (For more details see the related article in this newsletter edition.)

To join us for this complimentary, one hour lecture, please RSVP to lectureregistration@PQAalliance.org by no later than Tuesday, July 26th.

This telephonic lecture series is offered on a complimentary basis to PQA members, and their associates. Lectures are held each month on a Thursday at 1 PM Eastern Time.

About the Plans and Speakers:

CalOptima is a county-organization health system providing publicly funded health coverage programs for low-income families, seniors, and people with disabilities in Orange County, California. CalOptima serves its 400,000 members with a network of more than 7,000 primary care doctors and specialists, as well as 30 hospitals. CalOptima provides access to quality health care through three programs, including Medi-Cal, Healthy Families Program and OneCare. Kristen Gericke currently serves as the Director of Clinical Pharmacy Management at CalOptima.

Kaiser Permanente Colorado is the state's largest nonprofit health plan, proudly working to improve the lives and health of Denver, Boulder, and southern Colorado area residents for more than 40 years. Kaiser Permanente Colorado provides health care services to more than 533,000 members through 21 medical offices and a network of affiliated hospitals and physicians. The Kaiser Permanente Colorado Pharmacy Department employs over 750 individuals and offers a wide array of pharmacy services, including a robust clinical pharmacy program. Beth Chester is a pharmacist serving as Senior Director for Pharmacy Clinical Operations & Quality. She also leads the Pharmacy Department's utilization management, quality, and patient safety agendas.

Kaiser Permanente Hawaii has provided total health to the people of Hawaii for over 50 years serving more than 230,000 members at 18 clinics, located across the island chain, and Moanalua Medical Center on Oahu.  Kaiser Permanente Hawaii's patients have access to the state's largest medical group of more than 450 physicians and providers supported by 4,400 medical and support staff. Dr. Karen Ching is Hawaii Permanente Medical Group's Chief of Pharmaceutical Services.  She is broadly responsible, in partnership with the Director of Pharmaceutical Services, for the oversight of Regional Pharmacy Operations and Clinical Pharmacy Services.  Barbara Kashiwabara currently serves as the Director of Pharmaceutical Services, for Kaiser Permanente Hawaii, and is responsible for Strategy and Operations of the Pharmacy Department. Back to Top

CMS Opens Public Comment for the Standardized Format of CMR Action Plan and Summary

Beginning in 2010, Part D MTM programs are required to offer an interactive, person-to-person comprehensive medications review (CMR) to their MTM beneficiaries at least annually.  The Affordable Care Act directed CMS to work with stakeholders to develop a standardized format for the CMR action plan and summary. In March, the PQA Workgroup on MTM & Care Transitions, along with other stakeholders, provided initial comments to CMS on the draft standardized format.  Many revisions have been made and the new draft is available for further public comment.  The standardized form will be used by Part D sponsors beginning January 2013.  By using a standardized format, CMR data can be more easily shared between providers and incorporated into electronic health records.

The 60-day comment period began May 27 and will end on August 1, 2011.  The Federal Register notice can be viewed at http://www.gpo.gov/fdsys/pkg/FR-2011-05-31/pdf/2011-13328.pdf.  The revised standardized format can be viewed at http://www.cms.gov/PaperworkReductionActof1995/PRAL/list.asp  (CMS- 10396).  The PQA Workgroup on MTM & Care Transitions will review the revised document and provide input for the next round of comments.

To comment electronically on the revised standardized format, go to http://www.regulations.gov and choose "submit a comment" then enter "CMS-10396" within the ID space.  Written comments can also be received by regular mail at: CMS, Office of Strategic Operations and Regulatory Affairs, Division of Regulations Development, Attention: Document Identifier/OMB Control Number, Room C4-26-05, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. Back to Top

PQA Welcomes New Members: Apothecary Products, CVS Caremark, Daiichi Sankyo, Northeastern University, The University of Arizona and Walmart

About Apothecary Products...
Apothecary Products, Inc. (API) was founded by pharmacist Terry Noble over 35 years ago. API is the leading provider to mass retail and chain drug of medication adherence tools such as pill boxes and liquid dosing aids.  A leader in innovation and quality, the most recent program, "Get the Most from your Medication", focuses on new marketing techniques and engaging the pharmacist to promote adherence tools without infringing on their valuable time. API tools represent a highly cost-effective and quick way to improve both patient and pharmacy drug adherence rates. API provides social media and other educational programs from a supply side in the fight against poor drug adherence.

About CVS...
CVS Caremark is the largest pharmacy health care provider in the United States. Through integrated offerings that cross the entire spectrum of pharmacy care, CVS are positioned to provide greater access to engage plan members in behaviors that improve their health and to lower overall health care costs for health plans, plan sponsors and their members. CVS Caremark is a market leader in mail order pharmacy, retail pharmacy, specialty pharmacy, and retail clinics, and is a leading provider of Medicare Part D Prescription Drug Plans. As one of the country's largest pharmacy benefits managers (PBMs), CVS provides access to a network of more than 64,000 pharmacies, including over 7,100 CVS/pharmacy(R) stores that provide unparalleled service and capabilities.

About Daiichi Sankyo...
The Daiichi Sankyo Group is dedicated to the creation and supply of innovative pharmaceutical products to address the diversified, unmet medical needs of patients in both mature and emerging markets. While maintaining its portfolio of marketed pharmaceuticals for hypertension, hyperlipidemia, and bacterial infections, the Group is engaged in the development of treatments for thrombotic disorders and focused on the discovery of novel oncology and cardiovascular-metabolic therapies.

About Northeastern University...
Founded in 1898, Northeastern University is a private research university located in the heart of Boston. Northeastern is a leader in worldwide experiential learning, urban engagement, and interdisciplinary research that meets global and societal needs. Northeastern's broad mix of experience-based education programs-their signature cooperative education program, as well as student research, service learning, and global learning-build the connections that enable students to transform their lives. The University offers a comprehensive range of undergraduate and graduate programs leading to degrees through the doctorate in nine colleges and schools.

About The University of Arizona...
The University of Arizona College of Pharmacy is committed to improving health care quality.  J. Lyle Bootman, PhD, ScD is Dean of the College and leads this effort.  Dr. Bootman is an elected member of the Institute of Medicine of the National Academies, where he served on the Board of Health Care Services for seven years, and was co-chair of the IOM committee which released the highly publicized report "Preventing Medication Errors."

About Walmart...
Walmart serves customers and members more than 200 million times per week at more than 9198 retail units under 60 different banners in 15 countries. With fiscal year 2010 sales of $405 billion, Walmart employs 2.1 million associates worldwide. A leader in sustainability, corporate philanthropy and employment opportunity, Walmart ranked in the top ten among retailers in Fortune Magazine's 2010 Most Admired Companies survey. Walmart currently operates 5,101 pharmacies. Back to Top