Quality vs Quantity:
The Next Era of
Healthcare
John A. Galdo, Pharm.D., BCPS, CGP (Jake)
Assistant Professor of Pharmacy Practice
Community Practice Residency Director
[email protected]

I do not have (nor does any immediate family member
have) actual or potential conflict of interest, within the
last twelve months, a vested interest in or affiliation
with any corporate organization offering financial
support or grant monies for this continuing education
activity, or any affiliation with an organization whose
philosophy could potentially bias my presentation.

I sit on workgroups for PQA and am a PQA Ambassador

Describe the shift of healthcare from a quantity to
quality system

Understand the 6* CMS Star Rating Pharmacy
Measures

Discuss opportunities pharmacists have in the new
healthcare system

In 2011, how much did the US spend on healthcare?
1.
2.
3.
4.
$500 billion
$1,000 billion
$1,500 billion
>$2,000 billion
• GDP $12.96 Trillion
• Reached $2.7 Trillion in 2011
• For healthcare
• $8,680 per person
• $1.2 Trillion is Government
• $848.9 Billion due to hospital
costs
• $320 Billion on medications
• Expected $4.78 Trillion (2021)
www.cms.gov Accessed online 10 September 2013.
Top Therapeutic Classes by U.S. Spending. IMS data updated February 23, 2012. Available from
http://www.imshealth.com/deployedfiles/ims/Global/Content/Corporate/Press%20Room/TopLine%20Market%20Data%20&%20Trends/2011%20Top-line%20Market%20Data/Top_Therapy_Classes_by_Sales.pdf
Accessed online 9 March 2013.

“Medications do not work in patients that do not take
them.”
◦ C. Everett Koop, M.D., Former U.S. Surgeon General

Primary non-adherence in post-MI ~24%
◦ 34% discontinue at least 1 medication
◦ 12% discontinue all medications

Industry average adherence ranges from 40 to 80%
Ho P, Bryson C, Rumsfield J. Medication Adherence Its Importance in Cardiovascular
Outcomes. Circulation. 2009; 119: 3028-3035
Forissier, T., Firlik, K. Estimated Annual Pharmaceutical Revenue Loss Due To
Medication Non-Adherence, CAPGEMINI CONSULTING 2012

Hospital Quality Alliance (HQA)
◦ Joint Commission on Accreditation of Healthcare
Organizations aka Joint Commission
◦ Centers for Medicare and Medicaid Services (CMS)
◦ American Hospital Association
◦ And others

Established in 2001
◦ Performance data sent to CMS
◦ Voluntary
Friedberg MW, Landon B. Measuring quality in hospitals in the United States: Core process
measures. In: Basow DS, ed. UpToDate. Waltham, MA: UpToDate. www.uptodate.com. Accessed
March 25th, 2014.

Receipt of hospital’s full Medicare payment contingent
upon reporting the initial 10-measures to CMS
◦ Still voluntary…

Initial starter set of measures reflected three health
conditions
◦ Acute Myocardial Infarction
◦ Heart Failure
◦ Pneumonia
Friedberg MW, Landon B. Measuring quality in hospitals in the United States: Core process
measures. In: Basow DS, ed. UpToDate. Waltham, MA: UpToDate. www.uptodate.com. Accessed
March 25th, 2014.

Quality of care delivered by the US healthcare system
is suboptimal

Principle of quality improvement is that what is not
measured cannot be improved
◦ Ergo, performance measurement and reporting is vital

Documentation is nothing without engagement to
understand and improve
Friedberg MW, Landon B. Measuring quality in hospitals in the United States: Core process
measures. In: Basow DS, ed. UpToDate. Waltham, MA: UpToDate. www.uptodate.com. Accessed
March 25th, 2014.
Structure
• Characteristics of
individual
healthcare
providers,
organizations, or
facilities
• Possession of
electronic medical
record,
percentage of
board certified
Healthcare
Processes
• Delivery of
specific clinical
services
• Percentage of
patients status
post MI who
receive a beta
blocker
Outcomes
• Ultimate goal of
healthcare
• Affected by
healthcare, but
also influenced by
patient factors
• 30-day mortality
rate
Friedberg MW, Landon B. Measuring quality in hospitals in the United States: Core process
measures. In: Basow DS, ed. UpToDate. Waltham, MA: UpToDate. www.uptodate.com. Accessed
March 25th, 2014.
Donabedian A. Evaluating the quality of medical care. Milbank Q 1966; 44:166.


Acute mycoardial infarction

◦ 8 Measures – statin at
discharge

Heart Failure
◦ 3 measures – ACE or ARB

Pneumonia
◦ 1 measure


◦ 2 measures
Emergency department
◦ 7 measures
Children’s asthma care
◦ 3 measures

Stroke Care
◦ 8 measures

Blood clot prevention and
treatment
◦ 6 measures
Surgical Care
◦ 10 measures
Preventive Care

Pregnancy and delivery care
◦ 1 measure

Outpatient imaging
efficiency
◦ 6 measures
Friedberg MW, Landon B. Measuring quality in hospitals in the United States: Core process
measures. In: Basow DS, ed. UpToDate. Waltham, MA: UpToDate. www.uptodate.com. Accessed
March 25th, 2014. Updated March 2015.




PQA was established in
2006 as a public-private
partnership with CMS
Consensus-based, nonprofit alliance with >110
member organizations
Work to improve the
quality of medication
management and use
across healthcare settings
PQA’s measures being
used not just in star ratings
Nau D. Medicare Star Ratings for 2014. Pharmacy Quality Alliance Quality
Forum Lecture Series. Webinar aired live October 31, 2013.

The Mission:
◦ To improve the quality of medication management and use
across healthcare settings with the goal of improving patients’
health through a collaborative process to develop and
implement performance measures and recognize examples of
exceptional pharmacy quality
http://pqaalliance.org/about/default.asp Accessed March 25th, 2014

Proportion of Days Covered (PDC)
◦ 18 years or older, threshold of 80 percent
◦ Reported for the following medication classes









Beta-blocker
Renin Angiotensin System Antagonist
Calcium Channel Blocker
Statin
Biguanide
Sulfonylurea
Thiazolidinedione
Dipeptidyl Peptidase-IV Inhibitor
Anti-retroviral*
*Threshold must be 90%
http://pqaalliance.org/measures/default.asp Accessed July 2, 2015

Antipsychotic Use in Children Under 5 Years Old
◦ Percentage of children

Adherence to Non-Warfarin Oral Anticoagulants
◦ Still PDC

Diabetes Medication Dosing
◦ Percentage of patient dispensed a dose higher than the daily
recommendation
 Biguanides, Sulfonylurea, TZD, DPP-IV
http://pqaalliance.org/measures/default.asp Accessed July 2, 2015

Diabetes: Appropriate Treatment of Hypertension
◦ Percentage of patients receiving medication for diabetes and
hypertension that are receiving an angiotensin converting
enzyme inhibitor (ACEI) and angiotensin II receptor blocker
(ARB)

Medication Therapy for Persons with Asthma
◦ Percentage of patients with asthma dispensed more than 3
canisters of short-acting beta2 agonist over a 90-day period
and no controller therapy
http://pqaalliance.org/measures/default.asp Accessed July 2, 2015

Use of High-Risk Medications (HRM) in the Elderly
◦ Percentage of patients 65 years of age or older and received two or
more prescription fills for a HRM

Use of Benzodiazepine Sedative Hypnotic Medications in
the Elderly
◦ Percent of patients 65 years or older who received two or more
prescription fills for cumulative period of more than 90 days

Drug-Drug Interactions
◦ Percentage of patients who received a prescription for a target
medication during measurement period and dispensed a concurrent
prescription for a precipitant medication
http://pqaalliance.org/measures/default.asp Accessed July 2, 2015

Cholesterol Management in Coronary Artery Disease
◦ Percentage that received at least one prescription for HMGCoA reductase inhibitor

Completion Rate for Comprehensive Medication
Review (CMR)
◦ Percentage that met eligibility criteria for medication therapy
management and received a CMR

Antipsychotic Use in Persons with Dementia
◦ Patients with dementia
http://pqaalliance.org/measures/default.asp Accessed July 2, 2015

Primary Medication Non-adherence (PMN)
◦ Percentage of prescriptions for chronic medications e-prescribed by
a prescriber and not obtained by the patient in the follow 30 days
 Not intended for use by PBM or health plans

Provision of MTM Services Post Hospital Discharge
◦ Percentage of high risk patients that have been discharged from
hospital and that received MTM from a pharmacist within 7 days

Readmission of Patients Provided MTM Post Hospital
Discharge
◦ Percentage of patients that received MTM that are readmitted
within 30 days
http://pqaalliance.org/measures/default.asp Accessed July 2, 2015

Medicare Part D Plan Ratings
◦ Star measures: medication adherence & safety
◦ Display measures: safety, adherence and MTM

Accreditation programs

National Business Coalition on Health (NBCH)

P4P Programs
◦ URAC & CPPA
◦ eValue8 (health plan evaluation)
◦ Integrated Healthcare Association of California
◦ Inland Empire Health Plan
PQA Patient Advisory Panel Introduction

Quality measure of the pharmacy benefits manager
(PBM)

Rate One to Five stars
◦ It’s a point system

Rating is NOT dependent on PQA measure… only 5 of
the 14 are PQA/Pharmacy related
http://pqaalliance.org/measures/cms.asp Accessed March 25th, 2014
Sogol E, Galdo JA. Quality Ratings Impact Community Pharmacy: The CMS
STAR Ratings. GPhA Journal. January 2014.
Measure Name
Weighting Category
Weight
Call Center – Foreign Language Interpreter
and TTY/TDD Available
Customer Service
1.5
Appeals Auto-Forward
Customer Service
1.5
Appeals Upheld
Customer Service
1.5
Complaints about the Drug Plan
Member Complaints, Improvement
1.5
Members Choosing to Leave the Plan
Member Complaints, Improvement
1.5
Drug Plan Quality Improvement
Member Complaints, Improvement
5
Rating of Drug Plan
Member Experience with Plan
1.5
Getting Needed Prescription Drugs
Member Experience with Plan
1.5
MPF Price Accuracy
Patient Safety and Drug Pricing
1
High Risk Medication
Patient Safety and Drug Pricing
3
Diabetes Treatment
Patient Safety and Drug Pricing
3
Medication Adherence for Oral Diabetes
Patient Safety and Drug Pricing
3
Medication Adherence for Hypertension
Patient Safety and Drug Pricing
3
Medication Adherence for Cholesterol
Patient Safety and Drug Pricing
3
http://pqaalliance.org/measures/cms.asp Accessed March 25th, 2014
http://www.cms.gov/Medicare/Prescription-DrugCoverage/PrescriptionDrugCovGenIn/Downloads/2015_Star_Ratings_UserCall-Slides_v2014_08_04.pdf. Accessed April 14, 2015
Measure Name
Weight
High Risk Medication
3
Diabetes Treatment
3
Medication Adherence for Oral Diabetes
3
Medication Adherence for Hypertension
3
Medication Adherence for Cholesterol
3
• 14 (was 18) total measures with different weighting
• 5 “Claims Based” measures = Pharmacy
• Account for over 50% of the total rating
http://pqaalliance.org/measures/cms.asp Accessed March 25th, 2014
Sogol E, Galdo JA. Quality Ratings Impact Community Pharmacy: The CMS STAR
Ratings. GPhA Journal. January 2014.
The Congressional Budget Office estimates that a 1% increase in the number of
prescriptions filled by beneficiaries
would
cause
Medicare’s
spending
If a patient
takes
their
medication
ason medical services
to drop 0.2%.
Increase certain
pieces of the pie
(e.g., drug utilization) …
… and you ultimately
decrease the bigger
pieces and total spend
If a patient takes their medication as prescribed, they don’t end up in the hospital!
Congressional Budget Office. Report Offsetting Effects of Prescription Drug Use on Medicare’s Spending for Medical Services.
November 29, 2012. http://www.cbo.gov/sites/default/files/cbofiles/attachments/43741-MedicalOffsets-11-29-12.pdf.
Adapted from PQA Ambassador Program

Description
◦ Percentage of patients 65 years of age and older who received
two or more prescriptions fills for a high-risk medication
during the measurement period
◦ Definition
 Measurement Period
 Period of time over which the prescription medication fill pattern is
assessed
 High-Risk Medication
 Select prescription drugs recommended to avoid in persons 65 years
and older per the American Geriatric Society Beers Criteria
Murphy E, Newsome R, Galdo JA. High Risk Medications in the Elderly: A Star Measure.
America’s Pharmacist. May 2014.
www.pqaalliance.org Accessed March 25, 2014

GG is an 85-year old Hispanic male, who resides at home with his family. The
patient’s son helps maintain GG’s medications, and he is prescribed the
following medications:

Lisinopril 20mg po qday
Metoprolol succinate 100 mg po qday
Digoxin 250 mcg po qday
Furosemide 20 mg po qday prn based on weight gain of 3-pounds in a day or
5-pounds over two days
Zolpidem 10 mg po qHS for sleep
Indomethacin 25 mg po TID for pain
Atorvastatin 40 mg po qday
Spironolactone 50 mg po qday
Tiotroprium 18 mcg inhaled qday
Diphenhydramine 25 mg po TID prn itching (OTC)
Multivitamin po qday











Lisinopril; Metoprolol succinate; Digoxin; Furosemide;
Zolpidem; Indomethacin; Atorvastatin; Spironolactone;
Tiotroprium; Diphenhydramine; Multivitamin

hypertension, heart failure, chronic obstructive
pulmonary disease, insomnia, chronic pain, vitamin
deficiency, and potentially status-post myocardial
infarction

Lisinopril; Metoprolol succinate; Digoxin; Furosemide;
Zolpidem; Indomethacin; Atorvastatin; Spironolactone;
Tiotroprium; Diphenhydramine; Multivitamin

Hypertension, Heart Failure, Chronic Obstructive
Pulmonary Disease, Insomnia, Chronic Pain, Vitamin
Deficiency, and potentially status-post Non-ST Elevated
Acute Coronary Syndrome

Digoxin

Zolpidem

Indomethacin

Diphenhydramine
◦ Reason: The maximum dose for digoxin is 125 mcg for geriatric patients
◦ Recommendation: Decrease digoxin to 125 mcg, monitor levels to 0.5 to 0.8
ng/mL per the DIG trial
◦ Reason: All non-benzodiazepine hypnotics are not recommended
◦ Recommendation: Non-pharmacological sleep hygiene
◦ Reason: Non-COX-selective NSAIDs should be avoided
◦ Recommendation: Acetaminophen, another NSAIDs would not be
recommended as the patient is status-post NSTEACS and has a diagnosis of
heart failure
◦ Reason: This is not a star rating red flag as the medication is OTC, however
geriatric patients should not be on first-generation antihistamines due to
the anticholinergic effects.

Description
◦ Patients who have received a medication for diabetes as well
as any drug that could be used for the treatment of
hypertension
◦ Definition
 Medication: Proxy for diagnosis of diabetes and hypertension
 Percentage of these diabetes-hypertension patients who receive an
ACEI or ARB
http://pqaalliance.org/measures/cms.asp Accessed March 25th, 2014
Sogol E, Galdo JA. Quality Ratings Impact Community Pharmacy: The CMS STAR
Ratings. GPhA Journal. January 2014.

Description
◦ Proportion of Days Covered is the PQA-recommended metric for
estimation of medication adherence for patients using chronic
medications
◦ Definition
 Statins
 Renin angiotensin system antagonists
 Four classes of oral diabetes






Biguanide
Sulfonylurea
Thiazolidinedione
DPP-IV inhibitor
Incretin mimetic
Meglitinides
http://pqaalliance.org/measures/cms.asp Accessed March 25th, 2014
Sogol E, Galdo JA. Quality Ratings Impact Community Pharmacy: The CMS STAR
Ratings. GPhA Journal. January 2014.

Proportion of Days Covered
(PDC) (Gold Standard)
◦ Denominator = number of days
between the first fill of the
medication during the
measurement period and the
end of the measurement
period
◦ Numerator = number of days
covered by the prescription
fills during the denominator
period

Medication Possession Ratio
(MPR)
◦ Summation of the “days’
supply” of medication refills
across an interval
◦ Numerator and denominator
calculated in differing ways
 Time interval as the time
between the first fill and last fill
of a medication = Overestimate
 Overlapping days covered
assumes that previous supply
exhausted
Adapted from PQA Ambassador Program
2014 Diabetes
PDC
<74%
>74%
>79%
>82%
-- Five!
2015 Diabetes
PDC
<74%
>74%
>79%
>82%
>85%
-- Five!
2014 Diabetes
PDC
<74%
>74%
>79%
>82%
77% PDC in
2014 is three
stars
-- Five!
2015 Diabetes
PDC
<74%
>74%
>79%
>82%
>85%
77% PDC in
2015 is TWO
stars
-- Five!
Caveat: No primary literature exists
to support these methods

Electronic Quality Improvement Platform for Plans &
Pharmacies

Developed by Pharmacy Quality Solutions (PQS) and
CECity

Owned by PQA
https://www.equipp.org/default.aspx Accessed March 25th, 2015
Sogol E, Galdo JA. Quality Ratings Impact Community Pharmacy: The CMS
STAR Ratings. GPhA Journal. January 2014.
Newsome R, Murphy E, Galdo JA. The ABCs of Quality. GPhA Journal. February
2014.
https://www.equipp.org/default.aspx Accessed March 25th, 2015
Sogol E, Galdo JA. Quality Ratings Impact Community Pharmacy: The CMS
STAR Ratings. GPhA Journal. January 2014.
Newsome R, Murphy E, Galdo JA. The ABCs of Quality. GPhA Journal. February
2014.
Adapted from PQA Ambassador Program
“Most Medicare Part D plans could move from 3 stars to
4 stars on each PDC measure if every pharmacy in its
network helped just one more RASA patient, one more
diabetes patient, and one more statin patient become
highly adherent.”
– David Nau, PhD, RPh, CPHQ, FAPhA
President, Pharmacy Quality Solutions, Inc.
Nau D. Medicare Star Ratings for 2014. Pharmacy Quality Alliance Quality Forum Lecture Series.
Webinar aired live October 31, 2013.
Star Rating
of the PBM
CMS
Community
Pharmacy?
PQA
PQS
EQuIPP

Adherence Programs
◦
◦
◦
◦
◦



Medication Synchronization
Patient Intervention
Packaging
Behavioral Interviewing
Pill Reminder Tools
Medication Therapy Management
Safety Alerts
Targeting of Patients and Providers
Adapted from PQA Ambassador Program

Adherence Programs
◦
◦
◦
◦
◦



Medication Synchronization
Patient Intervention
Packaging
Behavioral Interviewing
Pill Reminder Tools
Medication Therapy Management
Safety Alerts
Targeting of Patients and Providers

Better Patient Care, Increased Volume, Higher ROI,
High Performance Networks, Alternative Revenue
Sources

Competition, Licking and Sticking, Network Exclusions
Where will you be?
Incentives to motivate higher-value care
• 85% of all Medicare fee-for-service payments tied to quality or value by 2016, and 90% by
2018
Increasing tying payment to value through alternative payment models
• 30% by 2016 and 50% by 2018
• Alternative payment models include accountable care organizations and bundled-payment
arrangements
Changing the model of care delivered
• Health information technology reforms, eg transparency
• Leverage ACA established Patient-Centered Outcomes Research Institute (PCORI) to generate
and disseminate data
Burwell, S. Setting Value-Based Payment Goals – HHS
Efforts to Improve U.S. Health Care. N Engl J Med 372:10.
March 2, 2015.
April 6, 2015

Eliminate Pre-determined Thresholds
◦ CMS found sponsors have more significant levels on
improvement
◦ AKA “must” improve ‘x’ percent is now gone

New Measures
◦ MTM CMR Rate
 Assigned weight of “1”, and continue to only be “1”
 LTC beneficiaries are included in the denominator
 Hospice at any time during the plan year are excluded

Changes to measures
◦ Adherence and Diabetes Treatment
 Excluding ESRD patients
◦ Diabetes: Treatment of Hypertension
 PQA no longer endorses
 CMS will retire this measure in the CY2016
◦ Medication Adherence
 Use actual death date as disenrollment

Measure 1 (Opioid High Dosage): The proportion (XX out of 1,000) of
individuals without cancer receiving a daily dosage of opioids greater
than 120mg morphine equivalent dose (MED) for 90 consecutive days
or longer.

Measure 2 (Multiple Prescribers and Multiple Pharmacies): The
proportion (XX out of 1,000) of individuals without cancer receiving
prescriptions for opioids from four (4) or more prescribers AND four
(4) or more pharmacies.

Measure 3 (Multi-Provider, High Dosage): The proportion (XX out of
1,000) of individuals without cancer receiving prescriptions for opioids
greater than 120mg morphine equivalent dose (MED) for 90
consecutive days or longer, AND who received opioid prescriptions
from four (4) or more prescribers AND four (4) or more pharmacies.
PQA. Use of Opioids from Multiple Providers or at High
Dosage in Persons Without Cancer. May 2015.

Updates to the High Risk Medications

Statin Therapy in a patient with diabetes

Medication Synchronization
 Program acceptance and participation: Eligible patients who
participate.
 Patient contact rate: % patients participating who were contacted
with appointment call
 Med Sync Completeness: % patients enrolled with all chronic meds
included in their sync
 Med Sync Continuation: % enrolled with chronic meds synced and still
in sync after 6 months
SAP A
• Hospital Admission for ADR Anticoagulants
• Adherence to Immunosuppressants
SAP B
• MTM – Patient Satisfaction
• Transition of Care in LTC
• Primary Medication Non-Adherence
SAP C
• Hospital Utilization related to ADEs
• Concomitant Use of Opioids, Benzodiazepines, and Muscle Relaxants
• Gap in Therapy – Glaucoma
SAP D
• MTM: Specific Drug Problem Resolution
• Hepatitis C - Outcomes




Pharmacists are capable of impacting quality metrics and
improving patient outcomes!
Each pharmacy is being evaluated on how their patients
are performing on quality measures.
Health plans are utilizing preferred networks to get high
quality results from their patients (often at a lower costs).
Different philosophies from health plans and PBMs
pertaining to performance on metrics:
◦ Pay-for-Performance (P4P)-additional payments or overall payments
based on Star Measure Performance
◦ “Sticks & Carrots”-exclusion from network
Adapted from PQA Ambassador Program

There is a two year lag on claims data to the CMS star
ratings
◦ Perform now, stay in business in the future

Pharmacies can account for 50% of a PBMs quality
rating (aka, “star rating”)

Non-dispensing services, like medication
synchronization, are the future of community
pharmacy
John A. Galdo, Pharm.D., BCPS, CGP (Jake)
Assistant Professor of Pharmacy Practice
Community Practice Residency Director
[email protected]
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