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Transition to value-based care will proceed

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As the Pharmacy Quality Alliance (PQA) gears up for 2017, the outlook we envision consists of measuring what matters to patients, providers, plans and pharmacies.

PQA has a rather unique role in the marketplace as a measure developer, and since our process is very inclusive and participatory, we have experienced a strong growth in our membership base to over 200 members in 2016.

Laura Cranston_PQA

Laura Cranston, Pharmacy Quality Alliance

As a multi-stakeholder, we now represent all facets of the medication and immunization spectrum. The role that PQA plays in developing measures that can be used for public reporting of providers, health plans and health systems’ performance will continue to take front and center stage, even within a new administration.

While we can expect that Congress and our new president will be focused on making changes to the Affordable Care Act when they re-convene, the fundamental shift of our health care system from volume to value will remain.

This shift began in January 2015, when the Department of Health and Human Services (HHS) laid out goals of tying 30% of traditional (fee-for-service) Medicare payments to quality or value through alternative payment models (APMs), such as accountable care organizations (ACOs) or bundled payment arrangements by the end of 2016. HHS also set a goal of tying 85% of all traditional Medicare payments to quality or value by the end of 2016 through programs such as the Hospital Value-Based Purchasing Program and the Hospital Readmissions Reduction Program. These goals were met and surpassed very early in 2016, and the country is quickly approaching the 2018 goals of 50% and 90%, respectively.

This transition will continue to require strong measures that have been well vetted by multi-stakeholders in a transparent manner. While PQA will retain its focus on medication and immunization-related measures primarily designed for health plan accountability, we are beginning to look at developing measures as well for physician providers, and for pharmacy accountability. PQA will work to ensure that our measures are aligned with existing efforts in the marketplace, and are not overly burdensome on ­providers.

The performance measures that our health care system needs are twofold: outcomes-based measures and patient-reported outcomes measures. This is the new direction for measure developers, and while these types of measures are challenging to develop, it is the direction we must head.

On the upswing: Value-based payments

cdr-filler-opinion-750With the October 2016 release of the Medicare Access and CHIP Reauthorization Act (MACRA) final rules, we can see that value-based payment models continue to be a high priority. The rule finalizes the parameters of two value-based payment tracks for physician reimbursement: APMs and the Merit-Based Incentive Payment System (MIPS). Collectively referred to as the Quality Payment Program (QPP), both APMs and MIPS move Medicare reimbursement from fee-for-service to rewarding for value-based care.

For the APM track, providers are incentivized to participate in such models as ACOs, patient-centered medical homes, and bundled payment models. It will be critical to explore what role pharmacists and pharmacies may be able to play in this new system through team-based models of care, collaborative practice agreements or other innovative arrangements.

PQA is launching an ad-hoc MACRA Workgroup with several other pharmacy organizations and several physician-based groups to identify opportunities to collaborate with physicians in these value-based programs described within the final MACRA ruling, potentially expanding pharmacist-based, performance-based networks further. Currently, pharmacists are not recognized as eligible providers under MACRA; however, pharmacists are essential members in the patient care team.

Appropriate medication management is a vital component for improving quality of care and thus improving patient outcomes. Many of the quality measures and improvement activities included in the MIPS focus on various aspects of medication use and safety, creating an opportunity for pharmacists to engage in the program.

High priority: Potentially unsafe opioid prescribing

PQA continues to focus on performance measures that assess unsafe opioid prescribing and medication use. PQA’s membership endorsed three performance measures that examine multi-provider, high-dosage opioid use in persons without cancer.

In December 2016, PQA’s membership also endorsed a new opioid-related measure that assesses concurrent use of opioids and benzodiazepines. There are several entities that were anxiously looking forward to that final PQA endorsement, as they were looking to adopt that measure into various reporting programs.

In 2017, PQA’s efforts will turn to development of outcomes measures that examine hospital, emergency department and urgent care utilization related to prescription opioid overuse. Adoption and implementation of these measures is one approach to addressing the unsafe use of opioids and overdose epidemic facing the United States. Strong measures tied with engaged pharmacists will lead to better management and monitoring, and ultimately to better outcomes for patients.

CMS plans to use PQA’s measures in its patient safety overutilization measure reports which it provides to Part D sponsors. It has proposed adding the three PQA opioid utilization measures to the 2018 Part D Display Measures, which would use 2016 data.

Political tailwind for quality measures

Quality measurement will continue to have a strong political tailwind in 2017. The motivation for increased health care provider accountability through quality measurement is a priority that has strong bipartisan support.

Pharmacy is well positioned to be a part of this continuing dialogue, and PQA is pleased to play an active role in the dialogue on moving to a value-based system and to serve as a developer of meaningful metrics to address appropriate medication management.

Laura Cranston is executive director of the Pharmacy Quality Alliance (PQA).


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