Quality Measurement in Healthcare Reform

St. Louis—The Patient Protection and Affordable Care Act (HR 3590) introduces guidelines regarding quality improvement and makes quality a major part of the national healthcare strategy, according to a contemporary issues session at the AMCP meeting titled The Growing Emphasis on Quality Measurement under Healthcare Reform. David Domann, MS, RPh, director, health policy, advocacy, and quality, Ortho-McNeil-Janssen Pharmaceuticals, Inc, spoke on quality initiatives included in the healthcare legislation. The initiatives will begin in the next few years in terms of delivery models, payment models, and quality improvement and measurement.

Mr. Domann said that many of the provisions have not been tested and have not been funded, although he expects them to take place as planned. “There will be significant changes in delivery systems and payment models,” he said. For instance, by January 1, 2011, there will be a new office within the Department of Health and Human Services (DHHS) called the Center for Medicare and Medicaid Innovation. The purpose of the program is to test payment methods and healthcare delivery systems that reduce cost and improve the quality delivered under Medicare and Medicaid. The models introduced must improve quality without increasing cost, reduce spending without reducing quality, or improve quality and reduce spending. Preference will be given to models that improve coordination, quality, and efficiency of care for Medicare, Medicaid, and dual-eligible recipients.

Mr. Domann said the following models will be tested: promoting broad payment and practice reform in primary care, transitioning primary care physicians away from fee-for-service–based reimbursement, promoting care coordination, and assisting patients in making informed decisions. In addition, the law requires DHHS to provide grants or enter into contracts with eligible entities to provide patient-centered medical homes. By next year, a program called the Multi-payer Advanced Primary Care Practice Demonstration will aim to implement the reforms consistent with the medical home concept, in which the Centers for Medicare & Medicaid Services (CMS) plans on awarding grants to ≥6 states based on their ability to connect patients to community-based resources.

By January 2012, CMS will also have accountable care organizations (ACOs). Mr. Domann discussed information from CMS’s web site that indicated ACOs “facilitate coordination and cooperation among providers to improve the quality of care for Medicare beneficiaries and reduce unnecessary costs.” However, currently, ACOs are not fully defined, and questions remain regarding which organizations can become ACOs, as well as what requirements and level of quality performance standards they will have to meet. In September, DHHS Secretary Kathleen Sebelius announced she was seeking input on proposed structure, principles, and details for a National Health Care Quality Strategy and Plan, which will be sent to Congress by January 2011. Its framework is based on better care (addressing quality, safety, access, and reliability, as well as active engagement among providers, patients, and families), affordable care (reigning in unsustainable costs for families, governments, and the private sector), and healthy people/healthy communities (strong partnerships among providers, individuals, and community resources).

Mr. Domann also discussed the National Quality Forum (NQF), a nonprofit organization focused on improving healthcare quality. The NQF convened the National Priorities Partnership (NPP) comprising 32 multistakeholder organizations (representing consumers, purchasers, health professionals, health providers, suppliers, and health plans) as well as 6 federal government members that do not vote (CMS, Agency for Healthcare Research and Quality, Centers for Disease Control and Prevention, Health Resources and Services Administration, National Institutes of Health, and Department of Veterans Affairs).

The NPP created the following national healthcare priorities: equitable access, patient and family engagement, population health, safety, care coordination, palliative and end-of-life care, elimination of overuse, and infrastructure supports. The NPP also identified a list of 20 high-impact Medicare conditions based on current high cost or rapidly growing cost, with a top 5 of major depression, congestive heart failure, ischemic heart disease, diabetes, and stroke/transient ischemic attack. Mr. Domann then spoke about another initiative, the Pharmacy Quality Alliance (PQA), established in April 2006 as a nonprofit, public–private partnership with >60 members, including health plans, pharmacy benefit managers, pharmacies, federal agencies, pharmaceutical research and manufacturing companies, and consumer advocates.

The PQA’s mission is improving the quality of medication use by measuring and reporting performance information related to medications. According to Mr. Domann, the organization coordinates workgroups on performance measurement and improvement and provides communications and educational programming on quality measurement and performance improvement. In phase 1, PQA participants used claims data from pharmacies and health plans to create pharmacy performance reports. The data were aggregated and created benchmarks and Web-based reports for the pharmacies. In phase 2, beginning this year, the focus is on improving medication quality; pharmacist-provided interventions for medication adherence are being tested in Pennsylvania, Illinois, and Tennessee.—Tim Casey