A paper by Cock(2024) Provides an excellent overview of the organizations that develop quality metrics for pharmacy programs. The quality of pharmacy plans is critical because approximately 85% of the U.S. population obtains prescription drug coverage through a public (eg, Medicare, Medicaid) or commercial (eg, employer-provided) pharmacy plan. Below is a useful summary.
Selection of quality measures is based on testing of validity (to ensure that the measure accurately represents the aspect of quality for which it is intended to be measured), reliability (to ensure that measurements are precise and estimates are consistent), importance (i.e., aligned with key programmatic/population health priorities), Usability (i.e., whether the indicator is easy to understand), feasibility (the data collection burden required to evaluate the indicator), and consistency (whether it is consistent with and not duplicated with other quality indicators from other organizations).
It is important to note that recent legislation has affected the quality measurement of Medicaid programs.
Substance Abuse Disorder Prevention (SUPPORT) Act of 2018 Promoting Opioid Recovery and Treatment in Patients and Communities Act imposes new requirements for state Medicaid DURs [drug utilization review] Plans and Medicaid Contract Managed Care Plans. These requirements are designed to encourage the safe, effective, and efficient use of prescription opioids with a focus on deterring overuse and abuse. Specific topics for quality measurement include monitoring the concomitant use of prescription opioids with benzodiazepines or antipsychotics, ensuring appropriate opioid dosing and limiting days of supply, and identifying situations of suspected abuse. In addition, the SUPPORT Act requires that the Medicaid DUR program monitor the use of antipsychotic medications in children.
An organization that may be less familiar to general (i.e., non-pharmaceutical) quality measurement experts is the Utilization Review Accreditation Council (URAC).
URAC is the exclusive certified provider of pharmacy benefit management (PBM) companies that offer pharmacy benefit plans.Although URAC certification is voluntary, URAC-certified PBMs account for more than 90% of U.S. prescription drug volume
For more details on quality measurement, including how to determine quality measure attribution and how to implement medication therapy management (MTM), see the full article here.
