Academy of Managed Care Pharmacy: Evaluate Existing Quality Measures for Use in Exchanges

 Alexandria, Va., January 2, 2013 –The Academy of Managed Care Pharmacy (AMCP) recommends that the Centers for Medicare & Medicaid Services (CMS) evaluate existing national quality health measures before implementing quality metrics in state health insurance Exchanges starting in 2016.

AMCP’s recent comment letter to CMS stems from the agency’s request for information on ways health insurers offering “qualified health plans” in the Exchanges can foster and promote quality, including quality improvement strategies, enhancement of patient safety and public reporting beginning in 2016 under the Affordable Care Act.

Academy members have experience with the “star ratings” quality improvement and measurement strategies under Medicare Advantage and Medicare Part D programs. The star rating system is one of the first national programs to use quality metrics for health care services. The program measures performance in 50 areas, including those that affect pharmacists and adherence.

The Academy recommends that CMS begin by evaluating the star ratings program to select measures that improve quality, while eliminating those that do not, before incorporating these measures in the Exchanges. AMCP also suggests that CMS consider the measurements used to evaluate accountable care organizations (ACOs), patient-centered medical home (PCMH) models, and other innovative delivery systems when developing measures for use in the Exchanges.

The Academy’s comment letter also addressed several specific questions from CMS, including: What are the priority areas for quality rating in the Exchange marketplace? Should these be similar to or different from the Medicare Advantage 5-star quality rating system? 

To this question, AMCP’s answer included: To the extent possible, quality measurement should be consistently aligned among all programs, and the goals should be similar. However, the health care system must recognize that different measures may be more important in some populations compared with others. Furthermore, patients in various age groups, demographics and regions of the country have different needs than the Medicare population and this should be recognized in the Exchanges.

Quality measurements must accommodate these differences and should not penalize plans. For example, plans with younger populations may have fewer individuals using medications for chronic diseases; therefore, some measures related to medication utilization may not sufficiently determine the quality of a plan. In these plans, other measures, such as prevention or a focus on other diseases or conditions might be given more weight.

Aligning measures across programs also provides for more economic efficiency across the health care system. If providers and health systems must implement multiple measurement systems, the administrative and technology costs will increase; and thus, overall costs to the health care system will increase. This situation would undermine the goals of improving quality and lowering costs in the health care system.

To read AMCP’s Dec. 20, 2012, comment letter click here or visit