It recognizes the essential role of pharmacists, PBMs, and health plans in improving the quality of care provided to patients across all lines of business and supports a measure development process that integrates evidence-based medicine and stakeholder feedback in a timely manner. AMCP emphasizes the importance of aligning quality measures across benefit programs to ensure consistency, economic efficiency, and quality throughout the health care system. To promote fair competition among plan sponsors, AMCP advocates for the evaluation of quality measure policies and the continued development of performance measures. In collaboration with complementary organizations, AMCP seeks to align all health care stakeholders in advancing improvements in patient care management.
Quality measures are used to assess and record the performance of health care systems, organizations, and providers in how they deliver care. The Centers for Medicare and Medicaid Services (CMS) establishes care benchmarks for Medicare (Star ratings), Medicaid, and Affordable Care Act plans, while other organizations also develop and implement quality metrics for managed care organizations (e.g., URAC for pharmacy benefit managers, National Committee for Quality Assurance’s HEDIS measures for commercial and Medicaid-contracted managed care plans).1 Additionally, other organizations, like the Pharmacy Quality Alliance, “conceptualize, specify, test, refine, endorse, and maintain measures” related to medication use.2
Quality measures aligned across the industry can promote consistency, reduce administrative burden, and enhance patient equity. The development of quality measures should follow a transparent process incorporating input from pharmacists, health plans, pharmacy benefit managers (PBMs), and other stakeholders. Transparency ensures that measures are evidence-based and applicable in all real-world health care settings. Proper updates with the latest clinical evidence help quality measures maintain relevance and reflect advancements in medical science and patient care.
Limited data are available directly associating improvements in quality metrics with improved patient outcomes. However, some data suggest improved Star ratings are associated with fewer 90-day hospital readmissions, an increase in the use of higher-rated hospitals, and a decrease in the use of lower-rated hospitals.3
Additionally, higher Star ratings have been tied to greater plan enrollment, while lower Star ratings are associated with a greater likelihood of switching plans or moving to traditional Medicare.2,3 Though not directly related to patient health outcomes, this is a relevant outcome for plan sponsors competing in a crowded marketplace.
Finally, despite limited findings directly correlating health outcomes with improvements in quality metrics, Star ratings target measures that have been tied to health outcomes, such as medication adherence. For example, one study found that improving adherence to medications for common conditions like diabetes and hypertension could lead to millions of fewer hospital days and billions in savings for traditional Medicare plans,5 suggesting similar benefits for Medicare Advantage enrollees.
More information can be found in the JMCP Primer on Quality Measurement and Reporting in Pharmacy Benefit Plans.
Quality Performance Measures:
• 03/31/25 - Combined associated historical statements into one position statement and introduced “Background” and “Evidence” sections.
AMCP offers a wide variety of educational opportunities, from events and webinars to online training.
