Quality measurement is being rebuilt, and PQA is holding the pen. In his RISE Product & Pharmacy Strategy Summit keynote, Micah Cost, CEO of the Pharmacy Quality Alliance, told Medicare leaders the next five years will set the course for the next twenty.
Why PQA’s roadmap matters now
Here is why your team should care. PQA is the consensus body where member organizations each get one vote to endorse the quality measures your Stars and quality teams build around. The work is driven by subject-matter experts and spans four domains: appropriate use, adherence, safety, and medication management services. When PQA signals a shift, plan on your roadmap shifting too.
Quality is moving from process to outcomes
Cost was clear on direction. Measures are moving away from checking boxes on process and toward outcomes patients feel. Every endorsed measure still has to clear four bars: importance, feasibility, scientific acceptability, and real-world usability. And the guiding question is getting sharper: what changed for the patient?
PQA is building toward gaps you know well. Think medication use in chronic kidney disease, risk reduction for people with diabetes, and guideline-directed therapy for heart failure. The heart failure measure leans on diagnostic codes, which is new ground for the field. PQA is also reaching past claims data to get there.
Patients are helping build the measures
PQA launched a patient advisory council to ground quality in what patients value. As Cost put it, medications do not work in patients who do not take them. So measures are being built with patients, not only signed off by them. Research on comprehensive medication review points toward patient-reported outcome measures, a population-level read on whether care is working.
Pharmacy is stepping into value-based contracting
Medication therapy management is widening into full medication management, and pharmacy is becoming a quality partner. PQA is building pharmacy-level measures for areas like A1C and blood pressure, so pharmacists get credit for driving results. A pilot on immunizations and gap closure showed real hunger from health plans to work with pharmacies on value.
The catch? These deals are slow. Value-based pharmacy contracts take 12 to 18 months to sign. Service-based value does not slot neatly into agreements built around products. Success asks pharmacies to take on real risk, not chase a bonus, while plans put enough incentive on the table to make new care models work.
Your data has to count
Cost was blunt about the weak link. Pharmacy systems were built to bill, not to capture clinical care, so the data often misses what plans need for quality reporting. His advice: tell your vendors exactly what you need for the data to count, and invest in clean infrastructure before you sign. Pharmacies now track more than PDE records, including A1Cs, blood pressure checks, and immunizations. Ask what clinical data already flows to you.
Pharmacy access is the next research front
PQA is studying a real-world problem: what happens when a Medicare beneficiary loses access to their pharmacy. The team is talking directly with beneficiaries to map travel burden, longer drives, leaning on caregivers, shifting schedules, and spotty transportation, and how each one hits adherence. An update to the Medication Access Patient Journey Framework is on the way.
Do not walk away from quality strategy
Even with recent Medicare Part D changes, Cost urged plans to hold their quality medication strategy. The strategy feeds your other quality work and helps you handle the rising complexity of specialty drugs. The drivers of success? Get ahead of policy changes, balance formulary decisions against performance, use MTM as a quality engine, and hold vendors accountable. This moment is your chance to shape the next generation of quality measurement.
Key takeaways
- PQA is the consensus body behind the measures your Stars teams build around. Watch the roadmap.
- Quality is shifting from process to outcomes patients feel. Track what changed for the patient.
- New measure concepts target chronic kidney disease, diabetes risk reduction, and heart failure built on diagnostic codes.
- Patients are co-building measures. Expect patient-reported outcome measures for medication review.
- Pharmacy is becoming a value-based partner. Expect 12 to 18 month timelines and shared risk.
- Your pharmacy data was built to bill, not to count. Tell vendors exactly what you need.
- Pharmacy access research is coming, with travel burden and adherence in focus.
- Do not abandon your quality medication strategy after Part D changes. Specialty complexity is rising.
Questions to bring to your team
- Which of your measures are still stuck on process, and which outcomes would prove patient impact?
- Is your pharmacy network ready for value-based contracting, and who takes on the risk?
- Do your vendor agreements spell out the clinical data you need for quality reporting?
- How would pharmacy closures affect adherence in your highest-need members?
- Where does MTM drive quality for you today, and where is the gap?
Continue the conversation at an upcoming RISE event.