Over the last two decades, quality measurement has fundamentally transformed health care. What began as an effort to measure performance has evolved into something much more consequential: a mechanism for improving outcomes, driving accountability, and creating value for patients and the health care system.
Since its founding in 2006 as a public-private partnership with the Centers for Medicare & Medicaid Services (CMS), the Pharmacy Quality Alliance (PQA) has worked toward a simple but ambitious vision: optimizing health by advancing the quality of medication use.
Today, PQA measures are used across Medicare, Medicaid, the Marketplace Quality Rating System, and numerous state and private-sector programs, impacting more than 150 million lives. The success of these efforts reinforces an important truth: medications only create value when they are used appropriately (i.e., indication, effectiveness, safety, and adherence).
As health care continues its transition toward value-based care, quality medication use must remain a strategic priority for health plans, pharmacies, providers, policymakers, and patients alike.
Quality Medication Use Has Never Been More Important
The pressure facing health plans and providers today is significant. Medicare Advantage and Part D plans are navigating Stars fluctuations, Inflation Reduction Act implementation, reimbursement pressures, evolving risk adjustment methodologies, and rising drug costs. At the same time, stakeholders are being asked to deliver better outcomes, improve patient experience, and demonstrate value.
Consultants and experts across the health care industry continue to opine on the recent Clover Insurance Company vs. HHS court ruling and its possible impact on the future of the Medicare Part D Star Ratings program. However, the fact remains that medication-focused quality measures continue to represent some of the most important drivers of Part D Star Ratings performance, not just as standalone measures but as determinants of overall health outcomes. De-prioritizing quality medication use would inevitably lead to suboptimal care, worsening health outcomes, and a decline in overall quality and value across the spectrum.
PQA measures are among the few quality measures in Medicare for which CMS has demonstrated a direct relationship between better performance and measurable health care cost avoidance. Current CMS analyses suggest that adherence improvements associated with the PQA medication adherence measures correspond to approximately $25-$29 billion in annual avoided health care expenditures. Over the life of the Medicare Star Ratings program, the cumulative economic value of these measures likely reaches hundreds of billions of dollars, making them among the most financially consequential quality measures in Medicare. Additionally, this estimate only reflects the three adherence measures. It does not include potential savings from other PQA measures such as Statin Use in Persons with Diabetes (SUPD), completion rate for comprehensive medication review, or medication safety measures focused on polypharmacy and opioids. Therefore, the total economic value attributable to the full suite of PQA’s medication-focused measures is likely larger than the published CMS analyses.
Pharmacy costs and quality of care can no longer be viewed in separate silos. A comprehensive pharmacy strategy is increasingly central to the success of health plans, providers, and health systems, in driving quality and value. Quality medication use is no longer merely an operational concern; it is a business imperative that directly influences outcomes, performance, and sustainability.
Outcomes as Future Endpoints
For years, health care quality measurement focused primarily on processes. Did a service occur? Was a medication dispensed? Was a review completed? The importance of those questions cannot be understated, and while those questions remain important, the future of quality measurement requires us to ask an additional meaningful question: What changed for the patient?
Across the industry, there is growing sentiment that quality programs should increasingly evaluate outcomes that matter to patients. This includes clinical improvement, quality of life, medication safety, affordability, access, and patient experience. At PQA, we are actively exploring opportunities to advance person-centered outcomes measurement, including patient-reported outcome measures and other innovations that better reflect the patient’s experience throughout the medication use journey. The goal is not simply to measure whether care was delivered, but whether that care improved health.
Patients as Advocates for Quality
As measurement continues to evolve, patient engagement must evolve with it. Historically, patients were often asked to validate measures after they had already been developed. The future requires a different approach. Measures should be built with patients, not simply reviewed by them.
Patients, caregivers, and advocates bring unique perspectives about what defines successful care. Their priorities often extend beyond traditional clinical endpoints and include issues such as access, affordability, safety, education, and quality of life.
Meaningful quality measurement must reflect what matters most to the people receiving care. That is why PQA continues to engage patients throughout the measure life cycle .
PQA has worked for a decade to meaningfully include patient perspectives in our work, and we actively seek ways to improve how we do it. To further ensure that the voice of the patient is represented across our work, PQA launched the Patient Advisory Council this year. This council is tasked with advising PQA on what matters most to patients, their families and caregivers and providing input on strategies to meaningfully incorporate patient perspectives throughout PQA’s work.
Medication Management Drives Better Outcomes and Greater Value
Medication management remains one of the most promising tools available to improve quality and outcomes, and PQA remains committed to advancing the quality of medication management services to improve patient outcomes through pharmacist-provided and team-based care. As the health care system becomes more complex, patients increasingly need support navigating medication regimens, identifying medication-related problems, understanding treatment goals, and coordinating care.
PQA’s work in medication management is focused on advancing standardization, improving documentation, strengthening interoperability, and demonstrating the connection between medication management interventions and patient outcomes. We are also exploring patient-reported outcome measures related to comprehensive medication reviews as part of a broader effort to increase patient-centeredness within medication management services. Done effectively, medication management can improve outcomes while simultaneously supporting quality improvement initiatives and value-based care.
Data Is the Foundation for the Future
One of the most important lessons of the value-based care movement is that data alone is not enough. Data must be structured, shareable, interoperable, and actionable. Medication-related data contains some of the richest clinical insights available in health care. When integrated effectively, it can connect pharmacy, medical, quality, and care management functions to support coordinated patient care and stronger performance outcomes.
Organizations that invest in data infrastructure today will be better positioned to participate in value-based arrangements, improve quality outcomes, strengthen accountability, and respond to the evolving demands of quality programs.
Looking Ahead
The future of quality measurement will explore new clinical areas, measures focused on outcomes, inclusion of patients, and more sophisticated approaches to evaluating value. PQA continues to explore new measure concepts and expanded data sources to meet the opportunities and needs of the industry. At the same time, we continue to advance measurement concepts that demonstrate the correlation between quality medication use and meaningful outcomes.
Quality measurement is not just about reporting performance. It is about helping patients achieve better outcomes, improving the value of care, and ensuring the sustainability of our health care system. The organizations that thrive in this environment will be those that recognize quality medication use as a strategic asset rather than a compliance exercise.
The question is not whether quality measures will shape the future of health care. The true challenge is in shaping those measures in ways that truly improve the lives of the patients we serve.