Pharmacy Benefit Manager

First-time applicants for URAC accreditation often encounter the challenge of finding or creating a Quality Management Committee (“QMC”) within their organizations. This sometimes is “finding” because a committee by another name may already exist and need only a bit of tweaking to comply with URAC’s requirements for such a committee. In fact, an organization may have two or three committees that are likely candidates for such a designation, and therefore must either elevate one of the committees to that position or create a “super-QMC” to pull together the activities of the other committees. Other organizations will find it advantageous to create a new QMC out of whole cloth.

This is particularly true in the world of pharmacy benefit managers (“PBMs”). Most PBMs of which we at Integral Healthcare Solutions are aware will have to do a bit of fiddling with their committee structures to meet the various URAC standards that address the structure, role, and responsibilities of the QMC. It is timely then, as URAC reviewers criss-cross the nation conducting the onsite reviews of the 10 PBMs participating in URAC’s “beta” program for its nascent PBM standards, to summarize what a PBM QMC should look like and do. I use “must” where we found, in either standards or interpretive information accompanying the standards, specific reference to the QMC. I use “should” where we have concluded, based upon our years of experience with URAC-accredited companies’ QMCs, the QMC should be involved to be fully consistent with URAC’s view of QMCs.

Composition

The QMC must have as members:

• a member of senior management with the authority and responsibility for the overall operation of the quality management program (Core 32(e))
• at least one participating provider or a mechanism to receive input from participating providers (Core 33(e)).

Charter

The QMC must be “granted authority for quality management by the organization’s governing body” (i.e., the Board of Directors) (Core 33(a)).

Meetings

The QMC must meet at least quarterly (Core 33 (c)) and maintain minutes at all its meetings (Core 33 (d)).

Reports the QMC must receive

The QMC must receive, periodically:

• reports on progress in meeting quality improvement goals (Core 33(h))
• analyses of consumer complaints and appeals (Core 29)
• reports on ongoing compliance with URAC standards (Core 34(a))
• reports on objectives and approaches utilized in the monitoring and evaluation of QM activities (Core 34(b))
• tracking and trending reports of key indicators relevant to the scope of the entire organization and related to consumer and health care services (Core 34(c))
• reports on the implementation of action plans to improve or correct identified problems (Core 34 (d))

Reports the QMC should receive

The QMC should receive periodic reports on:

• the results of consumer satisfaction surveys (Core 25)
• the organization’s performance with respect to its standards to assure that consumers or clients have access to services (Core 26)
• ongoing compliance with operating requirements for the call center for in-bound telephone calls (CSCD 7)

Reports the QMC must make

The QMC must provide “on-going reporting to the organization’s governing body.” (Core 32(b))

Specific decisions it must make and actions it must take

The QMC must:

• approve the quality improvement projects to undertake (Core 33(g))
• annually evaluate the effectiveness of the QM program (Core 33(i))
• annually review and update the written description of the organization’s QM program (Core 32 (c))

Specific decisions it should make and actions it should take

The QMC should:

• approve the organization’s mechanism to respond on an urgent basis to situations that pose an immediate threat to the health and safety of consumers (Core 23)
• review and approve the organization’s systems:
  • for identifying and communicating drug-drug interactions at point-of-service (DrUM 5(a)); and
  • of drug utilization management tools, such as prospective and concurrent DrUM that identifies situations which may compromise the safety of the consumer (DrUM 5(b))

Ongoing activities of the QMC

The QMC must:

• provide guidance to staff on quality management priorities and projects (Core 33(f));
• monitor progress in meeting quality improvement goals (Core 33(h))

After a several-year dormancy, the idea of a URAC Accreditation Program for Pharmacy Benefit Managers (PBMs) has reawakened. URAC announced today that it has formed a committee to develop standards for PBMs. This comes years after the PBM industry first started discussions with all the major managed care accreditation bodies to see who would be interested in developing such standards.

None of the accreditation organizations were ready for the idea in the early part of this decade, when the idea was first floated. I'm guessing that URAC is better prepared to step into this arena since the advent more recently of the Core Standards, which provide a baseline of sound management practices across all types of organizations. This narrows the range of issues to be hammered out, since the "management 101" principles are handled in the Core module.

What will be interesting to see is how the committee handles the fact that non-M.D. pharmacists typically make the UM-like decisions in the drug use management component of PBM operations. I surmise that once that issue has been resolved (if it has not already been resolved), the rest of the issues will go pretty smoothly.