About this research: Developed and produced in collaboration with Kiser Healthcare Solutions in connection with the 2026 PQA Annual Meeting.
The Connective Tissue Opportunity that could catalyze its next 20 years.
About this research: Developed and produced in collaboration with Kiser Healthcare Solutions in connection with the 2026 PQA Annual Meeting.
I am excited to attend the PQA Annual Meeting this week for quite the momentous occasion of their 20th Anniversary. I anticipate well-deserving recognition for the work and achievement that has brought them here. Reid Kiser, my own colleague and former PQA leader, has contributed meaningfully to PQA's evolution over those years.
Twenty years is a meaningful milestone for any organization, and PQA's anniversary deserves recognition on its own terms. In two decades, PQA built a measure development infrastructure, earned a direct CMS relationship, and established itself as the authoritative body connecting pharmacy quality to health plan incentives at national scale. That didn't happen by accident.
Most conversations about pharmacy quality focus on what the measures cover and whether they reflect what clinicians care about. That framing misses the more consequential question: who has the structural position to actually connect clinical evidence to payer behavior at scale?
PQA's answer to that question is unique. Through its direct relationship with CMS and its central role in the Star Ratings quality framework, PQA has operational reach into every Medicare Advantage plan in the country, and arguably into payer and PBM pharmacy network management well beyond. When PQA develops or endorses a measure, health plans act on it. That is not an abstraction. It drives formulary design, care management investment, and member outreach programs across tens of millions of beneficiaries annually.
No clinical professional organization has that kind of direct operational leverage over payer behavior, including pharmacy professional organizations such as APhA, ASHP, AMCP, ACCP, NCPA, NABP, and JCPP, or medical professional societies such as the American College of Cardiology, American College of Radiology, American College of Physicians, or others. They have clinical authority. These professional societies own the guidelines, but the mechanism to translate clinical authority into payer action is exactly what PQA has built.
Going into this meeting, I wanted to share my own perspective on what I would love to see manifest over the next decade or more. I strongly believe the real opportunity ahead is for PQA to leverage that position not just to sustain its own measurement portfolio, but to become the connective tissue between clinical guideline development and operational quality measurement across the entire pharmacy and medication management landscape, becoming an even stronger catalyst for care and an elevated partner to pharmacy and medical societies alike.
Figure 1. PQA occupies a structural position no single stakeholder can replicate, sitting upstream of payer behavior through CMS and Star Ratings, and adjacent to the clinical organizations that hold guideline authority. The bidirectional opportunity is to translate clinical evidence into deployable measures, and return real-world utilization signal back to guideline developers.
The pharmacy quality ecosystem currently operates as two largely parallel and siloed systems. PQA-endorsed measures, anchored in pharmacy claims, proportion of days covered (PDC), and Star Ratings weighting, drive payer behavior at scale. Clinical professional organization measures, built around guideline adherence, clinical data, and specialty-specific process indicators, inform best practices and clinician behavior in clinical settings.
Each system is internally coherent. Neither is wrong. But they don't talk to each other, and that gap produces real downstream consequences in data and metric asymmetry for patients, providers, and plans alike.
Heart failure GDMT is worth examining closely here, and not as a hypothetical, but because PQA has recently embarked on HF GDMT measure development, launching a Heart Failure Technical Expert Panel in early 2026. That initiative reflects exactly the right instinct: moving toward the clinical data environment where GDMT actually lives. It also surfaces the structural challenge that makes this work hard. ACC/AHA performance measures for heart failure address SGLT2i initiation, ARNI use, and beta-blocker dose optimization, built on clinical data, EF documentation, and titration records. Existing PQA Star Ratings measures address medication adherence for overlapping drug classes, built on pharmacy claims and PDC thresholds. Both want the same patient on the right drugs. But they may use different metric definitions for numerators and denominators, different look-back windows, different exclusion criteria, and different data sources. The HF GDMT measure work PQA has initiated is a clear opportunity to reconcile those specifications deliberately through a co-development relationship with ACC and AHA that would make the resulting measure credible on both sides of the clinical-payer divide.
| Dimension | PQA / Star Ratings Approach | ACC/AHA Performance Measure Approach |
|---|---|---|
| Primary data source | Pharmacy claims; Part D fills | Clinical data; EHR documentation |
| Construct measured | Medication adherence (PDC threshold) | Guideline-indicated therapy initiation and dose optimization |
| HF-specific metric example | Adherence to RASA, BB, or SGLT2i (% PDC ≥80%) | SGLT2i prescribed for HFrEF/HFmrEF at eligible visit; dose titration documented |
| Denominator definition | Members with fills in measurement year; diagnosis-based eligibility | Patients with documented HF diagnosis + qualifying encounter + EF documentation |
| Exclusion criteria | Hospice, LTC, certain comorbidities via claims | Contraindications, documented intolerance, end-stage disease (clinician-attested) |
| Who acts on it | Health plans, PBMs, pharmacies, MTM programs | Cardiologists, advanced practice providers, hospital quality teams |
| What harmonization unlocks | Shared patient cohorts · Reconciled exclusions · Aligned incentives across the care continuum · Reduced double documentation burden | |
Figure 2. PQA's HF GDMT measure initiative makes this comparison timely rather than theoretical. The specification differences shown here are exactly what co-development with ACC/AHA would need to reconcile. PQA is already in a position to lead that work.
The point is not that one approach is superior. PDC is a practical, scalable proxy that drives real plan behavior. ACC/AHA performance measures reflect clinical nuance that claims data cannot capture. The opportunity is in bridging them. PQA is the only organization structurally positioned to support and convene that bridge work.
Understanding why the parallel systems persist requires understanding who governs each. The two ecosystems have different primary constituencies, which shapes both the measures they produce and the incentives they respond to. Harmonization is not simply a technical exercise; it requires building authentic shared ownership across governance structures that don't currently intersect.
Figure 3. The two ecosystems serve overlapping patient populations through fundamentally different institutional networks. Advocacy stakeholders, including patient organizations and life sciences companies, shape the agenda without holding governance authority. Measure harmonization requires co-development across the governing bodies, with advocacy voices informing rather than deciding.
The convergence of FHIR-based quality infrastructure, TEFCA network maturation, and a growing CMS interest in clinical data-based measurement creates a window that did not exist five years ago. The technology to build a shared data layer between clinical and claims-based quality systems is no longer theoretical. What has been missing is the organizational will and structural positioning to drive it.
PQA has what clinical organizations lack: operational payer reach and a direct CMS relationship that translates measure endorsement into health plan behavior. Clinical organizations have what PQA lacks: guideline authority, clinical data access, and the specialty trust that makes measures credible to the clinicians who must act on them. Neither side alone can close the loop. Together, they can build something the system has never had: a medication quality architecture that is both clinically rigorous and operationally viable and deployable.
Figure 4. The three-phase trajectory is not a radical departure from PQA's current work; it is an extension of it. Phase 1 is relationship investment. Phase 2 is technical infrastructure. Phase 3 is market positioning. Each phase builds directly on the previous one.
The infrastructure conditions for this shift are aligning. FHIR is becoming the standard data exchange layer across payer and provider systems. TEFCA is building the network architecture to move clinical data at scale. CMS is explicitly signaling interest in clinical data-based quality measurement through its Quality Measure Development Plan and digital quality measure initiatives. The window is open.
PQA's CMS relationship is a moat, and moats are only strategically valuable when they are actively leveraged. The opportunity is to use the payer reach that Star Ratings provides not just to sustain the current measurement portfolio, but to pull clinical-guideline-based metrics into payer contracts through a harmonization process that PQA leads.
That is a mission with real stakes. Better-harmonized quality measures mean clinicians and plans are pulling toward the same outcomes rather than optimizing against different scorecards. It means patients with heart failure get not just filled prescriptions, but the right drugs at the right doses with the right monitoring, consistently, across settings, across payers, across the country.
No other organization in the pharmacy quality ecosystem is positioned to lead that work. PQA is, and that is exactly why I am excited to join the 2026 PQA Annual Meeting this week.