URSA-PHARM-001: Outpatient Pharmacy PMPM Plan Spending

  • Published on Jul 17, 2025
  • 7 minute(s) read
Prev Next

Measure Description

Among active plan membership periods, the per-member-per-month payor spending on outpatient medication fills

Metadata

  • Measure Type: Rate Measure
  • Temporal Structure: Interval
  • Component Class: Long-Form
  • Denominator Case Field: Patient ID
  • Target Direction: Down

Denominator Description

The elapsed patient-months of active plan membership periods

Numerator Description

Total payor spending for outpatient pharmacy claims with covered start date falling within the observation period start and end dates

Published Fields

  • Data Model Keys

    • Patient ID
    • Primary Payor ID
    • Primary Plan ID
    • Primary Plan Attributee Provider ID
    • Empirical Attributee Primary Care Individual Provider ID
    • Empirical Attributee Primary Care Provider Group Provider ID
    • Document ID
    • Filling Provider ID
    • Prescribing Provider ID
    • Lifetime Medication Treatment Episode ID

  • Operations Support Fields

    • Patient Operational ID
    • Primary Payor Operational ID
    • Primary Plan Operational ID
    • Prescription Number

  • Patient Fields

    • Patient Date of Birth
    • Patient Age Integer
    • Patient Age Category Tier 1
    • Patient Age Category Tier 2
    • Patient Sex Category
    • Is Patient Sex Female
    • Is Patient Sex Male
    • PCP Attribution Category
    • Primary Care Engagement Category
    • Count Primary Care Visits in Last 36 Months
    • Specialty Care Engagement Category
    • Count Specialty Care Office Visits in Last 36 Months
    • Primary or Specialty Care Engagement Category
    • Count Clinician Office Visits in Last 3 Years
    • Count Hospital Inpatient Admissions in Last 12 Months
    • Count ED Visits Without Inpatient Admissions in Last 12 Months

  • Date Fields

    • Current Continuous Primary Payor Membership Episode Start Date
    • Current Continuous Primary Payor Membership Episode End Date
    • Current Continuous Pharmacy Claim Data Coverage Episode Start Date
    • Current Continuous Pharmacy Claim Data Coverage Episode End Date
    • Filled Date
    • Filled Date Year
    • Segment Start Date -- The start date of the reporting segment. (See also [URSA-CORE] Reporting Segment)
    • Segment End Date -- The end date of the reporting segment. (See also [URSA-CORE] Reporting Segment)
    • Segmented Period Start Date
    • Segmented Period End Date

  • Provider Fields

    • Count Distinct Filling Providers Last 12 Months
    • Count Distinct Prescribing Providers Last 12 Months
    • Count Distinct Opioid Prescribing Providers in Last 6 Months
    • Count Distinct Opioid Filling Providers in Last 6 Months
    • Count Distinct Opioid Prescribing Providers in Last 12 Months
    • Count Distinct Opioid Filling Providers in Last 12 Months
    • Empirical Attributee PCP Provider NPI
    • Empirical Attributee PCP Provider Description
    • Empirical Attributee Primary Care Provider Group Provider NPI
    • Empirical Attributee Primary Care Provider Group Provider Description
    • Count Visits with Attributee Individual Primary Care Provider in Last 36 Months
    • Count Visits with Attributee Primary Care Provider Group in Last 36 Months
    • Prescribing Provider NPI
    • Filling Provider NPI
    • Is Filling Provider Specialty Pharmacy
    • Is Filling Provider Mail Order Pharmacy
    • Filling Provider Description
    • Filling Provider Primary NUCC Provider Taxonomy Code
    • Filling Provider Primary NUCC Provider Taxonomy Description
    • Provider Fill Volume Percentile Rank
    • Provider Fill Volume Quintile Category
    • Is Filling Provider Major Chain
    • Filling Provider Major Chain Description
    • Filling Provider State Abbreviation
    • Filling Provider ZIP Code 5-Digit

  • Location Fields

    • Patient State Abbreviation
    • Patient ZIP Code 5-Digit
    • UW HIP Area Deprivation Index National Percentile
    • UW HIP ADI Quintile Category
    • CDC SVI Overall Quintile Category
    • CDC SVI Socioeconomic Theme National Percentile
    • CDC SVI Socioeconomic Quintile Category
    • CDC SVI Household / Disability Theme National Percentile
    • CDC SVI Household / Disability Quintile Category
    • CDC SVI Minority / Language Theme National Percentile
    • CDC SVI Minority / Language Quintile Category
    • CDC SVI Housing / Transportation Theme National Percentile
    • CDC SVI Housing / Transportation Quintile Category

  • Insurance Fields

    • Primary Payor Description
    • Primary Plan Description
    • Primary Plan Financial Class Description
    • Is Primary Plan Financial Class Commercial
    • Is Primary Plan Financial Class Medicare Advantage
    • Is Primary Plan Financial Class Medicaid
    • Is CMS ESRD Status
    • Is CMS Hospice Status
    • Count Active Plan Memberships
    • Is Dual Medicare-Medicaid Enrolled

  • Medication Fields

    • Is Patient with any Active Chronic Medications
    • Count of Fills in Last 12 Months Category
    • Count of Fills Last 12 Months
    • Count Opioid Fills in Last 6 Months
    • Count Opioid Fills in Last 12 Months
    • Aggregate Opioid Days Supply in Last 6 Months
    • Aggregate Opioid Days Supply in Last 12 Months
    • NDC Code 11-Digit
    • Label Description
    • Is OTC
    • Red Book Generic Cross Reference Code
    • Active Ingredients Description
    • Red Book Generic Formulation Code
    • Primary Agent Description
    • Form Description
    • Route of Administration Description
    • Quantity Dispensed
    • Days Supply
    • Days Supply Category Tier 1 Description
    • Is Single Day Supply
    • Is 30 Days Supply
    • Is 90 Days Supply
    • AHFS Therapeutic Class Code 6-Digit
    • AHFS Therapeutic Class Tier 1 Description
    • AHFS Therapeutic Class Tier 2 Description
    • AHFS Therapeutic Class Tier 3 Description
    • NCPDP Dispense as Written Code
    • NDC Count of Fills with Payment Percentile
    • NDC Count of Fills Quintile Category

  • Diagnosis Fields

    • CCW Count Category
    • Count CCW Conditions
    • Is CCW Asthma
    • Is CCW CKD
    • Is CCW COPD and Bronchiectasis
    • Is CCW Depression
    • Is CCW Diabetes
    • Is CCW Heart Failure
    • Is CCW Schizophrenia or Other Psychotic Disorders
    • Is CCW Bipolar Disorder
    • Is CCW Acquired Hypothyroidism
    • Is CCW Acute Myocardial Infarction
    • Is CCW ADHD, Conduct Disorders, and Hyperkinetic Syndrome
    • Is CCW Alzheimers Disease
    • Is CCW Alzheimers Disease and Related Disorders or Senile Dementia
    • Is CCW Anemia
    • Is CCW Anxiety Disorders
    • Is CCW Atrial Fibrillation
    • Is CCW Autism Spectrum Disorder
    • Is CCW Benign Prostatic Hyperplasia
    • Is CCW Blindness and Visual Impairment
    • Is CCW Breast Cancer
    • Is CCW Cataract
    • Is CCW Cerebral Palsy
    • Is CCW Colorectal Cancer
    • Is CCW Cystic Fibrosis and Other Metabolic Disorder
    • Is CCW Deafness and Hearing Impairment
    • Is CCW Depressive Disorders
    • Is CCW Endometrial Cancer
    • Is CCW Epilepsy
    • Is CCW Fibromyalgia and Chronic Pain and Fatigue
    • Is CCW Glaucoma
    • Is CCW Hip or Pelvic Fracture
    • Is CCW Hyperlipidemia
    • Is CCW Hypertension
    • Is CCW Intellectual Disability
    • Is CCW Ischemic Heart Disease
    • Is CCW Learning Disability
    • Is CCW Leukemia
    • Is CCW Lung Cancer
    • Is CCW Migraine and Chronic Headache
    • Is CCW Mobility Impairment
    • Is CCW Multiple Sclerosis
    • Is CCW Muscular Dystrophy
    • Is CCW Obesity
    • Is CCW Osteoporosis
    • Is CCW Other Developmental Delay
    • Is CCW Personality Disorder
    • Is CCW Pressure or Chronic Ulcer
    • Is CCW Prostate Cancer
    • Is CCW PTSD
    • Is CCW PVD
    • Is CCW Rheumatoid Arthritis or Osteoarthritis
    • Is CCW Schizophrenia
    • Is CCW Stroke or Transient Ischemic Attack
    • CCW Systems Category
    • Count CCW Systems
    • Is CCW System Behavioral Health
    • Is CCW System Cardiovascular
    • Is CCW System Congenital
    • Is CCW System Endocrine/Metabolic
    • Is CCW System Genitourinary
    • Is CCW System Hematologic
    • Is CCW System Musculoskeletal
    • Is CCW System Neurological
    • Is CCW System Oncologic
    • Is CCW System Ophthalmologic
    • Is CCW System Pulmonary
    • Is CCW System Other

  • Financial Fields

    • Medication Plan Paid Amount in Last 12 Months
    • Medication Patient Paid Amount in Last 12 Months
    • Total Medication Paid Amount Last 12 Months
    • Cumulative Calendar Year Rx Plan Paid Amount
    • Cumulative Calendar Year Rx Patient Paid Amount
    • Total Paid Amount
    • Plan Paid Amount
    • Patient Paid Amount
    • COB Paid Amount
    • Is Total Paid >= 1k

  • Metadata Fields

    • Random Integer 1 to 1000

  • Measure Fields

    • Denominator
    • Numerator

  • Module Fields

    • Medication Management Trigger Category
    • Is Patient with Active Medication Management Trigger
    • Count Active Medication Management Trigger Categories
    • Is High Medication Spend
    • Is Very High Medication Spend
    • Is High Number of Prescribing Providers
    • Is High Number of Filling Providers
    • Is Multiple Opioid Prescribing Providers Last 6 Months
    • Is Multiple Opioid Filling Providers Last 6 Months
    • Is Active Chronic Opioid Episode
    • Is High Number of Chronic Medications
    • Count Active Chronic Medications
    • Active High Risk Medication Episode Category
    • Is Any Active High Risk Medication Episode
    • Count Active High Risk Medication Types
    • Count Active Oral Antiplatelets
    • Count Active Anticoagulants
    • Count Active Cardiac Glycosides
    • Count Active Opioids
    • Count Active Oral Hypoglycemics
    • Count Active Insulins
    • Active Priority Adherence Medication Type Category
    • Is Any Priority Adherence Medication Active
    • Count Active Priority Adherence Medications
    • Count Active Priority Medication Types
    • Count Active Antidepressants
    • Count Active Antidiabetics
    • Count Active Oral Antidiabetics
    • Count Active Antineoplastics
    • Count Active Beta Blockers
    • Count Active Oral ACEI/ARBs
    • Count Active Statins
    • Active PDC Medication Type Category
    • Is Patient with Any Active PDC Medications
    • Count Active PDC Medication Types
    • Is Active Oral Antidiabetic PDC Medication
    • Is Active Oral ACEI/ARB PDC Medication
    • Is Active Statin PDC Medication
    • Is Targeted Medication Type
    • Is Chronic Medication
    • Is Priority Adherence Medication
    • Priority Adherence Medication Category
    • Is Antidepressant
    • Is Antineoplastic
    • Is Antidiabetic
    • Is Oral Antidiabetic
    • Is Oral ACEI/ARB
    • Is Statin
    • Is Beta Blocker
    • Is High Risk Medication
    • High Risk Medication Category
    • Is Anticoagulant
    • Is Oral Antiplatelet
    • Is Cardiac Glycosides
    • Is Oral Hypoglycemic
    • Is Insulin
    • Is Opiate Agonists
    • Is Medication Included in PDC Measures
    • PDC Medication Category
    • Is Sacubitril/Valsartan
    • Is Generic
    • Is Single Source
    • Is CMS Star Measures Oral Antidiabetic
    • Is CMS Star Measures Oral ACEI/ARB
    • Is CMS Star Measures Statin
    • Is CMS Star Measures Sacubitril/Valsartan
    • Is CMS Star Measures Insulin

  • [No Field Group]