Medication Adherence Poses Challenges

Medicare Advantage plans may have a difficult time attaining four- and five-star ratings under the Centers for Medicare & Medicaid Services’ (CMS) Five-Star Quality Rating System if they don’t keep up with the system’s changes.

“The area where plans have, by-and large, been very successful, but that pose the greatest challenge for 2012 is medication adherence,” says Stephen Wood, senior vice president at OptumInsight. “Each of the three factors around medication adherence has a big effect on Part C ratings and the overall plan.”

Those three factors are:

Drug safety,

Drug integrity, and

Audits.

Wood says the overall average for drug pricing and safety measures-which are weighted more heavily than many other measures when determining scoring under the Star system-tend to be in the 2.5 range, which puts them well below the 4-star threshold. “That alone pushes down average Part D scores by half a star overall,” he says.

The changes to the CMS rating system focus on outcomes more than processes. For example, while many of the measures match Healthcare Effectiveness Data and Information Set (HEDIS) evaluations, they are not weighted that high by CMS.

“It turns out HEDIS is only 29% of the total measures,” Wood says. “So the focus is really turning toward these new kinds of measures of how the members are getting care, accessing care or following medical protocol. We were a little surprised that HEDIS measures are not as inflated in 2012 as we thought they would be. We’re finding overall capabilities for plans are more important than specific capabilities.”

A glaucoma test, for example, is often not performed by a patient’s primary physician. But the overall capability is capturing that information about the patient, no matter which provider did it. The same goes for drug adherence. Are the members filling and refilling their prescriptions?

“Pushing pharmacy data back to the provider doesn’t happen,” Wood says. “The doctor writes the prescription and doesn’t know if it’s filled. In the new world, the doctor has to know, and if it’s not filled he has to call them up.”

Wood recommends plans focus on capturing as much member data as possible so they know as much as possible. “The mantra is ‘build member-centric databases,’” he says.

To do that, plans will have to excel at provider alignment of incentives with the plan’s goals. Pushing data out to physicians either through web portals or phone trees and then insuring they communicate back to the plan on what’s been done is more important than ever.

Wood suggests plans consider dividing providers into a number of different subsets for easier management. “Say you have 200 members at a provider vs. two members at another provider,” he says. “You’re going to want to work with those providers differently. You can set up a web portal for the 200-member provider and they’ll pay attention, but that might not be the case with the two-member provider.”

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