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Meeting the ‘status quo’ with CMS Star Ratings equals regression


CMS’ 5-Star Rating system requires proactive intervention to improve patient medication adherence, and leaves plans with little room to rest on their laurels.

In Lewis Carroll’s Through the Looking-Glass, the Red Queen tells Alice, “It takes all the running you can do, to keep in the same place.” The government’s Star Rating clinical performance measures impose a similar situation for Medicare plans-the topic explored in a panel discussion during an October 18 session at the Academy of Managed Care Pharmacy (AMCP) 2017 Nexus in Dallas.

CMS has implemented a 5-star quality rating system for Medicare plans. The Star Ratings program is meant to incentivize continuously improved quality of care with bonus payments.

The ratings involve 48 individual measures in nine domains, each weighted for importance. (For example, patient experience and access to care measures are weighted by a factor of 1.5, whereas outcomes and demonstrated improvement are weighted by 3 and 5, respectively.) The end result is a single Star Rating of 1 to 5, with five stars being the best possible rating.

Bonus payments are a “carrot,” said Steve Cutts, PharmD, vice president of pharmacy services and clinical strategy at Magellan Rx Management in Scottsdale, Arizona. Plans earning 4 or 5 stars earn a 5% bonus payment. Bonus payments are intended to be invested back in improvement efforts to benefit plan members.

A “laser focus” on transparency also provides a marketplace “stick” because consumers can compare different plans’ CMS Stars Rating, he said.

The 48 measures range from basic processes like completing comprehensive medication reviews (CMRs) for beneficiaries to overall outcomes.

Moving target

Star Ratings are a dynamic system-by design, their measures represent a “moving target,” Cutts said. That ensures that plans will invest in improved quality of care on an ongoing basis.

“The fundamental aim is to drive quality improvement and to reset the baseline from year to year,” Cutts explained.

Plan managers must anticipate shifting criteria because ratings for a given year are based on performance during a past year. The 2017 Star Ratings reflect performance in 2015, for example.

Because ratings depend on continuous improvement, it’s impossible to coast on past success. Maintaining success, like staying in the same place in the Red Queen’s race, requires a lot of effort.

“The status quo equals regression,” Cutts quipped.

“You have to stay ahead of the curve,” he said. “There are always new targets and you’ll find out how you’re doing only 10-12 months after the fact.”

Next: Performance to date and tips for success



Performance to date

For 2017, nearly half of all Medicare Advantage/Part D contracts earned at least 4 stars. Because larger plans were in that category, 68% of Part D beneficiaries are served by 4- or 5-star plans.

“They’re doing well, investing in their infrastructure,” Cutts said.

But because the baseline is reset each year and new measures are introduced each year, plans aren’t doing as well for calendar year 2016 as they did in 2015, Cutts noted.

“Despite higher treatment rates, we’ve seen decreases in Star Ratings because CMS is establishing a higher baseline each and every year,” he explained. “We’ve seen treatment rates go up 2% but ratings have gone down.”

Tips for success

Key clinical Star Rating measures for Part C include management of rheumatoid arthritis and osteoporosis in women aged 67 to 85 years with a bone fracture. Part D Star Rating measures include medication adherence for diabetes, statin use by diabetic patients aged 40 to 75 years, and medication therapy management completion rate for CMRs.

Key “core strategic” components, intended to improve patients’ treatment adherence, include work flow management, analytics, and clinically-driven messaging.

“Analytics: you want the ability to leverage pharmacy and medical data to identify baselines and outreach opportunities, and stratifications of the population so you can focus on the right group of members,” explained panelist Sagar Makanji, PharmD, vice president, clinical programs, Magellan Rx Management.

The work flow and process management component allows plans to track interventions. But more importantly, Makanji said, it allows identification of members within the noncompliant population whose behavior is most likely to be changed with interventions.

“It is also important to have a way to remove patients who do not have rheumatoid arthritis [for example] from the denominator data,” Makanji said. In terms of maximizing a Star Rating, decreasing the denominator population (the beneficiaries who should be receiving a given treatment) is just as useful as increasing the numerator of treatment-compliant patients, he explained. Both improve calculated treatment compliance rates.

Proactively identifying noncompliant patients to target for clinically driven messaging interventions is important to avoid delays, Makanji noted.

Patients who are only noncompliant for one medication are more likely to become compliant following contact by the program, clinicians, or pharmacists, than are those who are noncompliant for multiple medications, Makanji noted.

“Prioritize members with reversed or rejected statin claims,” he advised. “They were evaluated, went to the pharmacy and tried to fill the prescription, but didn’t pick it up or couldn’t get it for whatever reason. A little support or pull-through can get that member compliant.”

The clinical MTM CMR measure is based on what percentage of members in a medical therapy management program have undergone comprehensive assessments of all of their on-plan medications. It is a core requirement and success can depend importantly on engagement strategies, Makanji said.

Strategies include mailings, integrated voice response systems, live calls, pharmacy outreach, and even text messaging for “difficult to reach populations that don’t respond to other, traditional methods of contact,” he said. Using a caller ID that shows up on patients’ smartphones as “pharmacy” instead of the name of the insurance plan improves answer rates, he noted.

“The key thing here is, it isn’t one size fits all and at the end of the day, a lot of these strategies will be incremental,” he said.



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