Three ways to build a smarter Stars strategy


How advanced use of data and analytics can solve your biggest Star Ratings challenges

Recent changes to how Centers for Medicare and Medicaid Services (CMS) Star Ratings are calculated-  particularly the removal of the pre-determined thresholds-have many plans feeling like they are in a race, constantly looking over their shoulder to see who’s right behind them, and worried about how to stay ahead or take the lead.

Five-star cut points are shifting, and plans will not know which ones will adjust. Additionally, 2016 MA-PD Star cut points for categories such as diabetes adherence, high-risk medications and appeals are aggressive and will be a challenge for plans to achieve.

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Plans are currently performing well; nearly half of all MA-PD plans earned four or more stars in 2016. But how can plans keep maintaining this performance in the midst of this race?

Data analytics strategies for Star Ratings success

Mahon, PharmD

The answer is in knowing how your plan is performing in relation to your competition, including the 188 new plans in the marketplace that are not yet rated, and how those variables will affect the curve in 2017.

In our view, the following three data strategies-which are highly targeted and actionable-are important to a successful Star Ratings strategy.

  • Retrospective data. Most plans already use Retrospective Drug Utilization Review Data (RDUR), Acumen data, PBM data, and medical claims data every day. If you’re not, you must maximize use of these resources, looking under every rock to see what is the data are telling you and NOT telling you. For example, ACUMEN data is good; however, it is not real time and only provides population-level information. Plans should have their analytics team mine the data from a population level down to the member level and use those insights to drive member specific interventions. Also, how are you bringing all of these data sources together to fully understand the comprehensive picture of your current gaps-in-therapy, over- or under-utilization of therapy?

  • Data informatics. Data is not useful unless plans are able to easily identify patterns and opportunities for improvement. The goal of data informatics is to help simplify the terabytes of data available to a plan and make it usable. A recent example of a data informatics solution is an Express Scripts tool called MediCUBE, which simplifies most of the inefficient aspects of data mining and allows users to uncover insights about members, prescribers and pharmacy networks- quickly and effectively-with the ultimate goal of controlling costs and increasing profitability of medical and pharmacy benefit programs.  MediCUBE synthesizes a proprietary database of 11 billion prescription claims and four billion medical claim records for more than 180 million patients linked to more than four million unique healthcare providers. With it, plans can go beyond book-of-business reporting and see prescriber and utilization patterns that were not available to them before.  This allows plans to pinpoint intervention opportunities at the member, prescriber and pharmacy level.

  • Jawar, PharmD, MBA, CGPPredictive analytics. Now that four-star thresholds have been removed, plan performance is largely impacted by competing plan performance. Predictive data analytics can help a plan understand what its performance will be at the end of the year, and when coupled with benchmarking data, it can also show how a plan’s performance measures against the competition. For example, Express Scripts’ Constellation Ratings Advisor tool provides plans with a customized model that keeps up with changing CMS regulations and can identify areas where plans can boost Star Ratings performance and maximize Star Ratings reimbursements with real bottom-line impact. Managing prescription medications for a quarter of the Medicare market, our clients can use this information, which is built into Constellation, as a valuable benchmark for how their plan will perform against others in the marketplace.


NEXT: Putting the data to work: A case study


Putting the data to work– A case study

So what do you do with all this useable data? You must use it to design meaningful, prescriptive engagement with all the players that impact your Star Ratings including physicians, members and pharmacies. Leveraging data to connect with and empower pharmacies-and drive improved quality outcomes-is a powerful lever most plans aren’t pulling.

Consider: In 2014, Express Scripts and SCAN Health Plan, one of the country’s largest not-for-profit Medicare Advantage plans, partnered on an innovative quality retail network. SCAN, based in California, has 170,000 members with approximately 15% in their special needs plans. Together, we sought to improve SCAN member health, improve retail pharmacy collaboration, and achieve higher Star Ratings through an innovative retail pharmacy network design called the Quality Retail Network program.

This network leverages a novel value-based approach to drive quality-but it is not novel to healthcare, as it’s been used to drive medical provider quality for years.  Our program was a large-scale effort, including 70% of SCAN’s membership filling prescriptions at more than 1,000 pharmacies. 

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The key to success was serving up data to the participating retail pharmacies within their workflow, so they could easily act on the data and have a meaningful interaction with a SCAN Medicare member to reduce high-risk medication use, improve diabetes medication adherence or implement ACE/ARB therapy in diabetes patients who were not using an anti-hypertensive medication.  We also developed very clear, highly aligned and collaborative goals.

Early results from the program, which began in January 2014, show that when compared to a national sample of retail pharmacies, the pharmacies in the quality network achieved 60 percent higher performance scores for reducing the use of high-risk medications among SCAN members, and 23% higher scores for improving compliance with diabetes treatment guidelines among SCAN members. When compared to a sample of non-SCAN members using the same Quality Network pharmacies, the Quality Network achieved 34% higher scores for high-risk medications and 8% higher scores for diabetes treatment among SCAN members.

We also are seeing the percent of participating pharmacies with a low or medium average overall performance scores decline over the course of the program, while the percent of pharmacies with high average overall scores increases. In fact, when we began this program, only 24% of participating pharmacies had a high average score. By the end of the second quarter of 2015, nearly 40% of participating pharmacies achieved high average scores.

The bottom line: more pharmacies in the network are making continuous improvements across all performance indicators. SCAN members are using safer medication alternatives and more appropriate diabetes treatment as a result of the interventions and counseling they receive from pharmacists who are presented with actionable data in a format that works for them. 


To quote Chip & Dan Heath, authors of Made to Stick: Why Some Ideas Survive and Others Die: “Data are just summaries of thousands of stories-tell a few of those stories to help make the data meaningful.”  When data are timely, relevant, accurate, and complete, they become actionable and useful, and will help your plan provide better care to your Medicare members and pull ahead of the pack.

Snezana Mahon, PharmD, is senior director of Medicare Solutions at Express Scripts. Sharon K. Jhawar, PharmD, MBA, CGP, is vice president, pharmacy services, SCAN Health Plan.

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