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.
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?
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.
NEXT: 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.
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.