PBM s: Helping to Improve MA-PD Star Scores. James Brehany PharmD, PA-C, JD Associate Vice President, Pharmacy Services PerformRx
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1 PBM s: Helping to Improve MA-PD Star Scores James Brehany PharmD, PA-C, JD Associate Vice President, Pharmacy Services PerformRx
2 CMS Star Rating System Instituted in 2008 Applicable to MA plans, MA-PD plans, and PDP s Originally a source of consumer information Provide information giving individuals the ability to compare the relative quality of plans within a persons area Provide a comparison between MA plans and FFS Medicare Basis of Quality Bonus and Rebate Levels in 2012/2013/2014
3 Overall Quality Star Rating 2012/2013/2014 Bonus Applied to: 5 Star Plans 5% Blended Benchmark 4 and 4.5 Star Plans 4% New Benchmark 3.5 Star Plans 3.5% New Benchmark 3.0 Star Plans 3.0% New Benchmark 2.0 and 2.5 Star Plans None Not Applicable 1 Star Plans None Not Applicable Unrated: To new 3% New Benchmark Unrated: Too few members 3% New Benchmark CMS s Proposed Medicare Advantage Rebate Percentages Star Rating 2011 Rebate Percentage 2012 Rebate Percentage 2013 Rebate Percentage 2014 Rebate Percentage 4.5 to 5.0 stars 75% 73.31% 71.62% 70% 3.5 to 4.4 stars 75% 71.64% 68.29% 65% 1.0 to 3.4 stars 75% 66.65% 58.3% 50% SOURCE: AIS analysis of CMS proposed changes to the MA and Part D programs for contract year 2012,
4 2011 Five-Star Ratings 560 MA-PD Contracts 5 Stars Excellent Performance 3 contracts (1% of enrollees) 4 or 4.5 Stars Above Average Performance 74 contracts (23.2% of enrollees) 3 or 3.5 Stars Average Performance 271 contracts (60.4% of enrollees) 2 or 2.5 Stars Below Average Performance 48 contracts (7.2% of enrollees) 164 contracts (8.1% of enrollees) were either to new or not enough data for overall rating
5 Star Rating Categories Measure Domain Summary Overall
6 Summary Medicare MA Star Rating Five Categories with 36 Part C Measures Staying Healthy: Screenings, Tests, Vaccines (13 measures) Managing Chronic Conditions (10 measures) Ratings of Heath Plan Responsiveness and Care (6 measures) Health Plan Member Complaints and Appeals (4 measures) Health Plan Telephone Customer Service (3 measures)
7 Summary Medicare Part D Rating Four Categories with 17 Part D Measures Drug Plan Customer Service (7 measures) Member Complaints and Staying with Drug Plan (3 measures) Member Experience with Drug Plan (3 measures) Drug Pricing and Patient Safety (4 measures)
8 Overall Medicare MA-PD Star Rating Combines Part C and Part D scoring 9 Domains with 51 Total Measures Five Domains with 36 Part C Measures) Staying Healthy: Screenings, Tests, Vaccines (13 measures) Managing Chronic Conditions (10 measures) Ratings of Heath Plan Responsiveness and Care (6 measures) Health Plan Member Complaints and Appeals (4 measures) Health Plan Telephone Customer Service (3 measures) Four Domains with 15 unique Part D Measures Drug Plan Customer Service (7 measures) Member Complaints and Staying with Drug Plan (1 measure) Member Experience with Drug Plan (3 measures) Drug Pricing and Patient Safety (4 measures)
9 MA-PD Star Rating System Types of Measures Patient Experience 9 Measures (18% of Overall Score) Contract Performance 17 Measures (33% of Overall Score) 10 Part D 5 Part C Clinical Quality 25 Measures (49% of Overall Score) All Measures Currently Given Same Weight CMS has suggested giving additional weight to clinical/outcome measures as early as 2012
10 Clinical Quality Indicators HEDIS (Healthcare Effectiveness Data and Information Set) CAHPS-MA (Consumer Assessment of Healthcare Providers for MA plans) HOS (Health Outcomes Survey) Most of the 36 Part C measures for MA plans are HEDIS measures
11 Impact of Combining Part C & D Star Ratings 62 contracts (7% of enrollees) had improved star rating after Part D included 45 contracts (13% of enrollees) had lower star ratings after Part D plans were included
12 PBM s Expanding Role Clinical Measures
13 Part D Clinical Measures Using the Kind of Blood Pressure Medication That is Recommended for People with Diabetes Drug Plan Members 65 and Older who Received Prescriptions for Certain Drugs with a High Risk of Side Effects, when There May be Safer Drug Choices
14 Part C Clinical Measures Diabetes Care Cholesterol Screening Diabetes Care Eye Exam Diabetes Care Blood Sugar Control Diabetes Care Kidney Disease Management Diabetes Care Cholesterol Controlled Controlling Blood Pressure Rheumatoid Arthritis Management
15 Part C Clinical Measures Annual Flu Vaccine (Annual Measurement) Pneumonia Vaccine (Annuity Measurement) Osteoporosis Management in Women who had a fracture Appropriate Monitoring for Patients Taking Long Term Medications Improving Bladder Control
16 Planning Ahead 2014 Star Ratings Measurement Timeframe Prioritize Drugs contraindicated in seniors Pneumococcal Vaccine Measures that require impact during the calendar year» (Flu Vaccine) Reinforce member contact to improve CAHPS scores
17 Expectations Ability to impact star ratings can be influenced by Cut Point for a particular measure Current Measure Percentage Score Type of Plan Composition of Plan Enrollment (Demoraphics) Geographic Area Served by Plan Use of Good Electronic Medical Record Systems
18 Cut Points Appropriate Monitoring for Patients Taking Long Term Medications 3 Stars 78% - 90% 4 Stars 90% - 92% 5 Stars >92% Annual Flu Vaccine/Pneumococcal Vaccine 3 Stars >30 th percentile <60 th percentile 4 Stars >60 th percentile <80 th percentile 5 Stars > 80 th percentile
19 Cut Points Osteoporosis Management in Women who had a Fracture 3 Stars 41% - 60% 4 Stars 60% - 80% 5 Stars > 80% Diabetes Care Blood Sugar Controlled 3 Stars 49% - 80% 4 Stars 49% - 80% 5 Stars >87%
20 Changes Coming New Clinical Measures for 2012/2013? Advising Smoker and Tobacco Users to Quit Part D Medication Adherence Medication Therapy Management Measures
21 QUESTIONS?
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