It s in the Stars: What are Medicare Star Ratings?

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1 It s in the Stars: CMS Star Ratings and How Pharmacies are Affected What are Medicare Star Ratings? CMS Star Ratings Tracks patient outcomes Ratings range from 1 to 5 stars Overall score as a whole Individual category score Ratings of all Medicare plans can be found at:

2 Medicare Part C & D Plans: What s the difference? Medicare Advantage Plans (MA) are often referred to as Part C Medicare Prescription Drug Plans (PDP) are known as Part D Overall Star Rating for Health Plans Five categories Staying healthy Managing chronic conditions Member experience Member complaints and changes in plan s performance Customer service 2

3 Overall Score of Medicare Drug Plans The overall score for quality of those services covers many different topics that fall into 4 categories: Drug plan customer service Member complaints and changes in drug plan s performance Member experience with plan s drug services Drug safety and accuracy of drug pricing Stars Scores Excellent Above average Average Below average Poor 3

4 How it flows CMS Part D Plans Individual Pharmacies Prescribers Patients How does this affect pharmacy? At this time, Medicare does not give individual pharmacies star ratings Only health plans receive star ratings Pharmacy claims data is analyzed in the whole to assign a star rating to a Medicare Part D Prescription Drug Plan (PDP) or Medicare Advantage Plan with prescription drug benefits (MA-PD) 4

5 Why is This Necessary? Improve patient outcomes Medication non-adherence Costs > $300 billion annually In 2014, about 20% of Medicare patients were readmitted within 30 days of discharge About 70% of these are the result of a drug event Why is This Necessary? Approximately 265,000 emergency room visits in patients over 65 years of age are related to adverse drug events ~ 40% of these result in a primary admission and involve unintentional overdoses in patients taking five or more concomitant medications 5

6 Services that Impact Star Ratings Patient Adherence Monitoring Diabetes Blood pressure Cholesterol Medication Safety High Risk Medications Diabetes/RASA Medication Therapy Management Targeted Interventions Comprehensive Medication Reviews Medication Synchronization 6

7 Medication Advantage Plans (MA) Measure Weight Diabetes care-blood sugar controlled 3 Diabetes care-cholesterol controlled 3 Controlling blood pressure 3 *Improving or maintaining physical health 3 *Improving or maintaining mental health 3 Prescription Drug Plan (Part D) Measure Weight Medication adherence for oral diabetes medications 3 Medication adherence for hypertension 3 Medication adherence for cholesterol 3 High risk medications 3 Diabetes treatments Plan Ratings, Weighting for Part D 7

8 2013 Part D Average Rates for PQA Endorsed Measures Adherence Monitoring Diabetes Medications Oral, not insulin Hypertension Medications ACE Inhibitors ARBs Cholesterol Medications Statins 8

9 Proportion of Days Covered (PDC) Newer method of calculating adherence PDC threshold is 80% The level of proportion of days covered which the medication has a reasonable likelihood of achieving most of the potential clinical benefit How do the plans calculate pharmacies PDC? Count the total number of patients that had a PDC of 80% or greater and divide by the total number of eligible patients Practice Calculation Mrs. Smith s lisinopril was last filled for a 30 days supply. When she comes to fill it you notice it has been 40 days since she last had it filled. What is the PDC? 30/40= 75% What if it had only been 36 days? 30/36= 80% OUR MAGIC NUMBER! 9

10 Improvements in Adherence Rates Medication Safety Oral diabetes medications 10

11 High Risk Medications Classified under Drug Pricing and Patient Safety Analysis of the number of patients that have received at least two prescriptions for the same HRM during the measurement period with the number of people in the eligible population www. pqaalliance.org 11

12 What impact does HRM have This measure, related to the number of patients in your pharmacy that fit the eligible population criteria regarding high risk medications, can affect the star rating of plans that include your business in their network. 12

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14 Medication Synchronization What is it? All of the patient s medication are synchronized to be refilled on the exact same day of the month What are the benefits? It turns a reactive process into a proactive process Medication Synchronization Patient Benefits Better health Convenience Personalization Satisfaction Pharmacy Benefits Increased revenue Operational efficiencies Increased patient adherence 14

15 Low Performer Icon CMS currently assigns the Low Performer Icon (LPI) to contracts receiving less than 3 star for their Part C or Part D summary ratings for the last 3 consecutive years 15

16 How can I Improve Performance in My Pharmacy? Talk to your patients about the risk and the adverse drug events that could take place with HRMs Educate patients on the signs and symptoms Ask permission to contact prescriber for a safer alternative Technician s Role Technicians play a key role in star ratings What they can do: Call patients to remind them to pick up prescriptions Fax prescribers on patients refills Promote pharmacy services Delivery Auto refill Immunizations What they can t do: Counsel patients on adherence Discuss side effects/efficacy Recommend a plan 16

17 Technician s Role How can they assist pharmacists in improving star ratings Prior authorizations NDC not covered Promote pharmacy services Delivery Auto refill Immunizations Schedule CMRs EQuIPP Electronic Quality Improvement Platform for Plans and Pharmacies 17

18 What is EQuIPP? Multi-plan, multi-pharmacy collaborative Provides a neutral assessment of quality for trusted performance assessment and benchmarking by all parties Lays the foundation for performancebased contracts and payment systems for pharmacy networks 18

19 EQuIPP: Pros and Cons Pros You can focus on specific areas to improve your star ratings Can compare your ratings against state measures Cons Not every health plan participates Doesn t include cash paying patients Data is limited to whatever health plans choose to submit Data is 6 month range with a 2 month lag time EQuIPP Reports Performance Reports 19

20 2014 Part D Star Ratings Top Performers Kaiser Permanente Some Humana plans Most of these plans are on west coast Low Performers 39 plans were below 3 stars Most low-performing plans were in AL, GA, LA, TN and TX Performance Improvements MA-PDs average star rating* in 2013 was 3.66, compared to 3.44 in 2012 PDPs average star rating* in 2013 was 3.30, compared to 2.96 in 2012 A growing percentage of Medicare Part D enrollees are in plans with at least 4 star ratings *weighted by enrollment 20

21 What s in it for me? Pay for Performance (P4P)- pharmacies may be eligible for bonus payments based on star performance Preferred pharmacy network based partly on star performance of chains or stores Several plans have already implemented P4P for pharmacies, and several more will begin with enrollment. What s in it for me? QBP for large MA-PDs (Humana, United Healthcare, Aetna/Coventry, Cigna/Healthspring) may exceed $100 million 21

22 Example of P4P Caremark Silverscript Pharmacies are evaluated on 4 measures 3 PDC (proportion of days covered)/adherence RASA in diabetes % 90 day star prescriptions % Generics overall Pharmacies will receive a bonus payments 1x/yr based on performance Bonus is based on number of patients in addition to score on each measure How can I improve? Identify patients with <80% adherence Implement an adherence program Medication synchronization Auto refill Gap calls 22

23 Tools for Independent Pharmacies MyGNP mobile app A tool for patients to refill prescriptions using mobile technology, to locate stores in their community, and to get up-to-date information Good Neighbor University An on-line resource of education, announcements, and news for owners The Creative Pharmacist A training program to help improve outcomes for a number of chronic diseases Future Star Measures Antipsychotic medications prescribed for children under 5 years old Adherence to non-warfarin anticoagulants Primary Medication adherence Antipsychotic use in persons with dementia Use of opioids at high doses in persons without cancer 23

24 Future Star Measures Use of opioids from multiple providers in persons without cancer Use of opioids at high dosages AND from multiple providers in persons without cancer Diabetes medication dosing Biguanides Sulfonylureas TZD DPP IV inhibitors Future Star Measures Use of benzodiazepine sedative hypnotic agents in the elderly Medication therapy for persons with asthma Drug-drug interactions Cholesterol management in coronary artery disease Statin use in patients with diabetes (2016) 24

25 Medicare Advantage Payments The star ratings now affect payment to MA plans Quality Bonus Payments (QBPs) are being awarded on a sliding scaled according to star ratings 2015 payments will be bases on 2014 ratings which were based on 2012 and 2013 data Tools to Improve/Track Performance Merck s Adherence Estimator Simplify My Meds (NCPA) Pharmacist s Letter 25

26 Tools, continued PrescribeWellness MedHere Today Resources

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