Medicare Star Ratings
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2 Medicare Star Ratings Opportunities for Community Pharmacy David Nau, PhD, RPh, CPHQ Senior Director, Pharmacy Quality Alliance
3 CMS is expanding its value-based purchasing strategy to Medicare Parts C/D Part C = Medicare Advantage Part D = Prescription Drug Plans Medicare Advantage Plans that provide drug coverage (MA-PD) are part of Parts C & D Medicare plans receive plan ratings on safety and quality (stars); this info is provided to the public and now affects Medicare Advantage revenue
4 Medicare Plan Ratings Annual ratings of Medicare plans that are made available on Medicare Plan Finder Ratings are displayed as 1 to 5 stars Stars are calculated for each measure, as well as each domain, and overall (summary) Ratings of all Medicare plans can be found at:
5 Medicare Part C CMS contracts with NCQA to collect plan performance data using HEDIS measures for Medicare Advantage CMS utilizes a subset of HEDIS for the Part C plan ratings, including several medication related measures MAPDs are subject to Part C and Part D measures, and the overall rating for MAPDs is based on a synthesis across Part C and D measures.
6 Medicare Part D Plans receive an overall rating on quality as well as four domain scores (17 individual measures in total) Patient Safety/Adherence measures (from PQA): High risk medications in the elderly Appropriate blood pressure treatment in persons with diabetes (ACEI/ARBs used in patients with diabetes) Proportion of Days Covered (PDC) adherence Oral Diabetes Medications Cholesterol (statins) Blood Pressure (ACEI/ARBs)
7 Timeline/Process for PQA Measures in Part D CY 2010 data were used to calculate 2012 ratings In summer of 2011, Acumen calculated the PQA measures used by CMS Plans received first look at 2012 results in Sept 2011 CMS posted the 2012 Plan Ratings in October 2011 Medicare enrollment period for 2012 began in October 2011, and beneficiaries were able to view plan ratings when selecting a Medicare plan.
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11 Medicare Part D Display Measures Display measures are not a part of the Plan Ratings, but are used to provide benchmarks and feedback to plans Display measures (from PQA): Drug Drug Interactions Excessive doses of oral diabetes medications Adherence to antiretroviral meds for HIV/AIDS (new in CY2012) Comprehensive Medication Review (CMR) Completion Rate (CY 2011 rate to be reported in 2012)
12 Changes for 2012 Part D Ratings CMS added weightings for measures when calculating the summary stars. PQA measures are weighted 3x as much as most other measures in Part D; as such, they account for nearly half of the Part D summary star rating CMS added a high performer icon to Medicare Plan Finder to help beneficiaries find 5 star plans
13 Medicare Part D Measures National Averages MA PD PDP PDC Diabetes 73.0 % 74.4 % PDC ACEI/ARB 72.2 % 74.3 % PDC Statins 68.0 % 69.1 % Diabetes ACEI/ARB Use 84.1 % 82.2 % High Risk Medications 20.0 % 22.2 %
14 Medicare Part D Measures MA PD Thresholds 3 star 4 star 5 star PDC Diabetes 70.7 % 74.9% 78.8 % PDC ACEI/ARB 70.1 % 74.8 % 77.9 % PDC Statins 67.4 % 70.8 % 75.2 % Diabetes ACEI/ARB Use High Risk Medications 83.2% 86.0 % 87.3 % 22.2 % 14.0 % 9.3 %
15 Changes in Incentives for MA PDs Starting in 2012, Medicare Advantage plans (including MA PDs) will see a change in payments from CMS CMS is implementing a 3 year demonstration project to test Quality Bonus Payments (QBPs) for these plans Medicare Advantage plans will have a portion of their payment determined by their star rating (up to 5%) which may equate to millions of dollars per year.
16 Medicare Advantage Demonstration Project Quality Bonus Payments (QBP) QBP is a percentage increase in payment to the plan above the standard rate. For plans with less than 5 stars, the standard rate may be capped at pre ACA rates. For more details,
17 QBPs for MA PDs. Big Deal? The 2012 Medicare Advantage (MA) Rates were released in April 2011, and show how the star ratings will affect the CMS payments to MA plans. The difference in payment between 3 star and 5 star plans averages $16 per member per month but varies by the county of residence for the Medicare beneficiary If a plan with 1 million MA PD members could increase its stars from 3 to 5, the plan s revenue could increase by nearly $200 million per year.
18 Impact of Pharmacy Interventions? A large MA PD with 1 million members may have 100,000 patients on oral diabetes meds 3 stars = 70,700 adherent diabetics 4 stars = 74,900 adherent diabetics 4,200 pharmacies x 1 more adherent patient per store leads to a shift from 3 stars to 4 stars for MA PD
19 Implications of Medicare Ratings All Medicare plans have incentives to improve quality (e.g., marketing, enrollment advantages) Medicare Advantage plans will have even greater financial risks for quality in 2012 (QBPs) The plans incentives/risks will cascade to the pharmacy network contracts Preferred networks for high performing pharmacies Public reports on pharmacy quality Pay for performance incentives
20 How Should Pharmacies Prepare? Learn about Medicare plan (star) ratings Know the stars for your key plans Self assess your stores on adherence & safety Identify services that can improve star ratings Medication adherence & safety interventions Medication therapy management Be willing to participate in collaborative initiatives to drive improvements in star ratings
21 PQA s EQuIPP Initiative Launches in 2012 EQuIPP = Electronic Quality Improvement Platform for Plans and Pharmacies The EQuIPP Initiative is being launched this Spring in three states (Florida, Alabama, Pennsylvania) Through EQuIPP, community pharmacies can obtain their scores on PQA quality measures based on data from health plans or PBMs Pharmacies can also obtain access to QI tools and other resources through EQuIPP web based platform
22 EQuIPP Services in 2012 Plans Plan level scores and benchmarks on selected PQA measures for target states Pharmacy level reports for network pharmacies in target states Pharmacies Pharmacy scores on PQA measures, by organization, state, and a view by insurance mix Pharmacy organization management report Access to a base library of tools/resources for improvement
23 Plan 1 Plan 2 Plan 3 Data EQuIPP Reports Pharmacy 1 Pharmacy 2 Pharmacy 3
24 PQA s EQuIPP Initiative Launches in 2012
25 Pharmacy Comparison Report 25 PQA
26 Pennsylvania Confirmed Plans: Highmark, UPMC, Gateway, HealthSpring Possible Plans: Geisinger, Independence, Aetna Confirmed Pharmacies: Rite Aid, CVS, Giant Eagle, Target Florida Confirmed Plans: Humana, United, Wellcare, Capital, HealthSpring Possible Plans: BCBS FL, Coventry, Aetna Alabama Confirmed Plans: Humana, United, Healthspring Possible Plans: BCBS AL, Aetna FL/AL Confirmed Pharmacies: CVS, Target, WinnDixie
27 Summary The Medicare Star Ratings are getting a lot of attention by health plans, and they are redesigning benefits and programs to improve medication adherence and safety Pharmacies and plans can collaborate on QI, but pharmacies need to prepare now Through EQuIPP, community pharmacies can obtain their scores on PQA quality measures based on data from health plans or PBMs
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