How your pharmacy partners impact your Star Ratings

The Centers for Medicare and Medicaid Services (CMS) implemented the Five Star Quality Rating System to help educate consumers on quality of healthcare and make healthcare quality data more transparent. Health plans are rated on multiple measures, five of which are specifically related to medication management and the pharmacy: high-risk medications, diabetes treatment, medication adherence for diabetes, adherence for hypertension and adherence for cholesterol. Currently, these five measures account for almost half of a plan’s total score from CMS.

Related: What health execs should know about Medicare Star Ratings

CMS does not issue Star Ratings for pharmacies, only for health plans. However, the plans can assess how their network pharmacies meet medication management and adherence measures by simply reviewing claims. Regular claims for prescription coverage by patients, especially refills, is a leading proxy for compliance or “adherence,” which leads to better health outcomes. This allows plans to issue their own ratings for pharmacies and to evaluate those that better meet CMS-defined quality measures. To increase their own Star Rating, health plans can rework their preferred networks to include only pharmacies with high ratings on medication-related measures.

Curant Health director of clinical services Vickie Andros has implemented a new program with her team of clinical pharmacists to measure the impact those pharmacists can make on one of the five Star Rating measures attributable to medication management and the pharmacy: high-risk medications.

Medications flagged as being high-risk for the elderly are included on the PQA High-Risk Medications (HRM) measure drug list, which is based on recommendations from the American Geriatrics Society (AGS). Inappropriate use of these medications can lead adverse drug events (ADEs), the leading cause of hospital admissions. One study has shown that 30% of hospital admissions of elderly patients may be linked to drug-related problems and another study has shown that 35% of ambulatory older adults experienced an ADE and 29% required healthcare services.

The associated Star Measure that quantifies the use of high-risk medications in the elderly is defined as the percentage of Medicare Part D beneficiaries aged 65 years and older who received two or more prescription fills for the same HRM drug with a high risk of serious side effects in the elderly. This percentage is calculated as the number of member-years of enrolled beneficiaries aged 65 years and older who received two or more prescription fills for the same HRM during the period measured (numerator) divided by the number of member-years of enrolled beneficiaries 65 years and older during the period measured (denominator). (Note: Detailed information on Star Ratings for Medicare Advantage (MA) and Prescription Drug Plans (PDP) can be found on the CMS website. Open the zip file for 2016 Part C and D Medicare Star Ratings Data, select the folder 2016 Star Ratings Technical Notes, Fact Sheet, LPI List and Medication Lists, and open the 2016 Star Ratings Fact Sheet. Average star ratings for each measure, including HRM, can be found on page 15.)

Next: The HRM measure

The HRM measure is one that managed care executives, pharmacy benefit managers (PBMs) and pharmacists should focus on. It can serve as a useful metric in the development and execution of a pharmacist-led proactive patient outreach program to increase patient safety and potentially lower costs from ADEs. The primary aim of such a program is to prevent patients from being placed on HRM medication at the start of therapy if suitable alternative medications are available. This program component is best supported by a robust pharmacy fulfillment platform configured to flag elderly patients and HRM prescription orders.

The secondary aim is to conduct additional therapy evaluation with those patients taking high-risk medications to monitor how well the medications are working and to determine if medication side effects are having negative impacts. Pharmacists engaged in similar programs are well-positioned to engage other healthcare providers if patients’ side effects are severe and warrant therapy modification. Altering an elderly patient’s medication therapy to substitute medication that isn’t on the PQA High-Risk Medication list will lead to that patient being removed from the pool of patients used in the HRM star measure calculation.

In conclusion, in order to improve patient care and ultimately impact your plan’s star rating, learn how the pharmacies in your network are using these measures to enhance their business processes.

Marc O’Connor is chief operating officer for Curant Health. Curant Health provides medication management, patient support and pharmacy fulfillment services for patients nationwide.