How CMS Star Ratings
Will Affect Your Revenue
Star Measures 101 (Drug Topics)
Pharmacy Quality Measurement Q&A (Pharmacy Quality Solutions)
Star Ratings, MTM & Independent Pharmacy (AmerisourceBergen)
How to Find (and raise!) Your star Ratings (pharmacyowners.com)
Your Future is In the Stars (APhA)
Medicare Part D Star Ratings & Pharmacy Performance (iMedicare)
Provider reimbursement is evolving from fee-for-service to pay-for-performance. For independent pharmacies, this raises the need to define “performance” and determine how to measure and improve it. In the new era of performance, understanding what quality measures are important to health plans and PBMs is the starting point. To prosper in the evolving reimbursement model, you must start assessing how well your pharmacy is meeting these standard quality benchmarks.
The Centers for Medicare and Medicaid Services (CMS) implemented the Five Star Quality Rating System to help educate consumers on quality of health care and make quality data more transparent. Health plans are rated on multiple measures, with five specifically related to medication management: high-risk medications; diabetes treatment; medication adherence for diabetes; adherence for hypertension; and adherence for cholesterol. These five measures account for almost half of a plan’s total score from CMS.
Health plans earning high star ratings qualify for federal bonus payments and can market their plans year-round to consumers. Having a higher star rating also makes it easier to charge higher premiums. Health plans can get quite a bit of money for having higher star ratings — and pharmacy benefits are a vital part of that equation.
Part D Plan Measures That Pharmacies Directly Affect
Managing Chronic Conditions through Medication Adherence (PDC)
Adherence is measured using the Proportion of Days Covered methodology — what percentage of days does the patient have the medication. Adherence measures focus on three chronic disease categories:
- Oral diabetes medications;
- cholesterol medications (statins); and
- hypertension medications (renin-angiotensin system [RAS] antagonists).
Pharmacies also can affect star ratings by promoting medication safety and identifying gaps in therapy:
- The appropriate use of high-risk medications in the elderly; and
- Using the kind of blood pressure medication that is recommended for patients with diabetes.
Medication Therapy Management
An area where pharmacies play a critical role – and which is expected to count toward a plan’s star rating in 2015 – is comprehensive medication review (CMR) completion rates. Other measures under consideration include drug interactions, excessive doses of oral diabetes medications and HIV anti-retroviral medication adherence (via safety reports).
Why a Plan's CMS Rating Will Affect Your Operation
CMS does not issue star ratings for pharmacies, only for health plans. However, the plans can assess how their network pharmacies meet medication management measures solely by reviewing claims. This allows them to issue their own ratings to pharmacies and to evaluate which ones are better at meeting CMS-defined quality measures. To increase their own star rating, health plans can rework their preferred networks to include only pharmacies with high star ratings and send MTM cases only to pharmacies that show good patient outcomes. The better your pharmacy’s star ratings, the more patients and revenue you are likely to get.
Concerns & Financial Implications for Pharmacies
- Impact of MTM Demands: MTM will play a growing role in day-to-day operations. But reimbursements average around $60 for 30-60 minute sessions, less than the average hourly salary of the pharmacist conducting the sessions. This does not even consider other operational costs generated during that hour of time or the effect on pharmacy workflow. Like it or not, community pharmacies that want to continue to be part of health plans’ preferred networks will have to adapt their operations to efficiently provide MTM services.
- Competition With Mail-order: Three of the five assessment criteria for MTM deal with adherence measures based solely on the medication possession ratio gathered from pharmacy claims data. Mail-order pharmacies are able to automatically refill and mail out medications for patients, even when the patient doesn’t need or want the medication. Even if a patient is not actually taking the medication, the mail-order pharmacy has the claim billed to the health plan, giving it a higher adherence ratio.
Pay for Performance: A Likely Future
Health plans are rewarding top-performing physicians through Pay-for-Performance (P4P) models. A few are already venturing into P4P for pharmacies, such as HealthPartners, Humana and Inland Empire Health Plan. Under IEHP’s Pharmacy P4P Program — launched in October 2013 — pharmacies can earn a bonus payment every six months based on the quality of medication-related care they provide to IEHR members. Pharmacies are evaluated on how they perform on Medicare Part D Star Rating measures (e.g., medication adherence and safety) plus asthma and generic dispensing rate compared to predetermined standards.
Measurement & Management Tools are Essential
It is vital that you know and manage your pharmacy’s performance numbers for adherence and other key measures. You must understand where you need to improve and how you rank compared to your peers. Meeting and exceeding PBMs’ expectations is essential in ensuring ongoing network participation and steady access to patients. Many independent pharmacies do not have the tools to readily assess adherence, MTM outcomes and other clinical performance measures. Fortunately, there are vendor solutions available:
- Pharmacy Quality Solutions EQuIPP | www.pharmacyquality.com
PQS is the leading provider of medication use quality assessment services. EQuIPP is the PQS performance information management platform that makes unbiased, benchmarked performance data available to both health plans and pharmacy organizations. Both AmerisourceBergen’s GNP network and McKesson’s Health Mart network offer the EQuiPP platform to their members.
- Medhere Today | www.medheretoday.com
The MedHere Today Adherence Program uses the pharmacist-patient relationship to improve adherence and avoid waste and overfilling of medications. Independent studies by Pfizer on the MedHere program showed an average increase of 29 prescriptions per enrolled patient per year and significant increases in adherence across all therapeutic categories. MedHere’s Star Rating Solution Center is a resource hub for Star Ratings measures. Want to know what a “Diabetes PDC” is and how to improve it? MedHere’s Star Rating Guides and staff consultants provide a road map for driving “Star Rating” performance.
- PrescribeWellness | www.prescribewellness.com
PrescribeWellness’ solutions address such patient-related health challenges as medication adherence, appointment-based medications, chronic disease management, transitional care intervention, medication synchronization and behavioral change programs. Even if you don’t offer these services, you can use the PharmacyGrowth platform to improve the loyalty and medication adherence of current patients. The LinkWellness 3.0 dashboard enables you to easily administer medication adherence, chronic disease management, transitional care collaboration and other services by simplifying patent identification, recruiting, scheduling, performance and monitoring.