medicare star

Introduction

• Speaker: Krista D. Capehart, PharmD, MS, BCACP

• Director of the Wigner Institute for Advanced Pharmacy Practice, Education, and Research

• Clinical Professor, Department of Clinical Pharmacy, WVU School of Pharmacy

Objectives

• Pharmacy Quality Alliance (PQA): Explain its role in Medicare Star Ratings.

• Medicare Star Ratings: Describe their relation to appropriate medication use.

• Impact: Discuss how Medicare Star Ratings affect health plans and pharmacies.

• Proposed Changes: Describe changes to Medicare Star Ratings.

• Collaboration Opportunities: Identify ways pharmacists can collaborate to enhance health outcomes.

What is the Pharmacy Quality Alliance (PQA)?

• Mission:

  • Improve quality of medication management in healthcare.

  • Enhance patient health through collaborative performance measures.

• Strategic Objectives:

  • Established in 2006 as a non-profit alliance with over 100 member organizations.

  • Promotes appropriate medication use and develops performance measurement strategies.

Medicare Star Ratings

• Establishment: Created in 2011 by CMS to guide patient enrollment in Medicare Part C & D.

• Components:

  • Part C: Derived from HEDIS (Healthcare Effectiveness Data and Information Set) measures.

  • Part D Domains: Evaluates four key areas:

    • Drug Plan Customer Service

    • Plan Performance

    • Member Experience with the Plan

    • Drug Pricing and Patient Safety

Importance of Performance Ratings

• Performance Monitoring: Essential for feedback and competition among providers.

• Quality Standards: Establish benchmark metrics for healthcare providers.

• Best Practices: Encourages identification and implementation of best practices in medication management.

Star Ratings and Pharmacies

• Target Entities: Ratings primarily focus on health plans; however, pharmacies utilize EQuIPP to compare performance.

Drug Safety and Pricing Measures

• Performance Measures: Evaluates up to 30 metrics including:

  • Drug pricing accuracy

  • High-risk medication prescriptions

  • Medication adherence for diabetes, hypertension, and cholesterol medications

  • MTM (Medication Therapy Management) completion rates

Data Sources

• Prescription Drug Event (PDE) Data: Reports submitted by drug plans summarizing beneficiary prescriptions under Medicare Part D.

Benefits of Higher Ratings

• Enrollment Advantages: Five-star plans can market and enroll members year-round.

• Consequences for Low Ratings: Plans with consistently low ratings face enrollment restrictions and potential removal from Medicare.

Drug Price Accuracy Measures

• Scoring: Assessed based on accuracy of drug pricing information provided to Medicare beneficiaries.

High-Risk Medications

• Criteria: Evaluates prescriptions given to members aged 65+ for medications with high side effect risks based on the Beers criteria.

Medication Adherence Measures

• Diabetes and Hypertension: High adherence rates defined as being covered for more than 80% of days for specific medication types (oral diabetes medications, RAS antagonists).

MTM Program Overview

• Goals: Aims to help members understand and manage their medications effectively, including personalized assessments and action plans.

EQuIPP Platform

• Description: A platform for pharmacies to benchmark their performance against others and improve service quality based on medicinal outcomes.

Pay-for-Performance (P4P) Model

• Definition: A health care model rewarding providers for meeting specific quality benchmarks.

• Expected Outcomes: Aligning incentives may enhance healthcare quality.

Cost Effectiveness of P4P

• Evidence: Indicates mixed results concerning the effectiveness and sustainability of P4P programs.

Pitfalls of P4P

• Challenges:

  • Potential gaming of the system

  • Reduced intrinsic motivation among providers

  • Neglect of essential factors such as training and resources

Conclusions

• Collaboration Importance: Pharmacists, physicians, and patients are integral for improving overall healthcare outcomes, influencing nearly 50% of Medicare star ratings.

• Quality Focus: Health quality forms the foundation of the Affordable Care Act, providing rewards for high-quality performance.

• Role in Community Pharmacy: Community pharmacies can significantly enhance medication adherence and chronic disease management.

Challenges and Opportunities in Pharmacy

• Key Areas:

  • Reimbursement

  • Dialogue among healthcare providers

  • Patient education efforts

  • Building relationships across healthcare sectors

  • Navigating regulatory issues

Resources

• Extensive references for further reading on Medicare Star Ratings and related pharmacy practices.

• Various studies cited for credibility and continued education on the subject.