Managed Care Organizations and Medicare Star Ratings

San Diego—The emerging model for healthcare in the United States is value-driven healthcare, according to speakers at a Contemporary Issues session at the AMCP meeting. The session was titled How Much of the $3 Billion in Star Rating Bonuses Did your MCO Capture? The first speaker, David Nau, RPh, PhD, CPHQ, FAPhA, president, Pharmacy Quality Solutions, opened the session by defining value as the balance of quality and costs, creating an environment in which healthcare providers can “optimize value by improving quality while reducing costs.”

Noting that there are conflicting ideas about how to define and measure quality, Dr. Nau cited the Pharmacy Quality Alliance (PQA), a public-private partnership established in April 2006 to “improve the quality of medication management and use across healthcare settings.” The mission statement of the PQA includes the “goal of improving patients’ health through a collaborative process to develop and implement performance measures and recognize examples of exceptional pharmacy quality,” he said.

Dr. Nau continued by discussing the Medicare quality ratings established by the Centers for Medicare & Medicaid Services (CMS). The CMS Medicare Star Ratings are available on the CMS website as well as on the Medicare Plan Finder and are displayed as 1 to 5 stars. Stars are calculated for each measure, as well as for each domain, summary, and overall level.

Ratings on Part C are based on 37 quality measures that include member experience, process of care, and clinical outcomes. Medication adherence rates may affect some of the measures. For example, for diabetes care, blood sugar and cholesterol control are measured; for patients with hypertension, blood pressure control is measured.

Medicare Part D plans receive a summary rating on quality in addition to 4 domain and individual measure scores for a total of 18 individual scores, according to Dr. Nau. Five of those measures were developed by the PQA: 2 measures of medication safety (high-risk medications in the elderly and appropriate treatment for blood pressure control in patients with diabetes) and 3 measures of medication adherence (oral diabetes medications, cholesterol medications [statins], and blood pressure control medications [renin-angiotensin antagonists]). Dr. Nau noted that because of the higher weighting of clinically relevant measures, these PQA measures account for 45% of the Part D summary ratings in 2013.

Dr. Nau concluded his presentation by commenting that the Medicare Star Ratings are focusing increased attention on medication-related quality of care. Because the ratings are tied to the level of bonuses received, Medicare plans are implementing strategies for improving their Star Ratings, including pharmacy network changes and pharmacy pay-for-performance programs.

The session continued with a presentation from James Hopsicker, RPh, MBA, vice president, pharmacy programs, MVP Health Care. Mr. Hopsicker’s presentation centered on MVP Healthcare’s approach to Medicare Star Ratings. MVP is a non-for-profit health insurer headquartered in upstate New York serving >625,000 members in New York, Vermont, and New Hampshire, including >100,000 Medicare beneficiaries nationally.

MVP developed a team approach to support activities that would improve Star Ratings, Mr. Hopsticker said. Team member areas of interest included clinical, provider, communications, customer satisfaction, and data analysis. The team identified opportunities for improvements and developed “dashboards” to monitor performance.

Mr. Hopsicker described MVP’s pharmacy department as one with an “operational structure that supports Medicare Star Ratings goals.” Members of the MVP pharmacy team worked closely with pharmacy benefit managers and other vendors, he added.

He concluded his presentation by defining the key challenges and opportunities facing organizations looking to improve their Star Ratings: maintaining financially viable yet clinically sound programs; ensuring quality and availability of data; integrating laboratory data; and continuing to work with downstream entities to improve quality and ensure compliance.

“Keep the focus, be flexible, and anticipate change,” he concluded.

The next speaker was Brandy Fouts, PharmD, Medicare clinical services coordinator, Group Health Cooperative (GHC), who addressed the issue of adherence vis-à-vis Medicare Star Ratings.

Dr. Fouts outlined GHC’s approach to Star Ratings, saying that the organization views improving the ratings as an “organization-wide effort.” Divisional leaders were asked to provide operational accountability, a work plan was developed for each operational area with specific tactics outlined and updated monthly, and a dashboard was created for tiered checking and monitoring, she said.

She concluded by identifying the strengths and weaknesses of the Star Ratings system as it relates to adherence. She said the system provides a strong foundation for managing chronic diseases, highlights the visibility of the contributions of pharmacists, and allows for cross-functional alignment within the organizations. She cautioned, however, that there is no “silver bullet for nonadherence” and that Star Ratings provide only a “limited picture of health.”

The session concluded with a presentation from Matt Nye, PharmD, vice president, pharmacy support care services, Kaiser Permanente. Dr. Nye provided an overview of Kaiser Permanente’s approach to Medicare Star Ratings.

Kaiser Permanente is the largest nonprofit health plan in the United States, with 8.9 million members in 9 states and the District of Columbia, and 1.05 million Medicare members. The plan’s national pharmacy programs and services include 350 outpatient pharmacies with 9500 staff members, including 3000 pharmacists. Other services include ambulatory care pharmacy services, home infusion, drug distribution via mail order and central fill, and centralized services.

Dr. Nye described Kaiser Permanente’s approach to drug therapy management as “leveraging the medical and pharmaceutical expertise of an integrated practice model. Clinical experts work to establish comprehensive and attainable goals based on the best-available medical evidence, sharing accountability between physicians and pharmacists for assuring appropriate and judicious medication selection and use decisions,” he said.

He continued his presentation by listing 7 steps that can lead to “being successful with Stars”: (1) having a deep understanding of the measures; (2) internal measure tracking; (3) regular communication with stakeholders: (4) measuring specific plans that are customized by region; (5) involvement with PQA and Acumen; (6) ongoing follow-up; and (7) sharing successful practices.

In conclusion, Dr. Nye said that 7 of 8 Kaiser Permanente regions have a Part D Summary Rating of 5, and 5 of 8 regions have won the PQA Quality Award.