Star Ratings: Strategies for Improving High-Risk Medication Adherence

Tampa—The Centers for Medicare & Medicaid Services’ (CMS) 5-Star Quality Rating System provides beneficiaries with information on the quality of Medicare Advantage and prescription drug plans to help select an appropriate plan. Under this system, Medicare Advantage and prescription drug plan contracts are rated and rewarded based on a 5-Star rating scale that measures quality performance (ie, outcomes, intermediate outcomes, patient experience, access, process measures). The system helps the CMS identify variations in the performance of different plans, and it encourages poorly performing plans to improve by imposing compliance actions and rewarding high-performance plans with bonus payments

To help plans achieve this, a panel spoke on strategies to improve Star ratings at the AMCP meeting. They focused on strategies to improve 1 key clinical measure that the CMS evaluates when assessing Medicare Parts C & D: medication adherence.

According to the presenters, medication adherence comprises 30% of the overall Star rating score of these plans when considering high-risk medications (ie, oral diabetes medication, hypertension medications, statins). To improve medication adherence, the panel emphasized that there is no 1 solution, and increment improvement requires a variety of approaches.

To illustrate ways to improve Star ratings by improving medication adherence, the presenters focused on a strategy implemented by 2 medical plans with different member demographics: (1) Denver Health Medical Plan (DHMP), Inc., with about 4000 members, 90% of whom receive a low income subsidy; and (2) New West Medicare, a not-for-profit Medicare Advantage plan in Montana with about 22,000 members, 10% of whom receive a low income subsidy. Claims for both of these plans are processed by MedImpact Healthcare Systems, Inc., a national pharmacy benefit management company whose clients rate higher than the average national plan and provides expert guidance to Medicare plans nationwide.

Program Examples

Bimel Patel, PharmD, director of health outcomes, MedImpact Healthcare Systems, Inc., San Diego, California, spoke about the strategy by MedImpact to improve Medicare Part D Star ratings that included targeting high-risk medications. He described a number of programs designed to improve communications between prescribers and members to improve medication adherence. Important components of these programs are member engagement, provider awareness, point of sale management, and integration with care management of pharmacy outreach services. An example of a program is the High-Risk Medication Drug Utilization Evaluation Program in which members using high-risk medications are identified and the prescriber is sent letters to target these members through various means (eg, sending refill reminders to members). Another program, a retail-based program called the Choice90RX^®, offers prescribers the opportunity to change a 30-day prescription order to a 90-day supply. New 90-day orders are faxed to pharmacies and members are alerted to the change in prescription.

Michelle Beozzo, PharmD, director of pharmacy, Denver Health Medical Plan, Inc, Denver, Colorado, described medication adherence strategies at the Denver Health Medical Plan that include an interdisciplinary care team in which each special needs plan member is annually reviewed and individuals with proportion of days covered <80% in the past 6 months are identified as in need of outreach. Outreach includes calls made by a clinical pharmacist or nurse to identity and address barriers to medication adherence, with intensive outreach using a health coach for complex case management.

Reporting on outcomes in 2013, Dr. Beozzo said that use of high-risk medications was reduced by almost 70% compared to 2012. She also said that the proportion of 90-day fills for high-risk prescriptions increased by 50%. Adherence to high-risk medications also increased since 2012, with an 8.5% increase in diabetes adherence, 9% increase in hypertension adherence, and 8.2% increase in statin adherence.

Lessons Learned

The main lessons learned from adopting these programs, according to Dr. Beozzo, is the need for providers to evaluate the culture of 90-day supply restrictions and modify the organization prescription refill workflow protocols to increase 90-day prescriptions. Pharmacies need to include pharmacy management in initial planning, she said, and for members, it is important to tailor notification letters to member readability level and to include information to advertise other programs when possible.

Cory Hartman, MS, vice president of clinical operations and customer service, New West Health Services, Helena, Montana, also emphasized the improvements in medication adherence at New West Medicare based on MedImpact programs. Use of high-risk medications was reduced by 3% in 2013 compared to 2012, and the proportion of 90-day fills for high-risk medications increased by 50%. Adherence to medication increased by 2.7% for diabetes drugs, 3.8% for hypertension adherence, and 4.3% for statins.

For Mr. Hartman, the main lessons learned included the need for providers to modify the prescription fax letter to accommodate electronic prescribing providers, the need to modify letters to members to decrease calls and increase member satisfaction, the need to provide assurance to pharmacists that the 90-day program complied with the board of pharmacy requirements in Montana, and the need to address field member concerns about program details and opt-out procedures.