Update on Medicare Part D Star Ratings

San Francisco—In 2012, Medicare Advantage plans will receive bonus payments based on the quality of care they deliver. As part of the Patient Protection and Affordable Care Act, the Centers for Medicare & Medicaid Services implemented a demonstration project to reward plans based on a 5-star rating system.

At the AMCP meeting, a representative from a health plan and pharmacy benefit manager discussed several issues related to the topic during a Contemporary Issues session titled Medicare Part D Star Ratings Update.

Mitzi Wasik, PharmD, director of Medicare pharmacy programs at Coventry Health Care, said Medicare Advantage prescription drug plans receive 17 quality ratings across 4 domains. The bonus payments begin this year and are scheduled to last for 3 years. Plans that are rated ≥3 stars will receive a bonus between 3% and 5%, while those receiving <3 stars will not get a bonus.

For the 2013 ratings, plans were required to submit data by May 31, 2012. They will be notified in October 2012. Payments are based on data from 2 years earlier, so payments for 2013 will be based on quality measures from 2011. Dr. Wasik noted that when choosing plans for 2013, beneficiaries will see ratings from 2011.

For Medicare Part D plans, the star ratings system emphasizes patient adherence to hypertension medications, oral diabetes medications, and statins to control high cholesterol. Dr. Wasik said the goal is 80% adherence as measured by proportion of days covered, which she added is a more sophisticated measure than medication possession ratio (MPR). Although most plans use MPR internally to measure adherence, Dr. Wasik said it typically overestimates adherence.

The system also measures the percentage of people ≥65 years of age who receive medications that put them at high-risk for an adverse event. Medications based on the Beers list developed by the American Geriatric Society include icyclobenzaprine, carisoprodol, and conjugated estrogens. In addition, the system measures the percentage of beneficiaries who were dispensed a medication for diabetes and hypertension who were also receiving an angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker medication to treat diabetes.

According to Dr. Wasik, the measurements mentioned are weighed on a 3 times scale, whereas other measures carry less weight. Thus, these measurements play a major role in determining whether plans receive bonus payments.

Babette Edgar, PharmD, president of government services at Catalyst Rx, said many plans have responded by hiring staff and dedicating resources to achieve high ratings. Some pay bonuses and give raises to employees who are successful at improving ratings, and they have also increased pay-for-performance incentives to physicians. Dr. Edgar said plans should understand the implications of a high rating, which leads to increased marketing opportunities and likely more members and profits, as well.

Dr. Edgar added that Catalyst Rx, a pharmacy benefit manager, is hoping to increase adherence and help patients through Internet-based tools. Members can use a company web site to compare the cost of drugs at various pharmacies in their area; they can also track adherence through web site and e-mail reminders. Catalyst Rx also has a mobile application that is aimed at increasing convenience for its members, while supporting adherence and promoting generic drugs and formulary compliance.