Pharmacy News

Medicare’s Star Ratings Bring Opportunity for Pharmacists

[March 1, 2015, AJHP News]

Cheryl A. Thompson

BETHESDA, MD 12 Feb 2015—The extra weight that Medicare applies to the medication-adherence measures in its quality-rating system for health plans means opportunity and a revenue stream for at least one group of pharmacists.

Medicare’s “star ratings” system incorporates three measures of medication adherence. All three were developed and are maintained by the Pharmacy Quality Alliance, which has over 100 member organizations, including ASHP.

The measures are used to assess patients’ adherence to prescribed regimens of oral antidiabetic therapies in the absence of insulin therapy, renin–angiotensin system antagonists for hypertension management, and statin drugs for cholesterol lowering.

Medicare’s private health plan and prescription drug plan members are deemed adherent with a regimen if they obtain enough medication to cover 80% or more of the prescribed doses.

The federal government allows plans with a quality rating of five stars, the maximum, to market themselves and enroll people year-round.

In addition, starting this year, the government pays a bonus only to health plans that receive a rating of at least four stars.

The penalty in this arrangement is the designation “low performer.” When plans have less than a three-star rating for three consecutive years, the government designates them low performers and notifies plan members by letter.

Some health plans have turned to the University of Florida Medication Therapy Management Communication and Care Center for help with their star ratings.

Since August 2012, said Director Karen D. McLin, the center’s pharmacists and technicians have targeted the barriers that keep members of those health plans from adhering to medication regimens.

These “adherence outreach services,” as McLin calls them, constitute one of the center’s three service lines.

The program now brings in more than $2 million annually in revenue, with much of the credit given to Assistant Director Anna Hall.

McLin and Hall are clinical assistant professors at the university’s college of pharmacy.

Because health plans typically run several medication-adherence interventions simultaneously throughout the year, Hall said, it is hard to quantify the center’s specific effect on the plans’ star ratings.

But the center has been able to determine that it made “great contributions” to plans’ improvement in star ratings, she said.

Hall said the center’s technicians make the initial telephone call to the plans’ members and use a validated assessment tool to help determine patient-specific adherence barriers at play. Then, depending on the intervention appropriate for the particular barrier, either a technician or a pharmacist will take the next step.

Fourth-year pharmacy students, under the supervision of pharmacists, also provide some of the interventions, McLin said.

“We see a gamut of various challenges that patients face with being adherent to their medications,” she said, readily naming a dozen.

She said a key aspect of helping a patient overcome his or her challenges is uncovering the person’s specific barriers and working with the person to optimize medication use.

Several of the health plans use predictive analytics providers to identify the members who could benefit from the center’s adherence services, McLin said.

Other health plans, she said, rely on the center’s internally developed proprietary software platform that can calculate proportion of days covered—the basis of the adherence measures—and identify members to contact.

Once the center assesses a patient’s adherence barriers, McLin said, it offers tailored interventions, such as reminder tools and regimen simplification, and then ongoing follow-up support.

The center also offers refill synchronization services that enable plan members to pick up all their maintenance medications at their community pharmacy at the same time each month rather than in separate visits.

Call center staff can either coordinate refill synchronization or help facilitate it, McLin said. In coordinating synchronization, staff members contact the member’s local pharmacy, prescribers, and health plan or pharmacy benefits manager. If the member’s local pharmacy provides appointment-based medication synchronization, the center’s staff works with that pharmacy to facilitate the conversion.

Hall said that regardless of the intervention, “we see it through to completion” on behalf of the patient.

That means coordinating communication between the patient, his or her prescribers, and the pharmacy.

“I can imagine that [for a patient] it could be difficult to try to remember what opportunity the pharmacist mentioned and know exactly how to explain it to your doctor and what you want to ask for,” she said.

Some of the center’s staff members speak Spanish in addition to English, Hall said. For those languages not spoken fluently by any of the center’s employees, she said, a certified interpreter joins the telephone call.

Measurement of the center’s effect on star ratings is expected to come from research being conducted through the one-year, $50,000 grant that Hall received from the Pharmaceutical Research and Manufacturers of America Foundation.

That study, involving a single health plan, is designed to determine the effect of the center’s adherence services on the applicable star ratings, Hall said. The study, which runs through March 31, is also examining the combined effect of the center’s adherence services and a company’s targeted modeling on improving the plan members’ medication adherence.

The star ratings for private health plans, according to the Department of Health and Human Services (HHS), prompt Medicare beneficiaries to shop for coverage on the basis of quality.

About 60% of the enrollees in Medicare’s private health plans are members of plans with four or more stars, up about 31 percentage points from three years ago, HHS recently reported.

HHS on January 26 touted this increase in quality-based shopping for healthcare as an example of significant progress in reforming the healthcare delivery system in order to ensure better care, smarter spending, and healthier people.

The department also touted Medicare’s Hospital Readmissions Reduction Program as an example of delivery-system reform.

Pharmacists’ expertise in managing and optimizing medication regimens has a very important role in ambulatory care as well as in health systems’ initiatives to reduce 30-day readmissions, said Shekhar Mehta, ASHP’s director of clinical guidelines and quality improvement.

Mehta, who also serves as ASHP’s representative to the Pharmacy Quality Alliance, pointed to the results achieved by a care transition program and reported in AJHP [see May 1, 2014, AJHP Practice Reports].

The program focused on patients who were being discharged to home and featured bedside delivery of postcharge medications and follow-up telephone calls in the ensuing three days. Those patients who opted for the program had a lower likelihood of readmission in the first 30 days.


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