the cms five-star quality rating system: what it means to you and your pharmacy
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The CMS Five-Star Quality Rating System:What It Means to You and Your Pharmacy
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Today’s Speaker
Rick McKaigDirector, Managed Care
AmerisourceBergen Drug Corporation
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Learning Objectives
At the end of this program, participants should be able to:
• Describe the Medicare Star Ratings Program
• Explain the 5 Medication Use Measures
• Understand the role of EQuIPP™
• Identify effective means for community pharmacies to improve their individual performance on the medication use measures
• Acknowledge the short and long-term impacts of the Medicare Star Ratings Program on Community Pharmacy
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Disclaimers
CMS
• Assigns Star Ratings to:
– Part C Health plans
– Part D Stand-alone plans
• CMS does not assign Star Ratings to pharmacies
• But by proxy, others do
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Pop “Star” Quiz
$317 Billion 5 2006 74% P4P
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Pop “Star” Quiz
$317 Billion 5 2006 74% P4P
A. CMS’ annual expenditures on health care for seniors
B. Estimate of economic losses associated with non-adherence
C. Annual economic spend on pharmaceutical products
D. Projected value of estimated savings as a result of the ACA
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Pop “Star” Quiz
$317 Billion 5 2006 74% P4P
A. The enhanced dispensing fee for 5-Star pharmacies
B. The number of years before the 5-Star Rating system applies to pharmacy
C. The number of stars in the CMS 5-Star Rating system
D. The number of current enrollees in Health Exchanges
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Pop “Star” Quiz
$317 Billion 5 2006 74% P4P
A. The year the first Medicare Part-D prescriptions were filled
B. The year that pharmacy reimbursements first came under pressure
C. The year Medicare Part-D was enacted into law
D. The year Star Ratings started to be measured
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Pop “Star” Quiz
$317 Billion 5 2006 74% P4P
A. The decline in pharmacy reimbursements since 2006
B. The bonus percentage for 5-Star health plans
C. The percent of Medicare beneficiaries enrolled in either a PDP or MAPD plan
D. The 2014 inflationary growth rate of pharmaceuticals
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Pop “Star” Quiz
$317 Billion 5 2006 74% P4P
A. Public Private Partnership for Pharmacy founded by CMS
B. An acronym for pay for performance
C. Independent pharmacy group that advocates for pharmacy payment fairness
D. The group “People For Pharmacy”
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Bonus Question
Who was president when the surgeon general of the US coined the oft-repeated phrase “Medications do not work in patients who do not take them”
A. Jimmy Carter
B. Ronald Reagan
C. George H. Bush
D. Bill Clinton
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A basic understanding of Medicare will help Star Ratings make sense
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The ABCD’s of Medicare
CMS 2014 Statistics
Part-ABasic Hospital Insurance (1965)
Part-BBasic Medical Insurance (1965)
Part-CMedicare Advantage (1997)
Option for SeniorsReplaces Part-A and Part-B
Part-D (MA-PD)Insurance for Drugs (2003)
Part-D (PDP)Insurance for Drugs (2003)
41% of beneficiaries
2010 Affordable Care Act MA Bonuses for Star Performance
59% of beneficiaries
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Independents should be happy that Medicare has emerged as a major payer
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Growing Business
• 10,000 patients age in daily
• Average use is 2.5 Rx/mo
• Retiree coverage being replaced by Medicare Plans
• 35,000 Low Income Subsidy (LIS) patients under age 65 entering monthly
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Part-D Is Good for Independents
• Plan - patients pick it!
• Pharmacy—patients pick it!
• No employer or labor union in the middle
• Any willing provider regulations
Preferred Networks are a concern
• Chains accept lower reimbursement to drive foot traffic
• Today’s preferred networks are all about cost
• What if tomorrow’s networks could be based on quality, not cost?
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Pharmacy performance will determine P4P
2008CMS begins
collecting data
2009CMS starts reporting
Health Plan Star Ratings
Oct 2013 2014Health plansturn focus
to Pharmacy Networks
2015P4P
2016“Quality
Networks”
Your Pharmacy Can Be Ahead of the Game
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Independents Are Positioned Well
NCPA study on patient’s level of connection with the pharmacist
Independent Pharmacists Chain Pharmacy Mail Order
89%
67%
36%
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You should care because Star Ratings will impact reimbursements
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Adherence Is a National Problem
Source: IMS
For every
100prescriptions
written
15-20are refilled as
prescribed
25-30are taken properly
46-66come out of the
pharmacy
50-70Goes into apharmacy
“Drugs don’t work in patients who don’t take them.” — Former Surgeon General C. Everett Koop
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Stars Are Consumer Facing!
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Here’s What CMS Publishes
Medicare Star Ratings
Excellent
Above Average
Average
Below Average
Poor
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Reimbursements May Look Like This
Medicare Part D Star Ratings
Excellent
Above Average
Average
Below Average
Poor
Plenty of details not known yet, but expect that 4-Star pharmacies will be paid more than 3-Star pharmacies
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The five medication use measures comprise 48.5% of a PDP’s overall score
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1. Use of High Risk Medications in the Elderly
The percent of your Medicare patients 65+ receiving two or more prescription fills for a high-risk medicine
Cholesterol PDC
Blood Pressure PDC
Oral Diabetes PDC
Diabetes Treatment
High Risk Meds 3%
87%
82%
81%
76%
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2. Appropriate Treatment of Diabetes
The percent of your Medicare patients with meds for diabetes and hypertension also receiving an ACE inhibitor, ARB, or direct renin inhibitor med
Cholesterol PDC
Blood Pressure PDC
Oral Diabetes PDC
Diabetes Treatment
High Risk Meds 3%
87%
82%
81%
76%
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3. Adherence – Oral Diabetes Meds
The percent of your Medicare patients adherent with their oral diabetes meds
Cholesterol PDC
Blood Pressure PDC
Oral Diabetes PDC
Diabetes Treatment
High Risk Meds 3%
87%
82%
81%
76%
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4. Adherence – Blood Pressure Meds
The percent of your Medicare patients adherent with their blood pressure meds
Cholesterol PDC
Blood Pressure PDC
Oral Diabetes PDC
Diabetes Treatment
High Risk Meds 3%
87%
82%
81%
76%
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5. Adherence – Cholesterol Meds
The percent of your Medicare patients adherent with theircholesterol meds
Cholesterol PDC
Blood Pressure PDC
Oral Diabetes PDC
Diabetes Treatment
High Risk Meds 3%
87%
82%
81%
76%
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Thresholds Are Tightly Grouped
Reaching even the 2-Star Level will require the attentiveness of your pharmacists and technicians
Cholesterol PDC
Blood Pressure PDC
Oral Diabetes PDC
Diabetes Treatment
High Risk Meds 3%
87%
82%
81%
76%
11%
82%
73%
73%
70%
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A Typical Network of Independent Pharmacies
Source: EQuIPP™ May-2013 thru Oct-2013, based on 2014 thresholdsPDC is Proportion of Days Covered
Cholesterol PDC
Blood Pressure PDC
Diabetes PDC
Diabetes Treatment
High Risk Meds 61%
36%
77%
85%
88%
Stores that have reached 3, 4 or 5 Stars
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How you can find your Star Ratings
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EQuIPP™ – A New Industry Tool
Note: EQuIPP™ is a product offered by Pharmacy Quality Systems (PQS) which is a joint venture between Pharmacy Quality Alliance (PQA) a non-profit entity and CE/City, a technology vendor.
CMS
PDP Healthplan
PBM MTM MTM PBM
Rx Rx Rx Rx Rx Rx
Neutral Entity
• Plans provide claims
• Currently at 26% of Medicare beneficiaries
• Pharmacy Web App
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You have visibility to because the plans subscribe to EQuIPP
100% of Medicare Patients Measured
Health Plans
• Humana
• Coventry
• Wellcare
• HealthSpring / CIGNA
• Inland Empire Health Plan (CA)
• BCBS – Tennessee
• BCBS – North Carolina
• UPMC Health Plan (PA)
• Gateway Health Plan (PA)
26%
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Supplemental Reports to Support Star
Reminder: This report contains personal health information that falls within the definitionof “Protected Health Information” or “PHI” under federal law (HIPAA).
Star Ratings: Reducing High Risk Medication Use
Fill Date Rx Age Fill Days NDC Drug BIN Plan
3/21/14 123456 71 0 15 000378-5310-01 Zolpidem Tartrate 10 mg 156231 Silverscript
3/22/14 235689 68 1 30 00378-6410-01 Doxepin 100 mg 458921 Humana
3/23/14 568978 76 3 20 00185-0648-10 Diphenhydramine 25 mg 789456 Caremore
3/23/14 987654 81 2 30 00603-5167-32 Phenobarbital 64.8 mg 614575 Silverscript
Star Measurement This Report
Includes Medicare Part D fills from last week (Sunday through Saturday) for patients 65 or older who received at least one medication from the EQuIPP® list of High Risk Medications.
This measure calculates the percentage of Medicare Part D beneficiaries 65 years or older who received two or moreprescription fills for the same HRM drug with a high risk of side effects in the elderly.
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The Value of an EQuIPP™ License
• Health Plan Detail
• Performance Over Time
• State Peer Benchmarks
• Multi-Store Owner Benefits
• Improvement Strategies
• CE Opportunities
• Frequently Asked Questions
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How can a pharmacy perform well on Star Ratings?
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Rx inflow controls workflow Patient scheduling controls workflow
Patient initiates activities Pharmacy schedules activities
MTM performance crucialMTM’s treated as optional
Workflow Must Change
Tomorrow’s Successful PharmacyToday’s Successful Pharmacy
Personalized Service
Speedy Rx Service
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MTMs Have New Importance
• Independent pharmacy lags behind the chains
• Not just “brown bag” reviews
• Multiple “TIPs” for a single patient can add up
• TIPs, TMRs, Gaps
– Require less time
– May already be doing
Pharmacies must be enrolled with both Mirixa and Outcomes
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Healthplan reviews patient records and
identifies opportunitiesfor interventions
MTM & TIP Opportunities
Not every MTM activity is a Complete Medication Review
Improves the healthof patients
United Healthcare (using OutcomesMTM) and Caremark (using Mirixa) have based their initial Star improvement strategies on assigning activities to the patient’s pharmacy.
Pharmacists reviews opportunities and
counsels patient and records activity
MTM = Medication Therapy Management
CMR = Complete Medication Review
TIP = Targeted Intervention Program
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NCPA Simplify My Meds
Med SynchProactively adjust timing of multiple prescriptions
Operational PracticeFrequently call patients to review status
Study from NCPA sheds new light on med synchronization programs. January 17, 2014. Average enrolled patient was taking 5.9 synchronized medications.
NCPA Tool KitPatient brochures, enrollment forms, physician faxes, training, and more
NCPDP Codes to Synchronize Rx’sSCC 47, SCC 48
Control Group Med-Synch Patients
Days of therapy
Patients adherent
Additional fillspatient/year
337
56% 90%
+20
234
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Commercial Adherence Programs
• Variety of approaches
– Turnkey programs
– Consulting
– Software
– Packaging
• May include training of your staff
• Most include patient materials
– Patient letters
– Point of dispense messaging
Complementary with synchronization of patient’s prescriptions
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Leverage Your Dispensing System
• Enroll patients in Auto Fills
• Use Refill Reminders (email, text, outbound calling)
• Make refills easy to order (IVR, web, mobile)
• Synchronization (reporting, calendars, drug/patient id)
• MTM Interfaces
• Compliance packaging interfaces
Complementary with synchronization of patient’s prescriptions
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Achieving strong ratings will require changes in your practice,
here are a couple of success stories…
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Success Story: L&S Pharmacy Experience
• 300 patients enrolled (10% of patients)
• 8,700 more fills for the 300 patients
• 29 more fills per patient per year
• $113,000 increase in annual profit with existing patients
MedHere Today Appointment model
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Success Story
Study conducted by Virginia Commonwealth School of Pharmacy
Medication Control Group Study GroupSTAR
Equivalent
ACEIs/ARBs (Blood Pressure) 40.8% 79.5%
Beta Blockers (Blood Pressure) 38.3% 71.8%
CCBs (Blood Pressure) 40.3% 68.9%
Diuretics (Blood Pressure) 37.0% 66.1%
Metformin (Diabetes) 40.2% 76.6%
Statins (Cholesterol) 37.4% 76.2%
Study Measured Proportion of Patients Considered Adherent
Med Synch Based Appointment Model
• Small chain based in Minnesota
• Synchronize all of a patient’s chronic fill meds
• Patients are assigned a day of the month to pick up meds
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YOU CAN DO IT TOO AND WE’RE HERE TO HELP YOU!
Assessment Questions
1. The CMS Five-Star Quality Rating System are intended to help beneficiaries compare MAPD plans and prescription drug plans (PDP) on quality and service. True or False?
True
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Assessment Questions
2. Which is not one of the 5 key Star measures for pharmacy?
A. Members age 65 and older on medications with high risk side effects
B. Members with diabetes using recommended blood pressure medications
C. Taking insulin as directed
D. Taking blood pressure medication as directed
E. Taking cholesterol medication as directed
C. Taking insulin as directed
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Assessment Questions
3. A patient may have their high risk medication filled up to three times before it counts against the pharmacy. True or False?
False
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Assessment Questions
4. EQUiPP currently measures what percentage of Medicare patients?
A. 100%
B. 54%
C. 26%
D. 72%
C. 26%
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Assessment Questions
5. Pharmacies must enroll in either Mirixa or Outcomes to capture all of their available MTM cases. True or False?
False!!!!
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Questions
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