Pharmacy and the Medicare Star Rating System

Tori Socha

Atlanta—The Star Rating System created by the Centers for Medicare & Medicaid Services was added to Medicare programs to help educate beneficiaries about quality of care and increase the transparency of quality data available to consumers. The ratings are based on 5 domains and are released each year; beginning in 2012, payments to Medicare Advantage plans will be tied to Star Rating scores. Bonuses will be available for plans with ≥4 stars, and contracts for plans with <3 stars for 3 consecutive years will be terminated.

At the AMCP meeting, Beth Chester, PharmD, MPH, FCCP, BCPS, senior director, pharmacy clinical operations and quality at Kaiser Permanente Colorado, presented a Contemporary Issues session titled Medicare Plan Star Rating System Update. Dr. Chester titled her presentation “Pharmacy Impacting Medicare 5 Stars.”

Kaiser Permanente Colorado serves >530,000 members and has >20 medical offices, >5000 employees, and >800 physicians. The plan has utilized an electronic medical system since 1998, meets the standards for a National Committee for Quality Assurance¬–recognized medical home, utilizes medication therapy management services provided by virtual and physically integrated pharmacy teams, and is a Medicare 5 Star plan.

Dr. Chester highlighted some of the clinically oriented Part D measures the plan monitors: the use of high-risk medications (HRMs) in the elderly (members ≥65 years of age prescribed mediations with high risk of side effects); use of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers in patients with diabetes and hypertension (ensuring the proper use of blood pressure medications for patients with diabetes); and medication adherence (blood pressure medications, statins, and oral diabetes therapies).

As an example of the impact of pharmacy interventions in Medicare 5 Star metrics, Dr. Chester provided data on HRMs in Kaiser Permanente Colorado elderly beneficiaries. In the first quarter of 2000, the percentage of elderly beneficiaries prescribed an HRM was 32%; by the fourth quarter of 2008, the percentage had fallen to <16%. In July 2011, the percentage was 7.3%.

There are 3 parts of the HRM monitoring program, Dr. Chester said. The first, preparation and planning, involves identification of HRMs, followed by a review of the evidence for risk, confirmation of appropriate uses for HRMs, and identification of treatment alternatives. After engaging key stakeholders to create agreement with the findings of step 1, the process progresses to step 2, implementation. This step includes development of sustainable processes to support clinical interventions and their appropriate use, continued decision support at the point of prescribing and dispensing, development of formulary management strategies, and continued education of stakeholders. Pharmacists play key roles in the implementation step (clinical, outpatients, formulary), Dr. Chester said. The third step in the process is maintenance: identification of the applicable metrics, goals, and timelines; establishment of monitoring and reporting processes; and setting individual and team accountabilities.

Dr. Chester continued her presentation by outlining Part C measures that are influenced by pharmacy and pharmacists, including blood pressure control, cholesterol screening and control, diabetes care, osteoporosis screening and treatment, reducing the risk of falls in the elderly, rheumatoid arthritis management, and vaccinations for influenza and pneumonia.

In conclusion, Dr. Chester summarized the steps required for successful Star Rating programs: pre-work, including a clear understanding of the measure and engagement of all stakeholders; implementation, which is often multipronged and requires the establishment of sustainable processes; and finally, success and maintenance, calling for established goals, monitoring and reporting, and recognition and reward for positive outcomes.

The session continued with a presentation from Aaron Eaton, PharmD, senior vice president, consulting services, at the Gorman Health Group. Dr. Eaton provided an industry perspective on the Star Rating system.

He continued by outlining 4 domains of the system: (1) customer service; (2) complaints and audit findings; (3) member experience with the drug plan; and (4) drug pricing and patient safety. Those 4 domains include various components, such as time on hold when a member telephones, timeliness in providing a decision when members make an appeal, and fairness of the drug plan’s denials to members’ appeals (domain 1); beneficiary access and performance problems, members choosing to leave the plan, and complaints about the drug plan (domain 2); members ability to obtain information from the plan, and getting needed prescription drugs (domain 3); and high-risk medication management, diabetes management, management of Part D medication adherence for hypertension and cholesterol control, and accurate drug price information on the plan finder coupled with stable drug prices (domain 4).