Engaging the Community Pharmacy
Team in Medicare Star Ratings
Mitzi Wasik, PharmD, BCPS
Director, Government Pharmacy Programs
October 24th, 2013
Program Logistics
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Participation: asking questions and answering polls
Slide handout is available via “event resources” in the
lower left of the screen
Process for CE credit – view entire program and
complete evaluation
For assistance with technical problems click on the
question mark in the right corner of the screen
Support
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This lesson is supported by an education
grant from Voice Port
Disclosures
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Mitzi Wasik and the DSN Continuing
Education team do not have any actual or
potential conflicts of interest in relation to
this CE activity
Objectives
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Explain the Medicare Star ratings’ metrics related to
the pharmacy benefit
Describe how Star ratings impact Medicare
reimbursement
Identify changes to the Medicare Star ratings in 2013
Evaluate the engagement of consumer’s awareness
of Medicare Star ratings
Formulate a method to support the Star ratings in
community practice
Why STARS Ratings?
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Quality driven healthcare
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Push for value and quality in the healthcare
system
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Putting the patient first
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Overall goal: Improving value and quality while
decreasing costs
Medicare Ratings-Part D
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Patient Safety Measures (PSM) have been
adapted from

PQA (Pharmacy Quality Alliance)
 The
5 triple weighted Patient Safety Measures have all
been adapted from PQA
 HEDIS
 Consumer
Assessment of Healthcare Providers and
Systems survey (CAHPS)
 Health of Seniors survey (HOS)
Medicare Ratings – Part D
PDP and MA-PD Medicare plans are rated on overall on
quality
 Includes 4 domain scores with 15 individual measures
The first year a measure is included, it is weighted as a “1”
 The next year the weight may be adjusted
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
Measures are weighted 1x, 1.5x, or 3x
Weight is dependent on category
 All 5 Patient Safety Measures are 3x weight
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For PDPs these measures account for ~30% of overall rating
 For MA-PDs these measures account for 20% of overall rating
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STAR Ratings
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Ratings range from 1 to 5
5
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is the goal, 1 is not!
Plans that perform overall less than 3 for 3
consecutive years are at risk for losing their contract
If a plan receives < 3 stars
 There
is an indicator online to alert the beneficiary
 Beneficiaries may not enroll in these plans online,
enrollment must be done via phone

Enrollment in 5 star plans can occur at any time
(rolling AEP)
STAR Ratings
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PDP and MAPD are rated on separate curves
Each contract is individually rated on an overall
score as well as individual scores per measure
The curves are set from a national perspective
 There
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is no regional adjustment
For Part D Patient Safety 4 Star Thresholds have
been given for 4 of 5 measures (new in 2013)
Display Measures
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Display Measures (not included in annual ratings reported to
members) are also included in CMS review
2013 current patient safety display measures are
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Drug-drug Interactions
Excessive doses of oral diabetes medications
Comprehensive Medication Reviews (CMRs)
Adherence to antiretroviral meds
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Not an official display measure but currently tracked by CMS
Increases PDC (proportion of days covered) to 90%
2014 some Star measures being removed to display page:
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Enrollment timeliness
Getting information from drug plans
Call center pharmacy hold times
New Display Measures for 2014

Part C
 Pharmacotherapy
Management of COPD Exacerbation
(PCE) *
 Initiation and Engagement of Alcohol and Other Drug
Dependence Treatment (IET)
 HEDIS Scores for Low Enrollment Contracts

Part D
 Variation
of MPF Price Accuracy
* Moves from display measure to measure in 2015
New Display Measures

Pharmacotherapy management of COPD
exacerbations (PCE) for Part C for display in 2014 and
inclusion in 2015
 Percent
of COPD exacerbations for members age 40 or
older who had an acute inpatient discharge or ER encounter
 Dispensed a systemic steroid within 14 days and
 Dispensed a bronchodilator within 30 days
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MTM Program completion rate for CMR for Part D
 2014 display
measure
 2015 possible inclusion
Medicare Ratings 2014
CMS Star Rating Fact Sheet, October 2013
2014 Part D Measures
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Call Center – Foreign Language and TTY
Appeals Auto-Forward
Appeals Upheld
Complaints about the Drug Plan
Beneficiary Access and Performance Problems
Members Choosing to Leave the Plan
Drug Plan Quality Improvement
Rating of Drug Plan
Getting Needed Prescription Drugs
MPF Price Accuracy
The Five Triple Weighted Patient Safety
Measures
The Low Hanging Fruit for Pharmacy!
Weighted Measures
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New measures receive a weight of “1” in the first
year, and then assigned the weight per their
weighting categories
Triple Weighted Patient Safety
Measures
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High Risk Medications (HRMs) - based on PQA list of high risk
medications
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60 medications as well as oral/transdermal estrogen products
5 agents with parameters other than 2 fills (dosage, >90 days of
use)
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Diabetic Treatment
 1 fill of an oral anti-diabetic drug or insulin and a calcium channel block
or beta-blocker and on and ACE/ARB/DRI
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3 Adherence Drug Classes- Anti-diabetic drugs, RASA (renin-angiotensinreceptor antagonists) and statins
 2 fills of one drugs in above class
 Goal of 80% Proportion of Days Covered (PDC)
ACE-Angiotensin Converting Enzyme Inhibitor, ARB-Angiotensin Receptor Blocker, DRI-Direct Renin Inhibitor
Current Pharmacy STARS Measurements
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High Risk Medications (HRM)
 Based
on 2 fills of same HRM
 Meds pulled from PQA supported list derived from the
Inappropriate Medication Use in the Elderly (referred
to as Beers list)
 Prior
to 4/12, the last update to Beers was 2002
 Now published by the American Geriatrics Society
 Sample of meds included in the HRM measure
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20
cyclobenzaprine, carisoprodol, conjugated estrogens,
nitrofurantoin, antihistamines, antiemetics, etc
BEERS/PQA Update
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Published April 2012 with American Geriatric Society
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Website has many resources for providers and patients
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***Pocket cards for providers***
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App available for free
Important additions
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Glyburide – renal insufficiency caution
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Digoxin > 0.125mg average daily dose
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Non-benzo hypnotics > 90 days
Deletions
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Older drugs that are no longer in use
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Daily fluoxetine
High Risk Medications
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Difficult to measure to manage
 Removal
of drugs, utilization management
 Cannot remove patient from the numerator after 2
fills
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Current National Averages (through 7/13/13)
 MAPD
– 7.78%
 PDP – 10.17%
Current Pharmacy STARS
Measurements
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Diabetic Treatment
 Any
patient that has 1 or more fill or an oral diabetes
medication or insulin as well as to a beta blocker or
calcium channel blocker are included in the measure
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The measure assesses how many of these patients
are also on an ACE/ARB/DRI
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Only requires one fill!
Current Pharmacy STARS Measurements
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Barriers
 Cash
Claims
 Many
plans struggle with this measure
 Coordination
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Opportunity?
of care
Current Pharmacy STARS Measurements
Adherence
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 Patients
with 2 or more fills of an adherence medication
fall into the measure
 Current
measures include 3 drug class
 ACE/ARB/DRI’s, Statins, Diabetes Medications (except
insulin)
 Updated
 Goal
in 2012 to include inpatient hospital stays
is 80% adherence calculated by PDC
25
Proportion of Days Covered (PDC) vs.
Medication Possession Ratio (MPR)
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MPR tends to overestimate true adherence
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Does not have safety nets built in for early fills,
duplication in therapy classes, etc.
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PDC is a more sophisticated measurement to
account for days supply on hand, and above issues
http://www.pqaalliance.org/images/uploads/files/PQA%20PDC%20vs%20%20MPR.pdf
Self-Assessment
Polling Question 1
In your current practice, what do you routinely
check during the quality assurance process?
A. I only check the prescription for safety and
accuracy
B. I review the profile at each fill (new and refills)
to ensure all necessary medications are being taken
C. I check the profile for gaps in therapy when
dispensing new prescriptions
Self-Assessment
Polling Question 1
In your current practice, what do you routinely check
during the quality assurance process?
A. I only check the prescription for safety and accuracy
B. I review the profile at each fill (new and refills) to
ensure all necessary medications are being taken
C. I check the profile for gaps in therapy when
dispensing new prescriptions
Patient Discussion – Applying Skills
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Mrs. Curry, 66 year old female, presents to your
pharmacy for a refill on her glyburide
She has no new complaints and reports she is
doing well per today’s doctor check up
Her current medication list consists of 4 meds:
 Glyburide
 Metformin
 Metoprolol
 Keflex
Case Discussion
Polling Question 2
What medication(s) should the pharmacist
consider recommending to Mrs. Curry’s prescriber
to be considered for addition to her medication
regimen?
A. None
B. Aspirin, ACE/ARB/DRI and Statin
C. ACE/ARB/DRI
D. Insulin
Case Discussion
Polling Question 2
What medication(s) should the pharmacist
consider recommending to Mrs. Curry’s prescriber
to be considered for addition to her medication
regimen?
A. None
B. Aspirin, ACE/ARB/DRI and Statin
C. ACE/ARB/DRI
D. Insulin
New Cut Points Released for 2014
STARS (based on 2012 data)!
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2nd preview period was sent to plans on 9/4
5 Star cut points (compared with previous year):
PDC-Diabetes
2013
79.0 %
2014
77 %
PDC - RASA
79.7 %
79 %
PDC - Statins
75.4 %
75 %
Diabetes – HT
Treatment
HRM
87.8 %
87 %
< 5.0 %
<3%
Increasing STAR ratings – who is the
patient/beneficiary?
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Baby Boomers are making their entrance
10,000 older adults turn 65 years of
age….EVERYDAY
 About
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3% per year age-ins
A 65 year old patient is not a 75 year old
 Differences
in
 Technology
 Education
levels
Opportunities?
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Community pharmacy
The front line to the patient and provider
 Trusted health care professional
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Engaging the patient in their healthcare
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The missing link?
Partnering with providers
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Better educate and partner with providers on gaps in
care
Do STARS Make a Difference to the Patients?
JAMA Article
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Analyzed patient behavior in 2011
 952k
first time enrollees and 323k “switchers”
 Statistical
significance found with star ratings and plan
chosen
 STAR
ratings were less likely to influence, youngest,
black, low income, rural and mid-west enrollees
Impact of CMS’ Outreach
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Beginning last fall,
notices were sent to
enrollees in LPI
contracts to consider
better performing
plans
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From 2012 to 2013,
more patients
switched out of low
performing contracts
Of those in LPI contracts
that switched in 2013
Future of STARS?
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More outcomes based measures to be added
Quality will be at the forefront of the exchanges,
future of healthcare
Weed out the low performing plans and ensure
health plans are offering high quality health care
The “young” older adults will rely more on ratings to
choose health care which will increase the
competitiveness
Summary
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STAR ratings are pushing health plans to drive for
higher quality and older adults are noticing the
changes
Quality measurement has been a part of healthcare
for many years but in recent years is tied to
reimbursement
STARS will continue to evolve and more outcome
measures expected to be added to the STARS overall
rating
QUESTIONS
CE Credit
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Complete evaluation at the end of the webinar
Statement of credit available in CE/Test history folder
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