Improving Medicare Advantage Part D Star Ratings
Medicare Stars – Resource Guide
Introduction
California Quality Collaborative (CQC) aims to lead and engage in programs that will lead to
substantial improvement in Medicare Advantage Star measures, specifically in Part D pharmacy
measures. The work includes collaboration across multiple stakeholders, including health plans
and provider groups.
As a first step in supporting this work, a symposium was held on June 10, 2015 to identify and
spread best practices on Medicare Stars pharmacy measures. Attendees included health plans
and provider groups, who engaged in active sharing of best practices and problem solving.
Taking Action: Resources
CMS & IHA Links
 2015 CMS Medicare Advantage Star Ratings: Overview and Analysis:
http://www.achp.org/wpcontent/uploads/2015_ACHP_Star_Ratings_Overview_Web.pdf
 Medicare Stars Part C and D Measures and Performance Data:
http://www.cms.gov/Medicare/Prescription-DrugCoverage/PrescriptionDrugCovGenIn/PerformanceData.html
 Integrated Healthcare Association Medicare Stars Physician Group Clinical Care Report
Card - December 2014 Edition: http://iha.ncqa.org/reportcard/home.aspx
Speakers of the June 10th event plus audience members were the sources of the resources
shared below.
ROI of a Pharmacist (Return on Investment): How do we make the case for the ROI of a
pharmacist or pharmacy resident?

2011 US Public Health Services Report gives a 2 – 3 decade summary including the ROI
for pharmacists:
http://www.accp.com/docs/positions/misc/improving_patient_and_health_system_out
comes.pdf
Uninsured Patients / Patients With Few Resources: what are some resources that I can
use?

Rx Assist - http://www.rxassist.org/: Patient assistance programs are run by
pharmaceutical companies to provide free medications to people who cannot afford to


buy their medicine. RxAssist offers a comprehensive database of these patient
assistance programs, as well as practical tools, news, and articles so that health care
professionals and patients can find the information they need.
Patient Access Network - https://www.panfoundation.org/: The Patient Access Network
(PAN) Foundation is an independent 501(c)(3) organization dedicated to providing help
and hope to people with chronic or life-threatening illnesses for whom cost limits access
to critical medical treatments.
HealthWell Foundation [http://www.healthwellfoundation.org/]: The HealthWell
Foundation is a 501(c)(3) independent non-profit organization providing financial
assistance to adults and children to cover the cost of prescription drug coinsurance,
copayments, deductibles, health insurance premiums, and other selected out-of-pocket
healthcare costs.
Registries: which registries are groups in the room using?



Ascender (which is going off the market) [http://www.ascendersoft.com/]
Optum
ZirMed - formerly IHC [http://www.zirmed.com]
Groups that aren’t using a registry - are using their EHR
System Alignment / Customization: Medi-Cal, Medicaid resources - how do you get them
access?




Hire technicians (Medical Assistants/Physician Assistants) of the culture you’re serving
Case management
Home visits
Programs like Partner in Care’s Home Meds [http://www.homemeds.org/]:
HomeMeds is an evidence-based, technology-enabled intervention that addresses
medication safety among older adults by connecting homecare and other communitybased services to health care providers.
Patient Engagement

Motivational interviewing training – being taught in the pharmacy schools, along with
Shared Decision Making
Taking Action: Improvement Strategies
General Strategies
1. On-site
pharmacist
2. Home visits
3. Incentive
programs
4. Data
5. Patient outreach
letters
Description
On-staff pharmacist conducts care
management, data analysis and
other measure-specific
improvement work. Pharmacist
can perform outreach to patients
on medication adherence,
outreach to providers. Pharmacist
can also create partnerships with
local pharmacies to work with
patients.
Nurse conducts home visit to
complex, high needs patient,
typically around specific disease
or condition. In context of this
larger visit, review medication
adherence and prescriptions for
high-risk medications.
Pay group and/or providers
incentives on performance on
medication adherence, high-risk
medication measures.
Share data frequently with group
and/or providers on performance.
In conjunction with data sharing,
provide information about
improvement strategies. Stratify
data so provider can target highrisk patients.
Send letters to new patients and
non-adherent patients, reminding
them of medications and when
refills needed.
Notes for Follow-Up
Measure/Drug
Specific Strategies
1. High Risk Meds:
Prior
Authorization
2. High Risk Meds:
Formulary
change
3. Medication
Adherence:
Switch to 90-day
supply
Description
When prescription written that
puts patient at risk, request is
redirected through prior
authorization process to safer
medication. Pharmacy rejects
prescription, and prior
authorization goes back to
physician, recommending the
safer medication.
High-risk medication is removed
from formulary.
Work with pharmacies to switch
prescriptions to 90-day supply to
reduce burden on patient.
Notes for Follow-up
Background: Medicare Stars Overview
Medicare uses the Star Rating System to measure how well Medicare Advantage and
prescription drug (Part D) plans perform. Using ratings of 1 to 5 stars, Medicare reviews
and scores plans annually across several domains, assigning a star rating to summarize
the plan’s performance as a whole.
Medicare health plans are rated on how well they perform in five different categories:
1. Staying Healthy: Screenings, Tests, and Vaccines
2. Managing Chronic (Long-Term) Conditions
3. Plan Responsiveness and Care
4. Member Complaints, Problems Getting Services, and Choosing to Leave the Plan
5. Health Plan Customer Service
Medicare drug plans are rated on how well they perform in four different categories:
1. Drug Plan Customer Service
2. Member Complaints, Problems Getting Services, and Choosing to Leave the Plan
3. Member Experience with Drug Plan
4. Drug Pricing and Patient Safety
Measures
The CQC has chosen to focus on four pharmacy measures: high-risk medications and
medication adherence for diabetes, blood pressure and cholesterol. The measure
definitions follow.
1. High-Risk Medications: Plan Members 65 and Older Who Received Prescriptions
for Certain Drugs with a High Risk of Side Effects, When There May Be Safer Drug
Choices
This measure calculates the percentage of Medicare Part D beneficiaries 65 years
or older who received two or more prescription fills for the same high-risk
medication (HRM) drug with a high risk of serious side effects in the elderly. This
percentage is calculated as the number of member-years of enrolled beneficiaries
65 years or older who received two or more prescription fills for the same HRM
during the period measured (numerator) divided by the number of member-years
of enrolled beneficiaries 65 years and older during the period measured
(denominator).
2. Medication Adherence: Taking Diabetes Medication as Directed
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Percent of plan members with a prescription for diabetes medication who fill their
prescription often enough to cover 80% or more of the time they are supposed to
be taking the medication.
This measure is defined as the percent of Medicare Part D beneficiaries 18 years or
older that adhere to their prescribed drug therapy across classes of diabetes
medications: biguanides, sulfonylureas, thiazolidinediones, and DiPeptidyl
Peptidase (DPP-IV) Inhibitors, incretin mimetics, and meglitinides. This percentage
is calculated as the number of member-years of enrolled beneficiaries 18 years or
older with a proportion of days covered (PDC) at 80 percent or over across the
classes of diabetes medications during the measurement period (numerator)
divided by the number of member-years of enrolled beneficiaries 18 years or older
with at least two fills of medication(s) across any of the drug classes during the
measurement period (denominator).
3. Medication Adherence: Taking Blood Pressure Medication as Directed
Percent of plan members with a prescription for a blood pressure medication who
fill their prescription often enough to cover 80% or more of the time they are
supposed to be taking the medication.
This measure is defined as the percent of Medicare Part D beneficiaries 18 years or
older that adhere to their prescribed drug therapy for renin angiotensin system
(RAS) antagonists [angiotensin converting enzyme inhibitor (ACEI), angiotensin
receptor blocker (ARB), or direct renin inhibitor medications]. This percentage is
calculated as the number of member-years of enrolled beneficiaries 18 years and
older with a proportion of days covered (PDC) at 80 percent or over for RAS
antagonist medications during the measurement period (numerator) divided by
the number of member-years of enrolled beneficiaries 18 years or older with at
least two fills of either the same medication or medications in the drug class
during the measurement period (denominator).
4. Medication Adherence: Taking Cholesterol Medication as Directed
Percent of plan members with a prescription for a cholesterol medication (a statin
drug) who fill their prescription often enough to cover 80% or more of the time
they are supposed to be taking the medication.
This measure is defined as the percent of Medicare Part D beneficiaries 18 years or
older that adhere to their prescribed drug therapy for statin cholesterol
medications. This percentage is calculated as the number of member-years of
enrolled beneficiaries 18 years of older with a proportion of days covered (PDC) at
80 percent or over for statin cholesterol medication(s) during the measurement
period (numerator) divided by the number of member-years of enrolled
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beneficiaries 18 years or older with at least two fills of either the same medication
or medication in the drug class during the measurement period (denominator).
Challenges
 Securing group/provider buy-in; Medicare Stars can be viewed as more of a
plan priority.
 Plans are early in process of working with groups.
 Data challenges: plans are sending data to groups, but pharmacy data is an
issue; groups access different pharmacy data than plans; groups have more
complete data than plans. Don’t have generic drug data.
 Patient population (e.g. D-SNP) can be challenging to work with, reach.
 Drug adherence; many reasons why patients don’t adhere, can’t address
across the board. Physicians must engage patients.
Opportunities
 Improve plan-group-pharmacy communications.
 Home visit model.
 Plan: leverage quality work that group is doing.
Group: design incentives for PCP visits to address medication adherence.
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