In everyday life, before you visit a restaurant or hire a contractor, chances are you search online reviews to get a sense of the business’s capabilities and performance. The Centers for Medicare and Medicaid Services (CMS) wants consumers to follow suit when choosing their health and drug plan services. CMS has empowered people to do so through its Star Ratings program, a five-point measurement system that enables Medicare patients to compare health plans on the cost and quality of services provided.

Pharmacies influence Part D health plan Star Ratings in the following areas:

• Medication adherence
  The percentage of plan members taking prescribed diabetes, blood pressure and cholesterol medications as directed.

• Medication management
  The percentage of medication therapy management program enrollees who received a comprehensive medication review.

• Management of chronic conditions
  The percentage of plan members (aged 40-75) taking at least two diabetes medications who also filled a prescription for a cholesterol-lowering statin medication.¹
  

The better your pharmacy performs in these areas—especially the adherence measures, which are triple-weighted by CMS—the more attractive your pharmacy may be to regional health plans that value patient care and outcomes. Plus, increased prescription volume can translate to improved pharmacy profitability.

Independent pharmacies are already known far and wide for providing excellent patient care and instilling patient loyalty. CMS Star Ratings build on that foundation, but in a more targeted manner for Medicare patients who have adherence challenges.

The big question then is where should you look to get a handle on how you’re doing?

Adherence resources

The best place to start ramping up your understanding of Star Ratings and familiarity with relevant health plans is through EQuIPP^TM, an impartial performance management platform that benchmarks performance data. EQuIPP indicates how many patients your pharmacy cares for in the adherence metrics for diabetes, blood pressure and cholesterol, as well as the percentage of patients who are adherent for each measure. The platform also identifies, by name and date of birth, the “outlier” patients who visit your pharmacy but require more adherence assistance. Use EQuIPP to track your pharmacy’s performance over time and compare it to other pharmacies in your state and even the top 20 percent of pharmacies nationwide.

Another vital resource to track adherence and engage with patients is the PrescribeWellness Patient Engagement Center, which presents a real-time snapshot of your pharmacy’s adherence ratings and can be filtered by health plan, payer, physician and adherence levels. Like EQuIPP, the Patient Engagement Center pinpoints patients who are non-adherent, but it also includes a detailed pharmacy record and history for each one. This enables you to uncover opportunities to provide immunizations or other clinical services for patients at your store. PrescribeWellness offers additional modules that allow you to send text or voice messages to patients reminding them to refill their prescriptions or take advantage of medication synchronization to make it even easier to manage their medications.

Helping patients while building your business

The Star Ratings program is one measure of adherence, and the associated tracking tools bring this issue and the patient into focus on a number of levels. Adherence is not just filling prescriptions—it’s helping patients grasp what their medications do and why it’s important to take them in compliance with the prescribed regimen. Consequently, your interventions and education directly help patients live a healthier life. That, in itself, enhances ongoing patient relationships and nurtures loyalty.

From a business standpoint, better adherence also drives increased refill volume and revenue for your pharmacy. It’s as simple as making sure a patient fills their prescription 12 times a year instead of just 8 or 9 times.
What’s more, some health plans offer pay-for-performance (P4P) programs, through which your pharmacy can earn extra revenue. It’s generally a per-patient amount payable after year’s end to pharmacies in a health plan’s geography that reach specified adherence targets. The P4P payments may scale up as your adherence program helps patients become more adherent and the plan attains higher Star Ratings. In essence, you’re being rewarded for performance and outcomes that help improve patient care simply by doing what you do every day—engaging with patients.

Increasing patient adherence may also mitigate DIR fees imposed by a plan or payer. For instance, your PSAO may be evaluated on the aggregate performance of all member pharmacies; therefore, your pharmacy may qualify for a lower DIR fee based on your PSAO’s performance. (Note that, alternatively, some plans and payers tie DIR fees directly to individual pharmacy performance.).

 

The big picture

Overall, adherence measures matter to health plans when collaborating with pharmacies along the continuum of care. They typically make up a large percentage of a plan’s total Star Ratings score because proper medication and disease management prevents future spikes in health system costs and downstream health issues for patients.

With those thoughts in the forefront, CMS continually evaluates new Star Ratings measures and resets thresholds each year based on plan performance. Independent community pharmacies remain essential to the process because they see patients so frequently and have a unique ability to influence patient outcomes. By adding high-quality and high-value services, you can expect a larger role moving forward in the Star Ratings process, with ultimate benefits accruing not only to the patients you serve, but to your pharmacy’s bottom line as well.

^{1. Centers for Medicare and Medicaid Services. Medicare 2020 Part C & D Star Rating Technical Notes. https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/Downloads/Star-Ratings-Technical-Notes-Oct-10-2019.pdf}