Engaging the Community Pharmacy Team in Medicare Star Ratings

1. Mitzi Wasik, PharmD, BCPS Director, Government Pharmacy Programs October 24th, 2013 Engaging the Community Pharmacy Team in Medicare Star Ratings

2. Program Logistics 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 problemsclick on the question mark in the right corner of the screen

3. Support This lesson is supported by an education grant from Voice Port

4. Disclosures Mitzi Wasik and the DSN Continuing Education team do not have any actual or potential conflicts of interest in relation to this CE activity

5. Objectives • 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

6. Why STARS Ratings? • Quality driven healthcare • Push for value and quality in the healthcare system • Putting the patient first • Overall goal: Improving value and quality while decreasing costs

7. Medicare Ratings-Part D • 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)

8. 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 • Measures are weighted 1x, 1.5x, or 3x • Weight is dependent on category • All 5 Patient Safety Measures are 3x weight • For PDPs these measures account for ~30% of overall rating • For MA-PDs these measures account for 20% of overall rating

9. STAR Ratings • Ratings range from 1 to 5 • 5 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)

10. STAR Ratings • 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 is no regional adjustment • For Part D Patient Safety 4 Star Thresholds have been given for 4 of 5 measures (new in 2013)

11. Display Measures • Display Measures (not included in annual ratings reported to members) are also included in CMS review • 2013 current patient safety display measures are • Drug-drug Interactions • Excessive doses of oral diabetes medications • Comprehensive Medication Reviews (CMRs) • Adherence to antiretroviral meds • 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: • Enrollment timeliness • Getting information from drug plans • Call center pharmacy hold times

12. 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

13. 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 • MTM Program completion rate for CMR for Part D • 2014 display measure • 2015 possible inclusion

14. Medicare Ratings 2014 CMS Star Rating Fact Sheet, October 2013

16. 2014 Part D Measures • 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

17. The Five Triple Weighted Patient Safety Measures The Low Hanging Fruit for Pharmacy!

18. Weighted Measures • New measures receive a weight of “1” in the first year, and then assigned the weight per their weighting categories

19. Triple Weighted Patient Safety Measures • High Risk Medications (HRMs) - based on PQA list of high risk medications • 60 medications as well as oral/transdermal estrogen products • 5 agents with parameters other than 2 fills (dosage, >90 days of use) • 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 • 3 Adherence Drug Classes- Anti-diabetic drugs, RASA (renin-angiotensin-receptor 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

20. Current Pharmacy STARS Measurements • 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 • cyclobenzaprine, carisoprodol, conjugated estrogens, nitrofurantoin, antihistamines, antiemetics, etc

21. BEERS/PQA Update • Published April 2012 with American Geriatric Society • Website has many resources for providers and patients • ***Pocket cards for providers*** • App available for free • Important additions • Glyburide – renal insufficiency caution • Digoxin > 0.125mg average daily dose • Non-benzo hypnotics > 90 days • Deletions • Older drugs that are no longer in use • Daily fluoxetine

22. High Risk Medications • Difficult to measure to manage • Removal of drugs, utilization management • Cannot remove patient from the numerator after 2 fills • Current National Averages (through 7/13/13) • MAPD – 7.78% • PDP – 10.17%

23. Current Pharmacy STARS Measurements • 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 • The measure assesses how many of these patients are also on an ACE/ARB/DRI • Only requires one fill!

24. Current Pharmacy STARS Measurements • Barriers • Cash Claims • Many plans struggle with this measure • Coordination of care • Opportunity?

25. Current Pharmacy STARS Measurements • Adherence • 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 in 2012 to include inpatient hospital stays • Goal is 80% adherence calculated by PDC

26. Proportion of Days Covered (PDC) vs. Medication Possession Ratio (MPR) • MPR tends to overestimate true adherence • Does not have safety nets built in for early fills, duplication in therapy classes, etc. • 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

27. 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

28. 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

29. Patient Discussion – Applying Skills • 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

30. 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

31. 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

32. New Cut Points Released for 2014 STARS (based on 2012 data)! • 2nd preview period was sent to plans on 9/4 • 5 Star cut points (compared with previous year):

33. Increasing STAR ratings – who is the patient/beneficiary? • Baby Boomers are making their entrance • 10,000 older adults turn 65 years of age….EVERYDAY • About 3% per year age-ins • A 65 year old patient is not a 75 year old • Differences in • Technology • Education levels

34. Opportunities? • Community pharmacy • The front line to the patient and provider • Trusted health care professional • Engaging the patient in their healthcare • The missing link? • Partnering with providers • Better educate and partner with providers on gaps in care

35. Do STARS Make a Difference to the Patients?

36. JAMA Article • 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

37. Impact of CMS’ Outreach Of those in LPI contracts that switched in 2013 • Beginning last fall, notices were sent to enrollees in LPI contracts to consider better performing plans • From 2012 to 2013, more patients switched out of low performing contracts

38. Future of STARS? • 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

39. Summary • 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

40. QUESTIONs

41. CE Credit Complete evaluation at the end of the webinar Statement of credit available in CE/Test history folder Contact customer service with questions (800) 933-9666