As we begin a new year, many Medicare Advantage Part D (MAPD) plans are still reflecting on their 2019 Star Ratings performance. Plans are developing strategies and programs to focus their quality efforts amid the possibility that 2020 CMS Star Ratings performance thresholds increase yet again.

Since the inception of the Star Ratings quality framework in 2008, the performance thresholds by which plans are measured have demonstrated a generally increasing trend, encouraging plans to sustain their focus on improving quality and member satisfaction (and earn performance bonus dollars by achieving four or more stars overall). Arguably, the ratings system is working; while cut points continue to rise, 2019 member enrollment in MAPD contracts with four or more stars is projected to remain constant from 2018 at 73%, meaning that plans are generally rising to the challenges set forth by CMS and delivering increasingly better quality of services[1].

One area of the Star Ratings framework where plans continue to be challenged, though, is the medication-adherence related measures. These measures incentivize plans to ensure their members are taking important maintenance medications for the treatment of diabetes, hypertension, and hypercholesterolemia – critical to avoiding unnecessary hospital utilization. CMS triple-weights these measures to emphasize their importance. For the 2019 Star Ratings year, CMS increased the four-star thresholds for two of the measures by three and four percent, respectively. This move was generally considered by the industry to be a significant and challenging increase. As a result, about 45% of MAPD plans declined in their Star Ratings on these measures[2].

Why is this important? When accounting for the newly triple-weighted Statin Use in Persons with Diabetes (SUPD) measure for 2020 Star Ratings, medication use will account for 38% of plans’ overall star performance. This means that stumbling on medication-related measures can likely mean sub-four star performance overall, eliminating the plan from bonus eligibility[3]. Top-performing plans realize this and adapted accordingly: 89% of plans scoring five stars overall on the 2019 Part D measures have earned four or more stars on a majority of the triple-weighted adherence measures[4].

While these high-performing plans have figured out how to achieve high adherence scores, how should the rest of the market approach these critical quality measures? A core competency of RxAnte is helping plans improve their pharmacy quality scores. We do that year after year for 90% of medication-related measures we manage by following four key principles of designing and executing successful adherence programs:

1) Targeting: Not all members will benefit from an intervention – find the ones who will. Live interventions are an investment, and budgets are subject to constraints – using data such as fill history and receptivity to prior intervention attempts can help maximize the value of your intervention budget by identifying which members are likely to change their behavior based on outreach. As the year progresses and fewer members remain eligible to positively impact an adherence measure, prioritization of members is critical to ensure interventions are targeted to those who can achieve the 80% proportion of days covered (PDC) metric. When we deploy analytics-driven targeting such as this with our clients, we often see that they’re able to reduce intervention costs by tens of thousands of dollars while improving overall program effectiveness. In fact, we helped one regional plan client to discover they were misattributing nearly half of their intervention resources—totaling $60,000 annually – to members who already had or could not achieve the required 80% PDC rate to be deemed adherent.

2) Timing: Engage members at the right moment – before non-adherence occurs. Studies have shown that the most effective interventions are those delivered before the member decides to stop taking their medications. Here, using common lagging data indicators such as a 12-month rolling PDC are insufficient to drive adherence into four-star territory. The most effective tool will be one that analyzes therapy regimens and adherence behavior to identify intervention targets before they become non-adherent. For plans, this is a powerful capability – when we help our clients adopt this prospective approach, we often see first-year adherence rate increases of one to three percent on the basis of this improved targeting alone. With the addition of prospective targeting alone, RxAnte has witnessed plan clients’ adherence rates increase 1-2% in the first year.

3) Effectiveness: Once you’ve engaged the member, enable a rich and valuable conversation. If you’ve followed the two principles described above, you know you’re engaging a member who is truly at risk for non-adherence, and that it’s the right time to have the conversation. What follows is critical – enabling a valuable conversation to encourage medication adherence. To do this requires the caller to be armed with the appropriate member context such as medication regimen, fill behavior, previously recorded adherence barriers, and more. What follows can be a rich conversation about how to address the members’ concerns or challenges regarding their medications. RxAnte renders real-time data and contextual information directly to those doing live outreach through our RxEffect® workflow solution, enabling callers to improve key prescription-related metrics – same-day refill rates, 90-day prescription conversions, and adherence rates –for reached members. For a large regional plan client, plan members reached through the RxAnte RxEffect workflow platform refilled an average of four days earlier than those not reached—a nearly 5x improvement in same-day refill rates for that plan.

4) Scale: Engage enough members to achieve your quality objectives. Scale is the linchpin of an effective adherence program. Accuracy and effectiveness can only drive adherence improvement if accompanied by a sufficient volume of interventions throughout the year. To appropriately scale outreach, a plan use its adherence goals to drive the mix of interventions and overall investment needed to achieve those objectives. Advanced analytics are critical in this process to understand targeting depth, or the required volume and allocation of interventions needed to achieve your targets. Using this well-informed approach, we’ve watched our clients achieve continuous year-over-year adherence improvement by simulating multiple intervention scenarios and selecting the strategy that is likely to achieve their objectives while remaining in-budget for the year. Through simulations and the use of automated reporting and list creation in RxEffect, RxAnte assisted one plan client in more effectively scaling its adherence program—ultimately reallocating two staff away from administrative work and toward member outreach and intervention.

It’s true that designing and deploying a program that can effectively adhere to these principles is challenging, and requires either substantial internal investment in data science, technology platforms, and pharmacy expertise, or a vendor partner with proven experience. The alternative, though, is to ignore these critical triple-weighted measures, and that means taking a significant gamble on your overall Star Ratings future.

1,2,3,4 Source: Publicly available CMS data and RxAnte analysis.

Kerri Petrin, MPH, is the vice president of client services at advanced analytics and clinical services company RxAnte, Inc. Prior to RxAnte, Ms. Petrin held roles at the Office of National Coordinator for Health IT and The Brookings Institution.