In the face of CMS’s proposed changes to everything from cut points to quality measures, Medicare Advantage Part D (MAPD) plans are asking themselves some hard questions about their 2020 Star Ratings programs. We asked Deborah O’Connor, RxAnte’s Director of Business Development, for the answers.

RxAnte: Why should health plans care about medication adherence improvements as part of their quality measure programs? In other words, what are quality measure programs really good for?

Deborah O’Connor: We’ve been able to tie data points together showing that 38% of the overall five-star improvement is affected by the measures we address – the medication use measures. It’s not just a pharmacy quality improvement program, it’s an overall quality improvement program. We can also see in the data that only 4% of plans receiving five Stars for their overall rating did not also achieve four Stars or more in any of the adherence measures. This is because those adherence measures are so heavily weighted and impact the broader well-being of individuals with chronic diseases.

Another area these programs bring value in is quite literally the bottom line. There is a direct relationship between the length of time adherence is improved and the lower overall total cost of care. This is a direct impact to the overall financial bottom line across the health plan business enterprise.

So, basically, plans aren’t likely to be successful overall without prioritizing the improvement of these measures with a solid strategy in place and the right resources allocated to drive lift.

“It’s not just a pharmacy quality improvement program, it’s an overall quality improvement program.”

RxA: How can quality teams (and others in MAPD plans) defend requests for bigger budgets for quality measure programs?

DO: Quality programs that focus on lower priority areas can often be neglected without access to budget until Star performance suddenly drops and there’s a panic. Sometimes that’s not true, and that’s great, but a lot of times that’s just how it is. In those cases where they aren’t getting a lot of budget, business owners and quality program leaders end up with a lot of pressure on them to reach certain goals without the ability to deliver a results-oriented business case/projection to level set expectation internally and/or advocate for resource dollars.

In order to access budget investment within a health plan, it requires an ROI and numbers-driven proposition that can be confidently communicated to leadership. As a business risk and opportunity need to be quantified so budget plans can be supported and approved. It’s all very tightly managed, it has to be, because there is pressure to minimize margins and avoid unnecessary risk.

Unlike a provider market, for years health plans have been less consumer-focused and more of risk-reward and margins management focus. So for quality measure programs to be supported by funding, what we’re providing has to (and does) result in driving ROI.

The three buckets teams need to think of when asking for quality budget are quality improvement – not just within pharmacy but across the enterprise; the correlation between adherence and lower costs in managing patients; and creating operational efficiencies by automating internal operational processes and the incremental bonus potential from Star Rating improvement.

RxA: When is the best time to invest in and execute on medication adherence and Star Ratings initiatives?

DO: All throughout the year, because medication usage is behavior-related. This one is a hard question because it has such a deceptively simple answer, but the execution of it is more complex. It requires a lot of startup and upkeep to be effective: better workflows, more targeted and timely interventions, more meaningful interventions – which are actually different than targeted interventions, and things of that nature. It also requires plans to look at data differently, not just checking lagging late-to-fill indicators, but actually predicting and forecasting who will truly benefit from intervention and, therefore, cause the positive shift in Star Ratings plans need. This all has to be going on all the time, not at the end of the year when cut points and adherence data comes out from CMS. By then, it’s usually mathematically too late to impact measure improvement significantly enough to “win” at Star Ratings.

“Only 4% of plans receiving five Stars for their overall rating did not achieve four Stars or more in any of the adherence measures because they are so heavily weighted and impact the broader well-being of individuals with chronic diseases.”

RxA: How can MAPD plans get the most out of quality measures – regardless of where they are in this Star Ratings year?

DO: I advise plans to do a handful of things right now – regardless of when they are reading this:

First, recognize that you have to be able to rely on effective data forecasting your performance, which retrospective report data does not provide. Right out of the gate, RxAnte clients receive a highly accurate forecast of where their performance will be. This helps them have a data-fueled strategy to know what and how many interventions will be required to reach their goal. Without the ability to forecast and compare the impacts of different intervention mixes, it’s hard to create a program and protect yourself from unwanted surprises later in the year.

Second, think about ways to help your provider network drive performance in coordination with you. This is an area that we’ve had tremendous success helping our health plans with.

Lastly, don’t be afraid to reach out for a conversation and let us help you build the business case internally using your numbers. We’ve been working in the area of medication use for seven years now and have been successful helping plans drive continual, year-over-year improvement. We can be a valuable resource to you and are happy to help. We’re here for that, any time.