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On February 20th, the Centers for Medicare and Medicaid Services (CMS) released the anticipated Advance Notice for potential changes to the 2016 Call Letter and Part C and Part D payment policies. Overall, the letter contained no major surprises for the industry, but did provide some insight into CMS’s next focus areas including data integrity and value-based payment systems.

For the Medicare Star program specifically, CMS proposed several medication use related changes to the 2016 program (2014 calendar year measurement period).

  • 4-Star thresholds: CMS asserted that some features of the existing Star Rating calculation methodology (i.e., grouping of measure scores into categories, pre-determined thresholds) cause noise. CMS found more improvement across measures that had no pre-determined thresholds than those that did. Therefore, CMS has proposed removing all of the pre-determined 4-Star thresholds moving forward. Overall, this change will encourage plans to put more emphasis on improving their measure performance and staying ahead of their competitors. Plans should ensure they are doing everything possible to improve measure performance, understanding that even maintaining performance on some measures from year to year, such as the Part D Patient Safety adherence measures, requires vigilant, targeted outreach to the patients whose compliance is uncertain.
  • Measure retirement: CMS proposed retiring the cholesterol-related measures for cardiovascular and diabetes care, as well as retiring the diabetes treatment measure starting with the 2017 Medicare Star program (2015 calendar year measurement period) based on updated clinical guidelines. Overall, this puts more emphasis on the medication adherence measures as part of the overall Medicare Star Rating calculation. As such, plans should focus their strategy on improving adherence to diabetes, cholesterol, and hypertension medications as they will continue to be triple-weighted measures and now make up a larger percentage of the overall Star Rating calculation. For many plans, intervention budgets and capacity constraints will require smart and targeted approaches to focus delivery of high-value and high-cost outreach to those patients whose future adherence is uncertain.
  • MTM CMR completion rate: The MTM completion rate measure will become a 2016 Medicare Star Ratings measure. We believe this is a step in the right direction for holding MTM service providers accountable for outreach, and anticipate that performance guarantees will likely become even more prevalent and include more aggressive targets in MTM vendor contracts. Expanding to outcomes-based measures related to MTM services in the future seems like a logical next step to measuring the true quality performance of MTM programs.
  • Low-enrollment contracts: Star Ratings for contracts with 500 or more enrollees will now be reported. Plans should ensure tracking and outreach programs include the smaller groups.
  • Dual Eligible/LIS beneficiaries: Extensive research was conducted to determine the effect of having a high percentage of Duals or LIS beneficiaries in a contract, and some significant differences were found. Although CMS is not ready to make permanent changes, they proposed reducing the weight (by half) of six measures for MAPD and one measure for PDP, for which plans with Duals/LIS beneficiaries performed significantly worse. The weighting of certain measures has decreased, reducing their overall impact on the Medicare Star Ratings calculation. RxAnte agrees that plans with a higher concentration of duals/LIS may find improving certain measure outcomes, including medication use, more difficult for various reasons and hopes these weighting changes will make Star Ratings for these plans more equitable.
  • Data integrity: CMS relayed concerns about data integrity and is increasing audits and data validation efforts to ensure data reported is accurate. As an expert in the data analytics space, RxAnte is interested in tracking how data integrity will be ensured and prepared to participate in increased audit efforts. RxAnte continuously monitors requirements to ensure that our reporting is consistent and in compliance with CMS requirements.

Looking ahead to the Medicare Star 2017 program, CMS proposed the following changes:

  • Medication reconciliation: CMS proposed expanding the current measure, Medication Reconciliation Post Discharge to a wider age range and from Special Needs plans to all Medicare Advantage plans. Medication reconciliation is known to reduce readmission rates as well as improve adherence to medications. Medication reconciliation following discharge is an intervention RxAnte highly recommends to be a part of any plan’s intervention program approach and should be targeted at patients based on their outreach preferences and other factors.
  • Additional measures: CMS announced other potential new measures, many of which relate to areas correlated with high cost and unnecessary utilization:
    • Care coordination
    • Asthma treatment
    • Depression treatment
    • Statin therapy
    • Opioid overutilization
  • Value-based payment systems: Lastly, CMS announced an interest in exploring value-based payment systems (e.g., ACOs, bundled payments for episodes of care, primary care medical homes). CMS will request data and information from Medicare Advantage (MA) organizations regarding the use of incentive payments and value-based contracting. RxAnte believes value-based payment systems are an important and effective way for plans to engage their provider networks in improving quality without creating a structure that rewards for process. RxAnte will continue to assess the performance of value-based arrangements at improving medication use outcomes as compared to more traditional pay-for-performance programs.