Star Ratings, MTM and Independent Pharmacy

By Peter Kounelis, R.Ph.

Peter Kounelis, Senior Director of Provider Network Business Development, talks to about the correlation between MTM completion rates and Star Ratings, as well as best practices for achieving quality patient outcomes.

Q: Let's start with an overview. What are the basics of Star Ratings as they relate to pharmacy?

A: Medicare evaluates performance of Part D plans through many different quality measures. For 2015, there are 13 measures overall, five of which are directly related to medication use and are directly influenced by what pharmacists do on a daily basis. Those five measures are also triple-weighted in the summary rating of a prescription drug plan (PDP), which means those five measures of quality actually account for almost half of a Part D plan's overall Star Rating.
Of those five medication use measures, three of them relate to medication adherence and are focused on the categories of medications that are very common in Medicare beneficiaries, including diabetes medications (in particular the non-insulin products) and cholesterol medications, with a focus on statins. In addition to the adherence measures, there are two other safety measures. One looks at the use of high-risk medications in the elderly and another that looks at the use of RASA drugs and persons with diabetes.

Q: And when will all of this rating and measuring start?

A: The Medicare Star Ratings have been around since 2008, so Medicare has been evaluating Medicare PDPs for six years now. They continue to ratchet up their attention to the quality of those plans; however, there is some lag between reporting and ratings. The 2015 ratings, for example, will be based on 2013 data.

Q: Why are Star Ratings important to pharmacy now?

A: As CMS creates more financial implications for the plans, there has been a trickle-down effect on the physicians and pharmacies that are in those plans' networks. The incentives CMS has created for the plans include publicly reporting the plan's Star Ratings, which is starting to affect enrollment. New Medicare beneficiaries are tending to select the more highly rated plans, and as others switch plans, they're selecting those four- and five-star plans. An additional perk is that five-star plans have open enrollment year-round and can essentially "pick off" patients from other plans that don't have five-star ratings.
As for the financial rewards, plans that hit four or five stars on their overall Medicare Stars can get a 5 percent bonus from CMS, which is something that those five-star or four-star plans can build into their bids for the coming year. It's a downstream effect that is actually factored into the bid rates, rather than issued as a big one-time lump sum payment to those plans. But 5 percent for a large plan is a lot of money, so we end up talking about hundreds of millions of dollars at stake if a plan can get their ratings up to four and five stars - you better believe that's enough money to get their attention.
And now, we're starting to see the plans paying attention to how their physicians and pharmacies perform on those same measures. We have a growing number of plans that are making that focus more transparent to pharmacies by sharing their data through the EQuIPP platform. That means all of the data that's now being collected on those plans and all the claims pharmacies are filing for patients in those plans will factor into the quality rating system for each of those plans. Some of those incentives are coming out to pharmacies, and we have a growing number of plans, including a large national player in Silver Script, offering up bonus payments to pharmacies that have outstanding scores on those performance measures. We're going to see a lot more of that over the next few years.
The end result and impact for pharmacies is that, as CMS is looking at ways to reduce waste in the healthcare system by improving medication adherence, they're making more Medication Therapy Management (MTM) services available for plan members through community pharmacies via programs managed by Outcomes and Mirixa.

Q: Why are MTM case completion rates receiving increased focus from plans?

A: There is a set of measures called the "Display Measures," which don't factor into the official Star Ratings, but are quality measures that CMS tracks across every Part D plan. They include drug-drug interaction rates, excessive doses of oral diabetes meds and a MTM measure that examines the completion rate for comprehensive medication reviews (CMRs). Included in the changes CMS has proposed to ratings for plans in 2016 is a new measure based on the completion rate for CMRs.
MTM is not just about reviewing the medications. MTM is basically a facilitator that can improve patient care and, in turn, Star Ratings as well. In fact, some plans are actually providing validation payments to pharmacies that show adherence improvements. OutcomesMTM™ launched a longitudinal adherence program wherein pharmacists can enroll patients who have been identified as less than 80 percent medication adherent into a program with multiple checkpoints instead of just a one-and-done intervention. If that patient reaches at least 80 percent of prescription drug compliance (PDC) by the end of the year, the pharmacy is going to receive a validation payment from the health plan. So while we're not seeing a pay-per-performance scenario yet, the plans are showing signs of moving toward that, incentivizing pharmacists and making sure that they know that they're recognized. Despite this increased focus and incentive, it's important for pharmacies to remember that these interventions are not new.

Q: How do independents' completion rates compare to that of chain pharmacies?

A: OutcomesMTM reports that the large chains had a significantly higher completion rate compared to the independents in Q2 of 2014. But even though the data shows that fewer patients were touched by independents, successful completion was comparatively high when independents did have cases. Mirixa, another platform through which pharmacies have begun receiving MTM cases, also shows slightly higher "serve" rates by independents that can be attributed to independents' high-touch patient relationships.1 

Q: Is there a correlation between successful completion rates on the MTM side and improved Star Ratings?

A: What the MTM platforms, Outcomes and Mirixa, are telling us is that they're seeing, closures in the adherence gap and improvement in the elimination of high-risk medication. Those are the specific measures pharmacies can control. In fact, Outcomes reports customer improvement in four out of five measures based on a comparison of how plans performed before becoming Outcomes customers.2 To us, that demonstrates the value of the pharmacies receiving cases to work.

Q: What happens when a pharmacy doesn't work its MTM cases?

When a pharmacy isn't participating and they have a number of patients that need to be served specifically for CMRs, cases will ultimately get referred to a consulting pharmacist or call center within the plan's or platform's network. But that's only if the pharmacy declines the case, telling the referring platform they don't have time for MTM.

Q: What about pharmacies that receive cases for patients they're not familiar with?

A: While both Mirixa and Outcomes do try to avoid sending cases for patients with whom a pharmacist has no relationship, it's important to view situations like these as opportunities to gain a patient. A typical Medicare Part D patient spends anywhere from $3,000 to $4,000 a year in the pharmacy they choose.3 Pharmacies should seize the opportunity to earn that revenue.

Q: What are some ways receiving MTM cases can be more easily integrated into the pharmacy workflow?

A: This is a question we're starting to hear more and more from independents. They want to know how they can work like some of the chains are working and how they might operationally integrate data feeds and electronic interfaces for identifying MTM cases. And it's really an overarching question of how independents can be operationally efficient in conducting and tracking MTMs. While Outcomes does offer some partial integrations with pharmacy systems, what a lot of pharmacies are trying to do is self-identify potential cases when there's not an automated feed from their partners. But it's important for the pharmacist to remember that, at the point of dispensing medication, they're not privy to the disease, cost and medication thresholds a health plan has submitted at the beginning of a plan year. So there's good reason for using caution with self-identifying. There's always the risk that the pharmacy may conduct a MTM consult that is ineligible for reimbursement. That's why the MTM platforms' process flows are important. The health plan tells Mirixa/Outcomes what they're looking at, and they then create cases that they send to a pharmacy.
One way independent pharmacies can operationalize the MTM process is by involving support staff on the administrative end. The pharmacist is required for the actual consultations, providing that service and completing the interventions, but the technician can perform documentation, follow-up calls and scheduling. And at the pharmacist's discretion, they can use interns. We have multiple pharmacies that use their interns to provide the services and do everything the technician does as well. These completions are so valuable that building them into the workflow makes financial sense for the pharmacy.

Q: Why are auto-refills a hot topic?

A: There is a desire to balance a number of factors when it comes to auto-refills. While many patients like the convenience of auto-refills and the pharmacy certainly wants to promote good adherence and easy access to medications, Medicare does not allow them. CMS' policy will likely evolve over time as we all work out the tug-of-war between different issues and different things all stakeholders are trying to accomplish.
We have heard from many independents that synchronization programs have helped with patient adherence, but neither auto-refills nor synchronization programs change the need for the pharmacy to be proactive in calling patients to confirm they are still taking medications, are able to pick up the prescriptions and that nothing has changed - creating a reminder system that works within the CMS' policy will be key.

Q: What else can pharmacies do - outside of MTM - to impact their Star Ratings?

A: There are two critical things pharmacies can do to impact Star Ratings beyond MTM. The first is being proactive. Don't wait for a case to show up to be involved in improving quality measures. Second, continuously engage patients. Ask them about any questions or concerns they have every time they come in. Leveraging close relationships with patients will be key to these efforts.

Q: How can the pharmacist approach situations where a provider is unwilling to change medications?

A: This issue is most relevant to safety measures and generally occurs when the pharmacist identifies a high-risk prescription. The most important thing pharmacies can do is document their efforts - every action and every intervention - and recognize that the system is still evolving. We've seen this in health plans' asking for data on refusals and even intervening when two or more high-risk prescriptions are filled consecutively. And since the patient can sometimes refuse a change in medications, it is important for a pharmacist to keep a record when they consult on high-risk drugs.

Q: Any final thoughts on the overall benefits of MTM programs?

A: Beyond improving Start Ratings, customer retention through medication adherence is just good business. In addition to being a quality metric, MTM programs simply produce healthier patients and better outcomes. It's also a way for independents to raise their prescription counts and sales by identifying issues through their high-touch patient care.
On the revenue side, the potential for bonus payments and the fact that pharmacists are now being recognized and paid for clinical services through MTM services is a huge win for independents. It's a critical step in recognizing the valuable role of the pharmacist in healthcare.
Learn more about Star Ratings and independent pharmacy at

1. Nwachuku, U and Amin, R. Star Ratings Round Table. AmerisourceBergen/Good Neighbor Pharmacy ThoughtSpot 2014. MGM Grand, Las Vegas, NV. 1 August 2014.
2. Ibid
3. Ibid

About the Author

Peter Kounelis, R.Ph.

Vice President of Elevate Provider Network
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