Medicare Advantage plans have a clear opportunity to improve quality by delivering more comprehensive, timely medication reconciliation services to recently discharged members.
Unplanned hospital readmissions are a perennial concern in health care. In addition to being disruptive and stressful for health plan members, avoidable readmissions cost the health care system an estimated $17 billion dollars annually.
Reducing all-cause hospital readmissions rates is crucial for Medicare Advantage (MA) plans that want to perform highly on the influential Star Ratings scale. Readmission rates are an important key performance indicator and may influence member decisions about choosing a plan partner.
Research shows that Medicare Advantage members have higher rates of risk-adjusted 30-day readmissions than their traditional Medicare counterparts. And since more than a quarter of 30-day readmissions are directly tied to medication adherence reconciliation issues, MA plans have a clear opportunity to improve quality by delivering more comprehensive, timely medication reconciliation services to recently discharged members.
Gaps in Medication Reconciliation Lead to Avoidable Readmissions
Understanding why a patient returns to the hospital soon after discharge is key to preventing avoidable readmissions and solving the challenges of follow-up care. Medication reconciliation is at the heart of the solution. In Measurement Year 2021, more than half of the Star Rating quality measures are weighted to medication-related measures, including the Part C measure for Medication Reconciliation Post Discharge (MRP).
As CMS explains, MRP “shows the percent of plan members whose medication records were updated within 30 days after leaving the hospital. To update the record, a doctor or other health care professional looks at the new medications prescribed in the hospital and compares them with the other medications the patient takes.”
As CMS actively reevaluates the role and expands the scope of medication reconciliation in its MA quality measures, plans will need to implement new strategies for addressing the root causes of avoidable readmissions for their members. In addition to considering a new COVID-19 vaccine Star measure, CMS announced the Contract Year 2022 MA Star Ratings will change from the MRP measure to the Transition of Care measure. CMS defines a transition of care as the movement of a patient from one setting of care to another. Settings of care may include hospitals, ambulatory primary care practices, ambulatory specialty care practices, long-term care facilities, home health, and rehabilitation facilities. This is a material change that will impact how a significant number of plans manage transitional care.
In a sample cohort analysis for a Dual Special Needs (DSNP) MA plan in 2020, AdhereHealth conducted individualized postdischarge medication reviews via telepharmacy for 5000 MA members in 2020. In that sample, an alarming 61.9% had at least 1 drug therapy problem (DTP) that would have gone unaddressed without telepharmacy outreach (Figure 1).
Additional findings from the cohort include (Figure 2):
These pervasive issues lead to medical errors and complications that drive health plan members directly back to the emergency room and inpatient setting.
How can health plans identify and address medication reconciliation problems to keep members on track with recovery after a recent hospitalization? To improve their MRP measure and reduce cost of care, health plans should consider adopting an approach that leverages real-time data and timely telepharmacy outreach as part of a strategic, proactive plan.
Integrating Digital Data With Personalized, Pharmacist-Led Outreach
The difficulties begin with the inability to capture accurate medication histories from patients as they are admitted into the hospital and continue along various touch points within the health care system. Challenges are especially acute among patients who have complex medication regimens to treat chronic conditions and those who are managing multiple social determinants of health (SDOHs).
For example, paper-based processes for collecting and adjusting medication records can be slow, costly, and prone to errors. While health plans may have access to medication history data, they do not always have the latest information about admissions and discharges—or any medication changes that occurred during these events—leaving them unable to quickly connect with members.
With the right technologies and predictive analytics capabilities, health plans can access clinical histories, claims data and pharmacy data in real time. Artificial intelligence can automatically capture and analyze all relevant data, and then immediately prompt specially trained pharmacists to conduct an outbound call to complete MRP measures within 48 hours of discharge. Documentation of the MRP with a medication action plan is sent electronically to the provider and successful HEDIS gap closure for the measure is submitted with the filing for a zero-dollar medical claim.
What’s more, these modern systems have the ability to collect accurate, comprehensive data about SDOH, which have historically been difficult to gather, standardize, and share through existing health information technology systems.
Pharmacists can and should take a more active role in leveraging these data assets to improve MRP processes. Studies have found that pharmacy-led interventions may help reduce readmissions to the hospital, particularly among high-risk patients. These services do not require face-to-face encounters, which is why a growing number of health plans are now using a tele-pharmacy approach to conduct MRP measures, identify potential adverse drug reactions, and highlight cost-saving substitute opportunities.
Because adherence to medication is critical in the days after a postdischarge window, the speed at which plans can connect data with the member and a pharmacy professional to review medication information is vital.
Reaching out to the patient within the first 5 days of discharge can achieve significant results. A telepharmacy approach enables MRP measures to be conducted quickly while opening the conversation to several other SDOH factors that may prevent patients from following through on medication instructions, such as language barriers or access to transportation and other fundamental challenges. Ensuring the patient has been provided with health literacy content on their conditions, which medications to discontinue, and new medications that need to be filled is key. Ensuring the patient has continuity of care with their community physician will help reinforce the components of the MRP, especially if the doctor has timely access to the document.
A Combined, Ongoing Effort to Improve Outcomes for Members
Keeping patients out of the hospital means staying on top of the health status of everyone in a health plan all year long. For MA plans, this often requires a shift in mindset and the adoption of new models for delivering holistic care. Access to comprehensive patient data from all points of the care continuum, in real time, can enable this to happen. Leveraging that data with the power of predictive analytics will enable pharmacists to strategically engage with members and conduct MRPs while simultaneously addressing SDOH issues and working to improve other key Star Rating measures.
Take the real story of Mr Wilson, a patient in an MA plan (not his actual name to protect his privacy). Mr Wilson was prescribed valsartan, budesonide/formoterol, ranolazine, and 5 other medications for his hypertension, angina, arrhythmias, and chronic obstructive pulmonary disease. After being hospitalized for a recent stroke that left him unable to read or write, he became nonadherent to his medication. Before the nonadherence could result in an unplanned readmission, a skillful, licensed pharmacist from AdhereHealth reached out to Mr Wilson and educated him on the importance of adherence, especially when managing multiple chronic conditions. Mr Wilson reported forgetfulness and admitted that he’d lost one of his prescriptions. His outreach specialist coordinated a conference call with his pharmacy to replace the lost medication, and he was referred to health plan care management to address home health assistance.
Especially in the age of COVID-19, which significantly complicates the admission and discharge landscape, health plans will need to adopt new, more personalized and effective ways to address medication-related issues to prevent unnecessary recurring hospitalizations.
Although the issue of avoidable readmissions cannot be solved via medication reconciliation alone, it is perhaps the most critical piece of the puzzle. As such, having pharmacists play a leading role in the process due to their expertise makes logical sense. Equipping these experts with holistic, predictive analytics will only heighten their effectiveness on behalf of members both immediately after a discharge and throughout the entirety of their healthcare experience. Taking the opportunity to ensure the patient has a good understanding of their new medication regimen, access to pharmacy and community physician follow-up is key. Providing the primary care physician and the patient with timely access to the completed MRP assessment can make a difference in avoiding a readmission.
Jason Z. Rose, MHSA, is CEO of AdhereHealth.