The 2022 performance year’s Star Ratings require Medicare Advantage plans to take a more significant role in preventing readmissions.
Transitions of care have become a major focus for improving health care quality and patient experience and reducing hospital readmissions. The ineffective transferring of a patient from one care setting (eg, a hospital, nursing facility, primary care physician, long-term care, home health care, specialist care) to another often leads to confusion about treatment plans, missed follow-up appointments, patient dissatisfaction, medication nonadherence, and, most importantly, unnecessary readmissions.
Nearly one-fifth (19.6%) of Medicare patients discharged were readmitted within 30 days and 34.0% were readmitted within 90 days. These readmissions cost Medicare $17.4 billion annually. Reports indicate that up to 40% of all medication errors can be traced back to insufficient medication reconciliation during the transition of care.
In 2022, CMS has announced introduction of a new Star Rating measure, Transitions of Care (TRC), to promote better care coordination across the field.
Medicare Advantage (MA) plans should take note, as this measure will require a more significant role in preventing readmissions. Ensuring proper medication reconciliation after a hospital discharge will be a critical success factor. Patients are at their most vulnerable during the handoff from one clinical team to the next.
Of note, more than half of the Star Rating system is tied directly to medication-related management to safeguard patients during their interactions with the complex health care ecosystem. Overall, the annual MA Star Ratings Quality Bonus Payment (QBP) is $11.6 billion pool of value-based reimbursement dollars available to the highest quality plans in the nation every year. This accounts for approximately $450 per member per year for plans that reach 4 stars or more on the complex Star Ratings system.
The current Medication Reconciliation Post Discharge (MRP) measure requires MA plans to oversee medication reconciliation for individuals within 30 days of discharge to prevent an avoidable hospital readmission and keep patients healthier at home. Confounding factors, such as nearly 100 million Americans living in “pharmacy deserts” with low access to prescriptions, make it challenging for patients to adhere to medication instructions.
Further, the current process is fraught with other obstacles and pain points as well. Multiple providers are often involved during a hospitalization or emergency event, leading to confusion over who’s in charge of the patient’s care plan. Misaligned incentives can sometimes lead stakeholders to abdicate responsibility. Admission, discharge, and transfer (ADT) notifications don’t always get where they’re supposed to go in a timely manner. And patients can often fall through the cracks if they don’t have a strong relationship with a proactive primary care provider with access to health information exchange tools.
These breakdowns in communication are about to become even less tolerable when measuring managed care quality, with CMS’ addition of the TRC measure to the Star Rating Program in 2022. While some of these quality measures were present in the soon-to-be-retired MRP measure, the new TRC measure is far more complex to orchestrate across the health care continuum.
CMS defines a “transition of care” as any time a patient moves from one care setting to another, whether from a primary care provider to a specialist, from an inpatient bed to a skilled nursing facility, or from the hospital to the home. To get full credit for the newly designed TRC measure, plans will need to complete all of the following 4 objectives for patients 18 years and older:
With 2022 approaching quickly, MA plans only have a few short months to take charge of the new TRC process, including increased coordination of care for medication reconciliation processes. Historically, MA plans have not performed well on MRP measures. An AdhereHealth analysis found at least 50% of plans eligible to report on this measures did not reach the 4-Star threshold to qualify for the QBP pool allocated by CMS. To succeed with the more stringent TRC measures and secure high Star Ratings for quality care, MA plans will need to reexamine their current MRP strategies and take the lead with data-driven, holistic approaches that enable seamless transitions of care.
Leverage Predictive Analytics to Access and Aggregate Timely Data
Neither health plans nor providers can act on medication reconciliation if they are unaware that a patient has experienced a hospital event.
MA plans will need to adopt patient management tools with sophisticated predictive analytics, health information exchange capabilities, and intelligent clinical workflows that provide access to the most accurate, timely data available from all providers involved in the patient’s care.
With the ability to aggregate and analyze clinical histories, claims data, pharmacy data, and ADT notifications in real time, plans can take swift action: reaching out to the appropriate providers and patients for a conversation about medication changes.
Improved access to patient data can help MA plans complete this initial step more quickly, often within 48 hours, leaving less time for a medication issue to send a patient back to the emergency department.
Directly Involve Patients in Medication Reconciliation Through Telepharmacy Outreach
When it comes to transitions of care, MA plans might be more used to coordinating with providers than with patients. But directly incorporating patients and caregivers into the medication reconciliation process can reap significant rewards.
Pharmacist-led interventions that include outreach to patients may help to significantly reduce readmissions, especially among high-risk patients who often have a higher number of medications to manage. With a specially trained pharmacist to work one-on-one with patients, MA plans can be certain that their beneficiaries are receiving meaningful, personalized education and directives about how to take medications correctly.
These telepharmacy sessions can satisfy the patient engagement portion of the 2022 TRC measure as well as the medication reconciliation requirement. Telehealth engagements are also well received by patients who appreciate the convenience and lack of travel time, which may have negative implications for patient experience and CAHPS scores, helping MA plans stay one step ahead of their performance goals.
Commit to Sustained Medication Management With Wraparound Pharmacy Services
Medication optimization goes beyond the immediate requirements of the postdischarge period. As patients recover at home, they often need ongoing support and education about medication safety and adherence.
MA plans should consider using a hospital event as a jumping-off point for a deeper conversation about medication management and the social determinants of health (SDOH) that might make self-care more difficult.
Addressing these issues and providing patients with additional resources, such as compliance packaging options to boost adherence, and community-based services to solve socioeconomic issues, are key to preventing avoidable hospitalizations.
It is also important to establish a comprehensive, proactive relationship with patients to empower individuals and their caregivers to become more familiar with their medications so they can advocate for themselves when a hospitalist or specialist makes a change.
Meeting the patient where they are at home is a critical component of preventing readmissions. Patients who live in pharmacy deserts or don’t have access to medications within a few miles of their home benefit from mail-order prescription drug programs. In the case of underserved Americans such as dually eligible members for Medicare and Medicaid, a private couriered pharmacy supports overcoming individual SDOH barriers that interfere with access.
By transforming medication management into an ongoing relationship, MA plans can capitalize on their perfect positioning as the guardians of medication safety. With the approaching changes to the new TRC measure and the accompanying impact on Star Ratings, MA plans now have even more reason to take control of this critical process.
As Star Ratings represent more than $10 billion in the annual MA QBP, focusing on proven, scalable methods to prevent readmissions is an imperative. Leveraging a technology-driven telepharmacy approach empowers care teams, helping them support a better continuity of care from the hospital to the community, fulfill the TRC measure, prevent unnecessary health care costs, and ultimately foster better outcomes for patients.
Jason Z. Rose, MHSA, is CEO of AdhereHealth.