Optimizing Care Delivery with Medicare Star Ratings: The Successes and Challenges of Managed Care Organizations

In an educational seminar entitled "How Much of the $3 Billion in Star Rating Bonuses Did Your MCO Capture?," David Nau, RPh, PhD, CPHQ, FAPhA, along with his colleagues, discussed Medicare star ratings and how managed care organizations have implemented practices and processes to ensure the delivery of high-quality care to their members.

On Thursday afternoon at the AMCP Annual Meeting & Expo, David Nau, RPh, PhD, CPHQ, FAPhA, the president of Pharmacy Quality Solutions, kicked off an educational seminar titled, "How Much of the $3 Billion in Star Rating Bonuses Did Your MCO Capture?" Beginning with his presentation, "Medicare Star Ratings," Nau noted how the US healthcare system was trending towards value-based purchasing, with value defined as the balance of quality and costs; however, one of the biggest challenges in driving better quality is often its varied interpretations. The Pharmacy Quality Alliance (PQA) is a consensus-based and non-profit alliance with over 100 organizational members that has a mission of "improving the quality of medication management and utilization across healthcare settings with a goal of improving patient health through a collaborative process to develop and implement performance measures and recognize examples of exceptional pharmacy quality." Driving improved patient outcomes while implementing cost-containment strategies is on the forefront of healthcare reform, and the federal Medicare programs have been utilizing the Medicare Star Quality Rating System, which ranges from 1 to 5 stars, and is calculated for each measure, domain, summary, and overall level, to drive further attention to medication-related quality by associating financial implications to its star ratings. Accountable care organizations and accreditation programs, much like Medicare, are pushing for additional data on medication-use quality. In an effort to improve star ratings, Medicare has implemented various programs and strategies, such as pharmacy network changes.

In his portion of the presentation, James Hopsicker, RPh, MBA, the vice president of Pharmacy Programs discussed the approaches his organization has taken to achieve a 4.5-star plan for all CMS contracts. With a multidisciplinary team, Hopsicker noted that his organization implemented a targeted approach for both the member and provider. Members were offered an improved enrollment process, simplified website, vaccine-specific reimbursement form, enhanced chronic condition management programs, improvements to the medication therapy management (MTM) process, and enhanced education on measures. From the provider end, gaps-in-care reports were created, the Medicare Physician Quality Reporting System and high-risk medication reports were developed, and education on the Stars Program and measures was provided. He noted that while his organization has had its successes, such as its MTM program, there are still many challenges to overcome and areas for further improvement.

Brandy Fouts, PharmD, the Medicare clinical services coordinator of Group Health Cooperative took the podium and began her presentation, "Group Health Cooperative: Addressing Adherence in the External Group Practice." Servicing over 660,000 members, 1280 primary care providers, and 27 specialties, Group Health HMO and PPO achieved an overall 5 stars and a 3.5-star rating in 2013, respectively. Their approach to star ratings was an organization-wide effort to work with the existing management to improve performance by asking the divisional leaders for operational accountability, and developing work plans, updated monthly, for each operational area with specific tactics. Chronic disease management, she said, involved the implementation of comprehensive care, use of available technologies, and collaborative care. Medication adherence was reinforced with programs that were driven by both the organization and provider, such improved benefit design, increased education, and the use of feedback tools.

Matt Nye, the vice president of Pharmacy Care Support Services, National Pharmacy Programs and Services of Kaiser Permanente began his portion of the presentation, "Kaiser Permanente's Approach to Medicare Stars," with a brief company overview, stating the coverage of 9 states and the District of Columbia, with 8.9 million members, 165,000 employees, 15,000 physicians, 36 hospitals and medical centers, and 1.05 million Medicare members. The National Pharmacy Programs and Services of Kaiser Permanente includes outpatient, inpatient, and ambulatory care pharmacies and services, home infusion, drug distribution, mail order and central fill operations, and centralized services. He stated that the approach to drug therapy management was to "leverage the medical and pharmaceutical expertise of an integrated practice model," with clinicians leading the effort to establish comprehensive and realistic therapeutic, evidence-based goals. There is an emphasis on sharing accountability between physicians and pharmacists to ensure the appropriate use of medications. A deep understanding of the star measures along with internal and external organizational processes and protocols have allowed Kaiser Permanente to achieve a Part D summary rating of 5 in 7 of the 8 regions.