What do medication adherence and Centers for Medicare & Medicaid Services (CMS) star ratings have in common?
Both are topics of increasing interest to health plans, and thus both topics should be of increasing interest to healthcare providers. In this post, we'll take a closer look at these topics by exploring the concept of CMS star ratings, identifying the medication adherence measures included in the Medicare star ratings system, discussing the importance of medication adherence and why plans and providers should prioritize improvements in this area, and another quality area where medication adherence is taking on increasing importance.
What Are the CMS Star Ratings?
Each year, CMS publishes Medicare Advantage (i.e., Medicare Part C) and Medicare Part D star ratings. They measure the quality of health and drug services received by consumers enrolled in Medicare Advantage (MA) and prescription drug plans (i.e., PDPs or Part D plans). Star ratings are intended to assist Medicare consumers in comparing the quality of available Medicare health and drug plans, thus better empowering these patients to be more active participants in their healthcare and make decisions in their best health and care interests.
Medicare determines its star ratings, an overall performance assessment, from information gathered via member satisfaction surveys, plans, and healthcare providers. Data collected for the star ratings come from a variety of sources, including Health Effectiveness Data and Information Set® (HEDIS®), Medicare Health Outcomes Survey, and Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys. A health or drug plan can earn a rating between 1 and 5 stars, with a 5-star rating considered excellent and a 1-star rating considered poor.
Medicare updates its star ratings each fall for the following year, and these ratings can change each year.
Note: It is important to distinguish Medicare star ratings, which are given by Medicare to health plans and the subject of this blog post, to Medicare's hospital quality star ratings, which are given to hospitals. As Medicare notes about the latter, "The overall star rating for hospitals summarizes quality information on important topics, like readmissions and deaths after heart attacks or pneumonia. … The overall rating shows how well each hospital performed on an identified set of quality measures compared to other hospitals in the U.S." CMS released its latest hospital quality star ratings in April 2021. Both types of star ratings are intended to improve patient empowerment, engagement, and decision-making.
What Are the CMS Star Measures?
For 2022, Medicare Advantage with prescription drug coverage contracts are rated on up to 38 quality and performance measures. MA-only contracts — those without prescription drug coverage — are rated on up to 28 measures. Standalone prescription drug plan contracts are rated on up to 12 measures.
The stars quality measures for Medicare Advantage (i.e., Medicare Part C) are divided into five categories:
- Staying healthy (i.e., how frequent members receive screenings, tests, and vaccines)
- Managing chronic conditions
- Member experience with the health plan
- Member complaints and changes in the health plan's performance
- Health plan customer service
The stars quality measures for Medicare Part D are divided into four categories:
- Drug plan customer service
- Member complaints and changes in the drug plan's performance
- Member experience with the drug plan
- Drug safety and accuracy of drug pricing
As CMS states, most Medicare Advantage plans include Medicare Part D.
CMS Star Ratings: Medication Adherence Measures
Medicare adherence is an area of focus for three Medicare Part D stars quality measures:
- Medication adherence for cholesterol (statins), which is described as follows: "Percent of plan members with a prescription for a cholesterol medication (a statin drug) who fill their prescription often enough to cover 80% or more of the time they are supposed to be taking the medication."
- Medication adherence for diabetes medications, which is described as follows: "Percent of plan members with a prescription for diabetes medication who fill their prescription often enough to cover 80% or more of the time they are supposed to be taking the medication."
- Medication adherence for hypertension (renin angiotensin system (RAS) antagonists), which is described as follows: "Percent of plan members with a prescription for a blood pressure medication who fill their prescription often enough to cover 80% or more of the time they are supposed to be taking the medication."
Where do these medication adherence measures come from? They were developed and are endorsed by the Pharmacy Quality Alliance (PQA). PQA describes itself as a "national quality organization dedicated to improving medication safety, adherence, and appropriate use."
Five PQA measures will be included in the Medicare 2023 Part D star ratings: the three medication adherence measures identified above as well as "medication therapy management (MTM) program completion rate for comprehensive medication reviews (CMR) and "statin use in persons with diabetes." As a result, PQA notes its measures account for a significant portion of a health plan's Part D overall performance star rating.
Why is medication adherence important for cholesterol, diabetes, and hypertension? Consider these quotes:
- "Medication adherence directly influences the extent to which statins prevent cardiovascular disease (CVD) events, including mortality. Poor statin adherence can also increase CVD-related emergency department visits, hospitalizations, and healthcare costs." (Source: U.S. Pharmacist)
- "At least 45% of patients with type 2 diabetes (T2D) fail to achieve adequate glycemic control. One of the major contributing factors is poor medication adherence. Poor medication adherence in T2D is well documented to be very common and is associated with inadequate glycemic control; increased morbidity and mortality; and increased costs of outpatient care, emergency room visits, hospitalization, and managing complications of diabetes." (Source: Patient Preference and Adherence)
- "Medication adherence is critical to successful hypertension control for many patients. However, only 51% of Americans treated for hypertension follow their healthcare professional's advice when it comes to their long-term medication therapy. … High adherence to antihypertensive medication is associated with higher odds of blood pressure control, but non-adherence to cardioprotective medications increases a patient's risk of death from 50% to 80%." (Source: Million Hearts)
To summarize, good medication adherence leads to improvements in health and wellness as well as a reduction in admissions and readmissions. Poor medication adherence increases health risks, mortality, emergency room visits, admissions, and readmissions. Considering the substantial impact improving medication adherence can have on care quality, health outcomes, patient satisfaction, and healthcare costs, it comes as no surprise that Medicare would emphasize the importance of medication adherence measures in how it calculates star ratings.
Overview of HEDIS® Medication Adherence Measures
While this blog post focuses on CMS STAR ratings and medication adherence, we would be remiss if we didn't touch on the HEDIS® medication adherence measures. While, as previously stated, CMS star ratings take HEDIS® data into account, HEDIS® is very important on its own.
As the federal government notes, more than 90% of U.S. health plans use HEDIS® to measure performance on important dimensions of care and service, and more than 190 million people are enrolled in health plans that report quality results using HEDIS®.
There are currently two HEDIS® medication adherence measures for 2022, as the National Committee for Quality Assurance identifies in this document — one of which is similar to a CMS STAR ratings medication adherence measure:
- Statin therapy for patients with diabetes (SPD), which is described as follows: "The percentage of members 40–75 years of age during the measurement year with diabetes who do not have clinical atherosclerotic cardiovascular disease (ASCVD) who met the following criteria. Two rates are reported: 1) Received statin therapy. Members who were dispensed at least one statin medication of any intensity during the measurement year. 2) Statin adherence 80%. Members who remained on a statin medication of any intensity for at least 80% of the treatment period."
- Adherence to antipsychotic medications for individuals with schizophrenia (SAA), which is described as follows: "The percentage of members 18 years of age and older during the measurement year with schizophrenia or schizoaffective disorder who were dispensed and remained on an antipsychotic medication for at least 80% of their treatment period."
Improving Medication Adherence Measures Performance With Cureatr
Considering the importance of medication adherence for quality ratings and the many other areas affected by patient adherence with medication regimens, health plans and healthcare organizations should be targeting medication adherence as a component of care for improvement. One way payers and providers are achieving improvements in medication adherence is by partnering with companies like Cureatr, through its Cureatr Clinic, to provide medication management services and support to members and patients.
Cureatr Clinic’s team of clinical pharmacists engages with patients — often during transitions of care, including discharge — and analyses medication regimens, performs medication reconciliation, and helps patients secure medications and support services, all of which contribute to improved medication adherence and performance on medication adherence Stars and HEDIS measures. Health plans focused on improving medication adherence are investing in such services and solutions themselves and are increasingly looking to contract with providers prioritizing improvements in medication adherence since provider performance directly affects payer quality rating performance.
Schedule a consultation with a member of the Cureatr team to learn how our services and solutions are helping solve healthcare's medication management puzzle.