Star ratings: A big deal for pharmacies gets bigger

The feds are ramping up their embrace of quality measures, and the pharmacy industry is smack in the middle of the action. With information generated by Medicare, the federal government is tracking the performance of health plans, which in turn are pressuring pharmacists to help boost their scores. Pharmacies that do more to help patients stay healthy may be in the line for larger payments.

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David Nau“Increasingly, your performance on quality measurements matters to your bottom line,” said David Nau, RPh, PhD, CPHQ, FAPhA, recently during his presentation “Quality improvement: Opportunities beyond Medicare” at the NACDS Total Store Expo. Indeed, health plans may consider performance on quality measures when they decide whether to include individual pharmacies in narrow or preferred pharmacy networks.

Nau has been monitoring the changing times as president of Pharmacy Quality Solutions, a joint venture of the Pharmacy Quality Alliance (PQA) and CECity. PQA, a nine-year-old nonprofit alliance of more than 100 member organizations, develops strategies for measuring and reporting medication performance details.

Star Ratings

So far, the biggest changes have come in connection with Medicare, which awards Star Ratings of 1 to 5 stars on the basis of 15 individual measures. Of those criteria, five analyze medication safety or medication adherence. The results account for 50% of the Part D summary ratings for 2015, which were based on 2013 figures and released last year.

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“The Centers for Medicare and Medicaid Services [CMS] updates the selection of performance measures each year, but most stay the same,” Nau said. “However, the performance targets change each year. The bar rises. The performance level necessary to achieve a 5 Star Rating for a health plan continues to get higher and higher, so they’re constantly needing to look for ways to further improve to keep themselves in the upper tiers of performance. They’re looking to their pharmacy networks to help them achieve better performance.”

The Star Ratings are crucial in two other ways. For one thing, a growing number of consumers use them as a source of information when they choose a health plan. For another, health plans can lose their contracts with Medicare if they continue to receive poor ratings.

Higher stakes

The next set of Star Ratings will be based on data from 2014. One new measure will analyze the percentage of patients who are eligible for medication therapy management (MTM) and completed an appropriate comprehensive medication review.

“CMS has tracked this for a couple of years, but it’s only now appearing as a Star measure. This means that MTM has higher stakes,” Nau said. “Health plans will continue to escalate their expectations with demands and perhaps incentives for pharmacists to complete more comprehensive medication reviews.”

What to do? Nau recommends that pharmacists boost their numbers by focusing on better patient communication.

“All too often, we see an offer for MTM services thrown out in a poorly communicated way that discourages people from understanding what they’re being offered,” he said. “When a person is standing in a long line to pick up a prescription, you shouldn’t ask, ‘Do you want MTM service?’ Nobody will know what that is, and they’re hurried and rushed anyway.”

Instead, he said, “You have to build a rapport with your patients and find the right time to talk to them.”

New measures

Two new measures, both endorsed by PQA, are under consideration as potential Star Ratings measurements: Statin therapy levels in certain diabetic patients (are statins being prescribed as often as they should be?) and opioid use (is it being overused?).

“They’re being measured, but it’s not clear whether they’ll be included as part of the overall Star Rating of health plans,” Nau said.

PQA is tracking statin/diabetes numbers as part of its Electronic Quality Improvement Platform for Plans & Pharmacies (EQuIPP).

While it’s too early to know whether the measurements will actually be used, pharmacists “should be paying attention, because it’s being measured and tracked,” Nau said.

In the big picture, pharmacists can rely on the EQuIPP platform as “a foundational piece that helps them know what they’re doing well and not doing well,” Nau said. “EQuIPP is a neutral intermediary. We sit in that space between the pharmacy benefit manager and the pharmacy, and make the performance calculations in an unbiased and transparent manner. Essentially, it’s their official report card on quality measures.”

Randy Dotingais a medical writer in San Diego.