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The Path to Higher Quality Scores: Five Areas Where Your PBM Can Impact Your Star Rating

June 21, 2018

In 2008, the Centers for Medicare and Medicaid Services (CMS) developed a five-star rating program to measure the quality of Medicare Advantage (MA) and Part D Prescription (PDP) plans in order to help Medicare beneficiaries find a high quality program. Over time the rating system has evolved, with the measures used to rate programs continually changing. In 2012, CMS began tying the rating system to bonuses for MAs. That means a four-star rating or higher not only provides plans with better consumer appeal, but it can add revenue as well.

The performance of your Pharmacy Benefit Manager (PBM) can influence your star ratings, as the drug plan has several measures tied to it. However, the extent to which the PBM addresses these areas can vary widely and with mixed results. It’s important to work with a PBM that shares your business goals and has the people, processes and tools in place to meet performance objectives. A strong PBM partner can positively influence your star ratings and the health of your members, whereas a PBM with less effective programs can negatively impact them. With this in mind, there are five areas to consider in evaluating the performance of your PBM for helping you achieve your star rating goals:

1| Alignment of Your Customer Service Goals

While it sounds basic, several star-rating measures are linked to simply offering beneficiaries a quality prescription benefit with the support they deserve. This includes CMS requirements such as providing a call center with foreign language interpreters and options for the hearing impaired. There are also measures for improving beneficiary access, the number of complaints or members leaving the plan, and the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) rating of the plan.

Working with a PBM that has similar customer service goals and values to your plan can help ensure your members are getting the care they need. A PBM should realize the impact they have on a member’s life, making a difference with a member-focused call center and website functionality. A PBM’s leadership should also provide support to help improve overall star performance. EnvisionRx has a dedicated Star Rating Task Force comprised of senior leadership that understands how we impact a plan’s star rating and continually develops improvements to increase star ratings for our clients.

2| A Strong Compliance Team that Augments Your Staff

With continual regulatory changes, it may be difficult for plans to stay abreast of requirements. A PBM is in a unique position to help plans achieve a constant state of audit readiness and the highest levels of quality. Having a PBM with a strong compliance department can help keep you up to date on changes, improve member outcomes and avoid monetary penalties, while gaining bonuses for high performance. 

Hardwiring CMS’ standards for an effective compliance program into your plan—both directly and indirectly—affects star ratings. Indirectly, compliance programs impact the following star measures:

  • D-01 – Call Center – Foreign Language Interpreter & TTY
  • D-02 – Appeals Auto-Forward
  • D-04 – Complaints about the Drug Plan
  • D-05 – Members Choosing to Leave the Plan
  • D-09 – Getting Needed Prescription Drugs
  • D-10 – Medicare Plan Finder (MPF) Accuracy

The PBM’s performance directly impacts star measures that relate to the elements of an effective compliance program. The beneficiary access and performance problems (BAPP) measure combines information on notices of non-compliance, warning letters, and ad-hoc corrective action plans and their severity. An effective compliance program also includes an appeals process protocol for handling member disagreements to coverage determinations, the timely response to appeals and how often an independent reviewer agrees with a determination. Coverage Determinations, Appeals and Grievances (CDAG) functions continue to be scrutinized by CMS and are the leading source of penalties against prescription drug plans.

In order to get a high star rating and avoid penalties, it is important to have a PBM that has an effective compliance program that monitors and responds to regulatory changes, collects all the necessary data and provides reporting in the formats required by CMS. Additionally, the PBM should be timely in responses and provide the ability to track coverage determinations in real-time. EnvisionRx’s trusted, industry leading experts take a comprehensive and proactive approach to compliance to help plans meet their goals, increase member satisfaction and make a positive bottom-line impact.

3| Technology to Analyze Data and Determine Needed Actions

DUO_office_modern_working_meeting_glass_talking_iStock-881484382_300x200There are numerous regulations and reporting requirements tied to the various star-rating measures. PBMs can be an advocate for health plans by providing detailed plan performance data and reporting. Having a PBM with the technology and flexibility to provide you with the reports you need, when you need them and in the format required is essential to improving star ratings.

EnvisionRx’s data-driven analyses provide plan insight into the network, members and overall performance. Having this oversight allows plans to take action to reduce costs and close care gaps related to overutilization, underutilization, duplication of therapy and drug interactions. Additionally, with our Star Estimator tool, we allow you to track your plan’s progress and make informed decisions about Part D star measure improvement activities and resources. Utilizing our tool enables us to provide our clients with a dashboard that automatically calculates score gaps. It also determines the performance number needed to get to the next cut-point. This is a key component to our stars program.

4| A Comprehensive Formulary Strategy that Adjusts to Market Changes

A high-quality prescription drug plan includes a comprehensive formulary strategy, with several star-rating measures tied to providing the right medications to treat member conditions. Formularies should be determined in consultation with a team of healthcare providers and represent both brand and generic drugs in Medicare Part D eligible therapy drug classes. Having a PBM that ensures positive changes to the formulary throughout the plan year increases member satisfaction and member access. These changes include:

  • Expanding the formulary by adding drugs
  • Reducing cost sharing by lowering the tier of a drug
  • Removing utilization management requirements
  • Updating utilization management requirements to expand coverage based on new FDA-approved indications or compendia use

A PBM that continually monitors the drug pipeline and makes appropriate formulary decisions can help ensure your formulary is evolving with the industry. In order to achieve this, a PBM needs to balance clinical effectiveness, economic impact and member experience.

EnvisionRx formulary options focus on providing high value and low member disruption, rather than chasing rebates. Our Pharmacy and Therapeutics Committee, comprised of independent, external clinicians representing a variety of specialties, meets quarterly to review medications and proactively propose formulary updates. We have found that the member experience improves significantly when you tailor formulary change communications to educate and inform. This mitigates disruption before the point of service, allowing the member to prepare for upcoming changes.

5| Best-in-Class Clinical Programs to Improve Outcomes

Perhaps the most important and strongest weighted measures have to do with encouraging high adherence rates for members taking diabetes, hypertension and cholesterol medications and ensuring members with diabetes receive statins. A Medication Therapy Management (MTM) program is required by CMS for all Part D plan sponsors to ensure covered drugs are used to maximize therapeutic outcomes through improved medication use and reduced risk of adverse events. The effectiveness of the MTM program is determined by the number of Comprehensive Medication Reviews (CMRs) completed. However, this number is constantly changing because currently published star ratings are based on performance two years prior. This makes it difficult to know the exact number of CMRs requiring completion to maintain or improve that current rating.

Therefore, a PBM that lets you choose a completion rate for CMRs, and works with you to analyze past percentages to determine an appropriate target and performance guarantees, can help set realistic goals. An adherence intervention program is not required by CMS, but having a PBM that offers one is key to addressing members who are noncompliant with their medications. With analytics, a PBM can proactively identify non-adherence and intervene to bring members back on track.

DUO_pharmacy-man-pharmacist-talking_shutterstock_429503536_300x200A plan sponsor can conduct their MTM program in-house or use a disease management vendor, but there is a distinct advantage to using a PBM-operated MTM program. A PBM has real-time access to all prescription claims data to help guide CMRs with the most up-to-date clinical picture. This holistic view of the drug claims, call center activity and coverage determinations allows for CMRs where clinicians can provide members with increased access to information regarding their medications. However, not all PBM MTM programs are created equal. To have a real impact on closing care gaps and increasing adherence, it is important to have specially trained nurses and pharmacists conducting interactive, personalized CMRs. Some MTM providers have an automated recording call members and ask them to callback for an appointment or only use students and technicians to complete CMRs, while others require members go to a retail pharmacy to receive a review.

EnvisionRx utilizes MTM-certified nurses and pharmacists, known as Care Navigators, to contact the member directly for CMRs and adherence interventions. Patients can receive advice on their medications, get their questions answered, discuss side effects and cost savings opportunities, and any other barriers to adhering to their medication in the comfort of their home. Care Navigators can identify situations, such as safety issues, care gaps or a lack of adherence, and make recommendations to improve care. Additionally, with our technology platform, Care Navigators receive alerts regarding these Part C and Part D star-measure opportunities so they can discuss the issues with the patient and make a real impact in their care. The member can even be connected with the pharmacy for a prescription transfer or fill during their discussion.

Having this type of comprehensive and personalized care can ensure members are getting the safest, most effective treatment, are adhering to their medications, taking them properly and managing side effects. This not only helps you improve your star rating for CMR and adherence star measures, but it increases member satisfaction with the plan, which affects CAHPS scores and other measures as well.

A Partner to Help You Shine

Your PBM is a critical partner in improving and maintaining your star rating. It starts with a PBM that shares the same goals and values as you regarding member care and plan performance. Your PBM should have a knowledgeable compliance department with thorough appeals processes, and the technology and insight to properly coordinate data and reports. Additionally, clinical expertise is needed to continually update formulary strategies. It is also helpful to have a PBM that can provide an interactive, personalized MTM program. All of these elements can enhance your star rating while improving member outcomes and your bottom line.

Our visibly different approach provides transparent performance to protect your business and the member, delivers bottom-line impact with quality care and increased revenue, and offers quality assurance, ongoing insights and operational flexibility.

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