Medicare Part D plans are given a star rating (1 to 5 stars) by the Center for Medicare and Medicaid Services (CMS).  These plans are judged based upon 17 different measures, with five specifically dealing with drug therapy.  These five measures are as follows:

  • Percentage of beneficiaries (65 years or older) who received two or more prescription fills for the same High Risk Medication  (HRM) drug.  A lower percentage is preferred.
  • Percentage of patients who received appropriate hypertension treatment (ACEI/ARBs) for patients with diabetes.  When people with diabetes also have high blood pressure, there are certain types of blood pressure medication recommended depending on which diabetes medication the patient is on. A higher percentage is preferred.
  • Proportion of Days Covered (PDC) - patient's adherence to oral diabetes medications. A higher percentage is preferred.
  • Proportion of Days Covered (PDC) - patient's adherence to cholesterol medications (statins). A higher percentage is preferred.
  • Proportion of Days Covered (PDC) - patient's adherence to hypertension medications (ACEI/ARBs). A high percentage is preferred.

There are also Display Measures for Part D plans that are related to drug therapy.  A display measure is different than a quality measure because they do not directly affect the star rating of a plan but they ARE used to provide benchmarks and feedback to plans. One display measure on which pharmacies have an impact is the percentage of patients receiving excessive doses of oral diabetes medications.  Obviously a lower percentage is preferred.  Another display measure involving pharmacy performance involves drug-drug interactions (DDI). This measure is defined as the percent of Medicare Part D beneficiaries who received a prescription for a target medication during the measurement period and who were dispensed a prescription for a contraindicated medication with or subsequent to the initial prescription. Pharmacists should work to avoid adverse drug events from interactions between a patient's medications.

So How Does This Relate to Pharmacy Performance?

Systems such as Electronic Quality Improvement Platform for Plans & Pharmacies (EQuIPP) can track a pharmacy's performance based upon these measures. Through EQuIPP, pharmacies can obtain their scores on star rating quality measures based on data from health plans or PBMs.  Pharmacies do not receive an actual star rating, but these percentage scores serve as a point of comparison to other pharmacies in the area.  This is not yet an exact science.  Often times, the number of patients does not exactly line up with the number of patients in a particular pharmacy. The pharmacist must pay attention to the discrepancy in patient number.  The score one receives is then compared to the general EQuIPP average, the organization average, and the state average.  According to David Pope, PharmD, founder of Creative Pharmacist, other programs like this exist, but the CMS will primarily be referencing information from EQuIPP.

Why Does Pharmacy Performance Matter?

About a month ago, SilverScript announced that they will be implementing a network performance program effective immediately. All retail pharmacies in the CVS/Caremark Medicare Part D network for SilverScript are eligible to participate. From May 5, 2014 until December 31, 2014, participating pharmacies will be scored on the following:

  • Enrollee adherence to diabetes, antihypertension, and cholesterol medications (CMS Part D Star Rating measures 3, 4, 5 mentioned above)
  • Appropriate drug therapy for patients with diabetes and hypertension (CMS Part D Star Rating measure 2 mentioned above)
  • The percent of CMS Star drugs you dispense as an extended days supply (greater than or equal to 84 - 90 days which is shown to improve adherence)
  • Your overall generic dispensing rate for SilverScript enrollee prescriptions (can lower overall drug costs)

These different categories are weighted differently with the first criterion being 70% of the final score, the second criterion 15%, and the third and fourth criteria at 7.5% each.  CVS/Caremark teamed up with Mirixa, a Medication Therapy Management provider, to create the web-based Mirixa-Pro system.  Participating pharmacies with Mirixa may use this tool to improve their star metric performance.  Those pharmacies not affiliated with Mirixa may use their own performance tools.

The goal of this type of program is to encourage better performance by rewarding higher scoring pharmacies through performance payments. On the flipside, pharmacies with lower performance scores may be dropped from preferred networks. Currently SilverScript is a pioneer in the field of network performance programs but David Pope, PharmD, is confident that these will soon become commonplace as trends in healthcare move from focusing purely on reducing cost to emphasizing quality maximization.  He believes more organizations will follow in the footsteps of SilverScript.  Pope recommends that pharmacies take an active approach and start paying attention to their star metric performance before it is too late!

How can iMedicare help you take charge of your pharmacy’s star rating?

Here at iMedicare, we believe in actionable patient-specific changes to each drug regimen to improve their health and increase your pharmacy's Star Rating measures. EQuIPP will provide your pharmacy with a score for each category that you can compare to other pharmacies locally, and nationwide. iMedicare does not provide a score, but instead, will show you exactly how you can increase your performance in certain areas.  Our first addition to our Star Ratings report addresses the measure involving the appropriate drug therapy for patients with diabetes and hypertension. Since we integrate with virtually all software systems, iMedicare can generate a report showing diabetic patients in your pharmacy that are not currently on an ACEI/ARB.

You will be able to see immediately who can benefit from an intervention. We have also included a automatically customized letter that you can send to the patient’s physician to see if a change in their drug regimen is appropriate.  One more thing that only iMedicare can do is show you how much it would cost the patient if they were to be placed on an ACEI/ARB.  All the pharmacist would have to do is click “Import” on the left, and in a matter of seconds, add a specific ACEI/ARB to the patient’s profile to check out the change in monthly cost for their Part D plan.  Very soon, we are planning to add a High Risk Medications section to our Star Ratings report. We are constantly adding features to better help our customers!  Our aim is to provide ways for the pharmacist to take control of their performance as well as help their patient’s health.