What is a CMS Star rating?

Centers for Medicare & Medicaid Services (CMS) devised a plan quality performance measurement called CMS star ratings, which involve rating plan performance in four different categories. CMS star ratings are given to prescription drug plans based on their performance in:

1. Drug plan customer service: this includes how well the plan handles member appeals.

2. Member complaints, issues with getting services, and improvement in the drug plan’s performance: this includes how many problems Medicare found with the plan, how often members had problems with the plan, and how much the plan’s performance has improved over time.

3. Member experience with the drug plan: this includes ratings of member satisfaction with the drug plan.

4. Patient safety and accuracy of drug pricing: this includes how accurate the plan’s information is, and how often members with specific medical conditions are prescribed drugs in a safer and clinically recommended manner for the condition.

In a sense, a Part D prescription plan’s CMS star rating is a brief snapshot of the quality of the plan, based on customer feedback on the 4 categories. Thus, the star rating provides a great way to compare performance among different plans.

How do Star Ratings affect my pharmacy?

Although CMS Star ratings are only given to prescription drug plans, adherence to certain guidelines increase your pharmacy store performance measurement, which can be found through EQuIPP. In a nutshell, Medicare Part D plans are now evaluating the performance of their pharmacy network providers. Some plans such as SilverScript have publicly announced that they are improving standards in their networks by dropping poor performance pharmacies. These plans want pharmacies that have healthy and happy patients, which would lead to great customer feedback and higher CMS Star Ratings for the plans. Thus, many of the 2016 plans now have DIR (Direct and Indirect Remuneration) Fees that are directly based on your pharmacy’s store performance measurement. The better your store performance is, the lower your DIR fees will be!

Where does iMedicare come in?

Pharmacy performance measurements are determined by the overall health of the patients at your pharmacy. There are numerous factors that contribute to your pharmacy’s performance measurement, which can be located in our DIR Fees document under the Reports section in iMedicare! Out of the 7 different factors, the one most heavily weighted is diabetic patients not on statin therapy, making up 25% of your store’s performance measurement. iMedicare helps you identify those patients through the Star Ratings – Interventions report. All diabetic patients not on statin therapy at your pharmacy will be listed, and you can reach out to the patients' physicians to recommend prescribing a statin. Thus, your store performance measurement will be improved significantly through the usage of the Star Ratings – Interventions report.

How does this all relate to one another?

CMS' mission statement is to “Optimize health outcomes by leading clinical quality improvement & health system transformation”. By introducing the star ratings system, CMS wishes to incentivize both plans and pharmacies to improve patient health and happiness. Standards of plan service and pharmacy provisions will be elevated as the star ratings system continues to be refined.

With the powerful Star Ratings - Interventions tool in hand, you will be able to improve your pharmacy store performance measurement, receive higher reimbursements due to lower DIR fees, and feel like a Hollywood star!

As always, if you ever have any questions or concerns, definitely reach out to our team at iMedicare and we’ll be more than happy to answer them for you!