BETHESDA, MD 21 Dec 2016—The Centers for Medicare and Medicaid Services (CMS) in October awarded five stars for overall quality—the highest rating possible—to six high-performing Medicare Part D prescription drug plan sponsors.
The star ratings are based on performance data from 2015 and, for the first time, take into account whether Medicare enrollees receive a complete medication review (CMR) as a component of their Part D plan's medication therapy management (MTM) services.
CMRs may be conducted by a pharmacist or other healthcare provider and must include a written summary of the evaluation and an action plan to improve the patient's medication use.
But the CMR measure has little apparent effect on the drug plan sponsor's overall star rating.
David Chen, senior director of ASHP's Section of Pharmacy Practice Managers, said CMS and Part D plans have made great strides in providing MTM programs for Medicare beneficiaries.
"The program can continue to improve if CMS facilitates the connection of medical, prescription, and MTM services to overall patient outcomes by including local pharmacists on the MTM team," Chen said.
He also called for full disclosure about incentives that Part D prescription drug programs offer to MTM service providers and about penalties the providers face when they fail to meet the MTM elements specified in plan contracts.
"The lack of transparency makes it extremely difficult for pharmacies to understand how plans are managing data and translating the plan's responsibilities to CMS down onto individual pharmacies," Chen said.
Just one of the five-star overall performers—Blue Cross Blue Shield (BCBS) of Michigan Mutual Insurance Company—also earned five stars for its MTM services. The drug plans operated by the organization provided coverage for nearly 47,000 Medicare beneficiaries last year, according to CMS.
Among the other five-star Part D prescription drug plan sponsors, one earned two stars for MTM performance and two each had three or four stars for MTM services.
The MTM measure is based on the percentage of Part D enrollees who qualify for and opt to receive MTM services and who have at least one CMR. Drug plan sponsors began reporting CMR completion data to CMS in 2015, and 2016 was the first year that CMS released star ratings for that MTM measure.
The CMR completion rate for five-star BCBS of Michigan Mutual Insurance Company was 51.6%. CMR completion rates for the other five Part D plan sponsors with a five-star overall rating ranged from 12.6% to 42.1%. The highest CMR completion rate for any Part D plan sponsor in 2015 was 57.9%, and the lowest rate was 0%.
Julie Kuhle, vice president of measure operations for the Pharmacy Quality Alliance, said the CMR completion rate measure doesn't reveal much about the quality of the Part D plan's MTM services.
"The CMR measure is a process measure," Kuhle said. "It only shows that a CMR was done, not the quality of the CMR or how that service affected the patient's medication use."
PQA's mission is to support the development of performance measures to improve the quality of medication management and use. ASHP is a PQA member organization.
"We are very much interested in proposing, developing, and endorsing new measures into the MTM program for Part D that show what MTM services really do. That's good for patients, and it's good for pharmacists, too," Kuhle said.
She said one factor that likely contributes to the low CMR completion rates for Part D plan sponsors is the possibility of misaligned incentives.
"The savings are realized on the medical side, which Part D plans don't have responsibility for," Kuhle said.
Star ratings. Medicare's star ratings were developed to support the National Quality Strategy, which was unveiled in 2011 as required under the Patient Protection and Affordable Care Act.
According to CMS, the star ratings are consistent with the National Quality Strategy's priorities, which include reducing harm caused by the delivery of healthcare; promoting patient engagement, effective communication, and care coordination; providing effective care that saves lives; supporting healthy communities; and developing healthcare delivery models that are affordable for patients, payers, and other stakeholders.
From the patient's perspective, a Part D plan sponsor's star rating is meant to convey information about customer service, complaints and performance improvement, and enrollees' experiences with drug safety and the accuracy of drug pricing information.
CMS requires Medicare Part D drug plans to offer MTM services, and the agency has established a minimum threshold for targeting enrollees for the services.
In general, MTM services must be offered to enrollees who have two or more chronic diseases, take multiple Part D–covered drugs, and have estimated drug spending that exceeds a CMS-established threshold. Drug plan sponsors have some leeway to customize their programs, but the details must be approved by CMS.
For 2017, MTM services in the drug plans offered by five-star BCBS of Michigan are available to enrollees who have two or more qualifying health conditions, take at least eight Part D–covered medications each month, and spend at least $3919 on Part D prescription drugs annually, according to the program's website.
The spending threshold for MTM services in 2017 is $3919, up from $3507 in 2016 and $3138 in 2015.
Beneath the stars. CMS has acknowledged that Medicare beneficiaries aren't getting the full benefits of MTM services from their Part D drug plans.
"Evidence suggests that the MTM services currently offered by Part D plans fall short of their potential to improve quality and reduce unnecessary medical expenditures," CMS stated in an October 2016 communication.
According to the agency, misaligned financial incentives and regulatory constraints may prompt Part D plan sponsors to invest in MTM services "only at a level necessary to meet the minimum compliance standards."
And CMS acknowledged in November 2015 that its star ratings system may create "perverse incentives" for Part D plan sponsors to undermine the effectiveness of their MTM programs.
Such activities could include attempts by Part D plan sponsors to restrict eligibility for their MTM programs or encourage beneficiaries to opt out of the programs, CMS stated.
In a bid to improve MTM services, CMS developed an enhanced MTM model that's being tested by 22 drug plans offered by five Part D program sponsors. The pilot project started in January and will run for five years. The participating organizations serve about 1.6 Medicare beneficiaries in five U.S. regions, according to CMS.
Of the six Part D plan sponsors involved in the enhanced MTM project, three earned one star for MTM services in 2015, one earned two stars for MTM services, one earned three stars, and one earned four.
Lisa Hines, director of performance measurement for PQA, said the pilot project could help improve the science of MTM and promote innovation by Part D plan sponsors.
"I hope that we can gather some rich information from the participating plans to show an improvement, at least, in intermediate outcomes with MTM services . . . and a positive impact on quality and decreased costs with the appropriate alignment of financial incentives," Hines said.