3 ways pharmacies can build CMS Star Ratings


Community pharmacies competing with preferred pharmacy networks can sharpen their game by focusing on some of the things they do best.

Pharmacists can adapt to the evolution of their industry by understanding treatment guidelines, learning about local physician practices, and improving patient adherence, a leading pharmacist told an audience at the recent McKesson ideaShare conference in San Diego.

All these actions contribute to quality healthcare, which Medicare is now tracking to a greater extent than ever before. This matters

Janelle Ruisingerto pharmacists because they’re increasingly facing pressure to join preferred networks that link them to the success or failure of health plans.

“Medicare Star ratings are now available to our consumers, to the public. They help our Medicare patients choose which plan to enroll in. Plans with higher ratings will get incentives, better marketing, maybe year-round enrollment. Plans with low Star Ratings may be excluded or risk losing their CMS contract,” said Janelle Ruisinger, PharmD, clinical associate professor at the University of Kansas School of Pharmacy and director of the KU Community Pharmacy Residency Program.

See also: How retail pharmacists can help heath plans with CMS Star Ratings

Diabetes and statins

According to Ruisinger, who spoke at a session titled “Positively Impacting Performance Measures One Patient at a Time,” diabetes is one area that offers opportunities for pharmacists to boost patient health.

See also: Pharmacists must be proactive to improve Medicare Part D Star Ratings

Rates of diabetes are increasing, raising the question of how many diabetes patients should be on cholesterol-lowering drugs.

“Which patients with diabetes should be on a statin?” she asked. “The oversimplified answer is ‘All of them.’ But the true answer really depends on which guidelines and standards you’re following.”

The challenge, Ruisinger said, is that guidelines differ on the subject of who needs statins and who doesn’t, with the American College of Cardiology/American Heart Association, National Lipid Association, American Diabetes Association, and American Association of Clinical Endocrinologists offering various perspectives.

In order to obtain assistance from physicians, it’s crucial to understand which guidelines are popular among local doctors, she said. When it comes to treating patients, “it’s important that everyone is on the page and following similar guidelines. But it can be a little bit confusing.”

What if a patient doesn’t fall within the guidelines?

“Consider the benefits vs. risks and determine whether it would be appropriate to put that patient on statin therapy,” she advised.

Medication nonadherence

As for adherence, Ruisinger said, hospitalization costs associated with medication nonadherence are estimated at $100 billion annually. And each nonadherent patient costs an estimated $2,000 a year in extra physician visits.

“Typical adherence rates for patients with chronic illness are 50%,” she said. “Our patients take their medications about half the time.”

In some cases, patients refill prescriptions but never take them. In others, they never fill them in the first place.

“If your patient has diabetes and heart disease and they don’t adhere to their regimen, they’re twice as likely to die as a patient who does take their regimen,” she said. “It’s not only expensive, but can be very detrimental to our patients.”


Adherence vs. compliance

What to do? First, understand what adherence is.

“Adherence and compliance are not interchangeable,” Ruisinger said. “Adherence conveys a message of collaboration in which the patient is working with providers on mutually agreed-upon regimens.”

One common rule of thumb, she said, defines high adherence as when a patient takes prescribed medication at least 80% of the time.

“Let’s say the patient is taking one pill once a day. When you’re looking at 30 doses, they have to take 24 to be considered to be considered minimally adherent - 80% of the time.” 

The good news: “As we increase adherence, overall costs drop,” she said.

Adherence strategies

According to Ruisinger, pharmacists can improve adherence in a variety of ways:

  • They can help patients take medications correctly through the use of tools such as medication synchronization, pill boxes, and adherence packaging, and work with them to build medication-taking into their daily routines.

  • They can provide clear instructions, offer resources for patients who need more information, and help low-income patients who need find financial assistance to find it.

  • They can talk to diabetics about why it’s crucial to control blood glucose and address misplaced beliefs about insulin, sugar consumption, and the seriousness of diabetes.

Randy Dotingais a medical writer in San Diego.

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