Dancing as fast as you can? Get ready for CMS’ star ratings

July 10, 2014

Go ahead. Blame Obamacare. It won't make any difference.

David StanleySometimes I think if I hear the word “Obamacare” one more time I will have to scream. My head has already been filled with anyone and everyone's opinions of what's formally known as The Affordable Care Act, from the patient grateful he could have life-saving surgery now that he has insurance to the lady convinced the ACA was to blame for my store being temporarily out of 100-count loratadine tablets.

Everyone has something to say about the new healthcare landscape, and if you've worked in a pharmacy more than a few hours, I don't have to tell you that a good part of what's said lacks any connection to truth, logic, or common sense. Which is why what I'm about to say may surprise you.

The government takeover of your practice is here, and if you don't believe me, you only have to look to the stars.

All right, “takeover” might be too strong a word. And I don't mean you should consult your astrologer. But if you haven't heard of the Center for Medicare and Medicaid's (CMS) star rating system yet, you will. And if you think it won't change your day-to-day work life, you'll be very wrong.

 

The system

It works like this. CMS, the agency of the federal government responsible for administering the Medicare program, has issued “star ratings” for Medicare Advantage and Part D plans since 2008, in a fashion similar to, say, the way AAA might rate hotels along the interstate. A five-star plan is, in the eyes of CMS, “excellent,” while a one-star plan is considered “poor.”

There's an obvious marketing advantage for a plan that can score five stars. After all, why would travelers choose to stay in one-star hotels if they can avoid them? More important, CMS is about to give insurance plans the ultimate incentive to maximize their star ratings. Money.

Stick with me. Your role in all this is coming up soon.

Bonus payments will soon be coming to Medicare plans that can achieve higher ratings, and they won’t be chump change. It's estimated that a move from three to five stars will be worth a $200 million dollar revenue boost to a Medicare Advantage plan, and with that kind of money on the line, you can be sure plans will be doing everything they can to get their ratings up.

 

Your turn

This is where you come in.

Some of the things CMS will be measuring are things a pharmacy can have a direct impact on, such as medication adherence, appropriateness of drug-therapy choices for the elderly, and quality indicators such as ACE/ARB use by diabetic patients with hypertension.

PBMs fighting tooth and nail for a five-star rating are going to be looking for pharmacies that can achieve high scores in areas such as these. And with the top four PBMs handling 57% of retail prescription claims, what they want is what you'll be doing, at the risk of being left out of their networks.

Bottom line, get ready to perform adherence coaching and make MTM calls, because whether you know it or not, I can pretty much promise you that your store's performance is already being measured.

While it's not quite the socialistic world of “death panels” that some people were so convinced was on the way, it is a major change in the pharmacy world, instigated at the behest of bureaucrats in Washington, D.C.

 

Argue all you want

You can argue all you want about whether this is an overreach of government authority  or some well-needed accountability in how our tax dollars are spent. The reality is, like it or not, it's here.

My first venture into this new world went pretty well. Hoping to look good to the plan sponsors who are hoping to look good to CMS, I made a medication reconciliation call to one of my regular customers, who really seemed to appreciate the effort, telling me how nice it was to have an opportunity to sit down and straighten out her medication regimen.  We even managed to clear up a couple of little misconceptions she had about the medicine she was taking.

The end of the call drifted into small talk about this and that. Her final words were an opinion that Obamacare - the whole reason this call she enjoyed so much was being made - “would be the end of the best healthcare system in the world.”

Somehow, I managed not to scream.