Win-win: How retail pharmacists can help health plans with CMS Star Ratings measures


Health plans that have not scored at least three stars for the last three consecutive years will be vulnerable to elimination from the Medicare system. Pharmacists are in an ideal position to help with those scores.

Starting next year, Medicare health plans that have achieved three, four, or five stars in the Medicare Star Rating system are in a good position to continue to serve their beneficiaries. Health plans that have not scored at least three stars for the last three consecutive years will be vulnerable to elimination from the Medicare system.

Dan BenamozThe Medicare Star Rating program, created in 2007 by the Centers for Medicare and Medicaid Services (CMS), enumerated quality measures for health plans to meet and for Medicare beneficiaries to use in making informed decisions about healthcare enrollment. Of the performance measures now in place, half can be directly affected by community pharmacists working with the health plan.

“If anybody can say anything positive about the Affordable Care Act, we are finally putting accountability into the system. We are trying to get all the different health professionals that are operating in silos to start coordinating with each other, with the ultimate focus on better care for the patient,” said Dan Benamoz, RPh, founder and CEO of Pharmacy DevelopmentServices, a consulting services company for independent pharmacy owners. “So the government is going tohold people accountable for results.”


Weighted performance measures

In 2012, a new weighting system for performance measures was instituted for Medicare Advantage plans and Medicare prescription drug plans. Of the 10 triple-weighted measures, eight are related to medication therapy and can be influenced directly and indirectly by pharmacist interventions. Three measures that pertain to chronic disease management in Medicare Advantage plans are health services measures (Medicare Part C). They include:

• Diabetes care and blood sugar controlled

• Diabetes care and cholesterol controlled

• Controlled blood pressure

The five triple-weighted performance measures of the Medicare prescription drug plan (Part D) that pharmacists can influence are:

• High-risk medications in the elderly. This measure is adapted from the HEDIS measure, which involves a list of medications that places adults older than 65 years at high risk of adverse drug-related side effects. It was derived from the Beers criteria and updated in 2012 by the American Geriatrics Society.

• Diabetes treatment for individuals who also need treatment for hypertension. This performance measure demonstrates the percentage of patients with diabetes and hypertension who are receiving a renin-angiotensin system antagonist: ACE inhibitor, angiotensin-receptor blocker, or direct renin inhibitor.

• Medication adherence to oral antidiabetic medications

• Medication adherence to renin-angiotensin system antagonists

• Medication adherence to statins

High medication adherence is defined as more than 80% of days covered by a patient receiving the medications.


Preparing for CMS Star Ratings

Tony WilloughbyLast year, Health Mart launched a series of town hall meetings across the United States, inviting more than 2,500 of its participating pharmacists to learn about value-based reimbursement, the quality measures, and CMS Star Ratings.

This year, Health Mart is offering another series of town hall meetings to focus on the five medication-related quality measures noted above and to help pharmacists create action plans for their practices and communities, said Tony Willoughby, vice president and chief pharmacist, Health Mart.

First, he noted, it is important for pharmacists to leverage the long-term relationships they have with patients and to embrace behavioral coaching to improve outcomes.

“All the Medicare Part D performance measures, whether for medication adherence, the addition of medication, or a suggestion for alternative therapy, involve a behavioral change for patients. They have to do something differently,” Willoughby said. “What we find is that patients who come into our pharmacies are much more open to that type of coaching from pharmacists because of the long-term relationships that they have with them.”

This year’s ideaShare meeting introduced motivational interviewing techniques to help pharmacists communicate with patients and overcome barriers to medication adherence.

“We have taken pharmacists’ testimonials and leveraged those in a playbook released at our meeting that walks them through the patient encounter. In adition to providing education and intervention resources, we also understand the power of coaching. That is why we have formed an exclusive partnership with PDS to offer Health Mart pharmacies access to PDS coaching services,” Willoughby said.


Medication synchronization

Medication synchronization - the process of coordinating a patient’s medications so that they are filled and dispensed at the same time every month - has been demonstrated to have a positive impact on medication adherence. This in turn will help boost the pharmacy’s the medication adherence performance measures for the CMS Star Ratings program.

The average patient with a chronic condition picks up his medication approximately seven to eight times in a 12-month period. With the implementation of a medication synchronization program, the patient picks up his prescriptions approximately 10 to 11 times during the 12-month time frame.

“By taking control of when the prescriptions need to be filled within your store by a certain date, you understand your productivity day by day. This not only frees up time to provide other patient-centered services, but most important, gives the pharmacist a better view of the patient’s pharmacy record, to allow the pharmacist to identify medication-related interventions,” said Willoughby.

“If a diabetes patient is taking a diabetic medication and a hypertensive agent, but it is not the right one from the guidelines, this is a great opportunity to have that conversation with the patient. It facilitates a lot of positive principles in the way that we practice,” he said.


Medication therapy management

Benamoz of Pharmacy Development Services offers his members the SyncRx medication synchronization program for improved medication adherence and SyncRx+-a system for increasing the five quality measures by adding a medication therapy management component. SynchRx+ allows the pharmacist to do a comprehensive medication review in just seven minutes.

In addition to SyncRx and SyncRx+, Benamoz recommends providing patients with compliance packaging, so that all medications are organized for different administration times.

“Any time you want to change anybody’s behavior, you have to make it as simple as possible. That is what compliance packaging is,” Benamoz said. “I have yet to meet in five years an owner who wishes he could go back to the old way of dispensing. They all love it. They can organize their workflow and it allows them to shift the bottlenecks to off-peak hours.”

Pharmacists who haven’t yet implemented medication synchronization need to start by focusing on their Medicare Part D patient population, Benamoz said. He suggested identifying Medicare beneficiaries who are taking 10 or more medications and working with them on medication synchronization.

“Start with 10 to 15 patients when starting a medication synchronization program. To do all your patients overnight is a recipe for failure,” he said.



Examination of pharmacy performance using the EQuIPP scores is also necessary. EQuIPP stands for the Electronic Quality Improvement Platform for Plans and Pharmacies. According to the authors of a report about the Medicare Star Ratings published in the May/June 2014 Journal of the American Pharmacists Association, EQuIPP is a performance information management platform that “brings a level of standardization to the measurement of the quality of medication use and makes this information accessible and easy to understand.”

EQuIPP is available to health plans and community pharmacies at

All the triple-weighted Part D performance measures have been included in EQuIPP, so pharmacists can compare their pharmacy’s performance to that of other pharmacies in their region or state. Once pharmacists know which patients are having difficulty with medication adherence, they can initiate conversations to uncover barriers to adherence and also practice motivational interviewing techniques during medication therapy management sessions.

Pharmacists need to rise to the challenge to help improve medication adherence - and ultimately the Medicare Star Rating scores, said Benamoz. This will become important as health plans evaluate their pharmacy partners and reward pharmacies that perform well on the Star Ratings measures.

“Independent pharmacists need to embrace change, because that is where most of the opportunities come from,” he said.

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