Jun 26 2020

Discover How PrimeRx™ Distinguishes Your Pharmacy with "5-Star" Service Levels

How is it possible the nation's pharmacies have a laser-like focus on a rating system that doesn't even apply to them?

It's possible when the rating system involved is the Medicare Part C and Part D Star Ratings. Pharmacy performance affects a significant percentage of a prescription drug plan's overall score.  Thus, as plans consider which pharmacies to list as "preferred partners" for its beneficiaries, they will naturally want to steer patients to pharmacies that excel in ratings-related criteria.

The star ratings system was implemented in 2008 by the Centers for Medicare & Medicaid Services (CMS) as a way to measure quality and effectiveness of participating plans.  Medicare Advantage (Part C) and prescription drug plans (Part D) are assessed each year and awarded a star rating between one and five, based on performance on specific measures.

Each year, CMS publishes the star ratings ranking, which allows patients to compare plan performance, and to incentivize each plan to improve its score.  In addition, star ratings can be the basis for financial incentives for some plans and providers. 

In 2020, approximately 52% of Medicare Advantage plans with prescription drug coverage earned 4 stars or higher.  In terms of enrollment, CMS reports roughly 80%  of MA-PD enrollees will be registered for plans with at least 4 stars. 

Among stand-alone prescription drug plans active in 2020, approximately 30% have received at least 4 stars, accounting for coverage of about 28% of plan enrollees.

With pharmacy-performance tied to many of the rating criteria, a pharmacy committed to excelling in those particular areas would help plan managers increase their ratings.

Prescription drug considerations

  • Medicare plans that cover prescription drugs are assessed on factors that include:
  • Drug plan customer service:  How well the plan handles member calls and questions.
  • Member complaints and changes in the drug plan’s performance:  How often members had problems with the plan.  This includes how much the plan’s performance improved (if at all) over time.
  • Member experiences with the drug plan:  Member ratings of the plan.
  • Drug safety and accuracy of drug pricing.  Assesses accuracy of the plan’s pricing information and the frequency with which members are prescribed drugs in a way that is safe and clinically recommended for their condition.

Within these broad categories are several considerations that directly relate to pharmacy performance.  These factors include:

  • Ease of getting prescriptions filled when using the plan.
  • Accuracy of the plan in providing drug pricing information.
  • Diabetes, blood pressure, and cholesterol medication adherence:  Percent of plan members with prescriptions for these conditions “who fill their prescription often enough to cover 80 percent or more of the time they are supposed to be taking the medication.”
  • Members who had a pharmacist (or other health professional) help them understand and manage their medications. 
  • Extent to which patients with diabetes are taking drugs to treat high cholesterol. 
  • Plan members’ complaints about prescription drug coverage.
  • Comprehensive medication reviews (CMRs) were added to the list in 2017, as a way for CMS to assess the quality of medication therapy management services provided to Medicare beneficiaries.
  • Statin use for treating diabetes.

According to analysis by McKesson, pharmacy-related measures are weighted heavily and can impact up to 50 percent of a Medicare plan’s overall star rating.  It’s easy to see then, why plan administrators scrutinize pharmacy performance and only want to engage with high-performers.

Pharmacies can rely on their technology systems to satisfy pharmacy-related quality measurements.  A comprehensive pharmacy management system, such as PrimeRx™, will offer capabilities that include:

  • Medication Adherence
  • Comprehensive patient medication reviews
  • Management of statin-eligible patients
  • Assistance in obtaining medications
  • Outbound communication capabilities.

While it's true that pharmacies are not specifically subject to the Five-Star Ratings System, it's also true that positioning itself as a "Five-Star Champion" can boost a pharmacy's appeal to plan managers.