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Pharmacy Outcomes Will Make or Break Health Plans In Future

Pharmacy Outcomes Will Make Or Break Health Plans In Future

While about 50% of Medicare Advantage-Part D (MA-PD) plans (covering about 70% of enrollees) are 4-Star or greater, many plans still fail to attain high quality ratings. More importantly, there is some convincing evidence that even the best performers on the Medicare Star scale have a hard time maintaining their excellence. The high turnover rate in the 5-Star plans from 2015 to 2016 illustrates this fact.

So why the struggle? It really comes down to performance on the Part D pharmacy side of the house. As 2016 Star statistics show, the average Part C rating across all MA-PDs is about 4.5, impressive given where many plans were just five years ago. This has helped propel many 3.5-Star plans to 4-Stars over the past few years.

But MA-PD Star scores for Part D are sitting at about 3.5 on average and this creates a clear drag on some plans’ ability to hit 4-Star. Standalone Part D plans (PDPs) actually perform even lower on average for drug measures, sitting at 3.4-Stars for 2016. Scores for standalone PDPs actually dropped from 3.75 in 2015, although some measure changes may have driven at least some of this lackluster performance. Just 41% of PDP plans have achieved at least 4-Star status, and just 32% of standalone Part D members are in such plans – the obverse of what happens in the MA-PD world where seniors are now flocking to high performers. Auto-assignment of Low Income Subsidy (LIS) members has some impact on this statistic.

What can plans do to turn Part D performance around?

  • In general, plans must practice much better delegated oversight of Pharmacy Benefit Managers (PBMs) on compliance and quality issues. Compliance challenges in the Part D world are very notable in recent audit findings, and plans need to remember that better compliance track records will mean better outcomes on survey and other non-clinical measures.
  • On the Part D clinical measures, plans that delegate need to challenge their delegated PBMs to do a better job on non-adherence, drug interactions and safety, and closing drug care gaps. Active management by plans is essential to continue to improve quality.
  • Plans need to practice creative ways to link drug therapy programs with overall care management, by either forging better partnerships with their PBMs, or bringing the quality side in house. The ability to link interventions for “C” medical and “D” drug measures could actually help drive all measures (clinical, member satisfaction, and health outcome) even higher. This is especially important for those in Special Needs Plans (SNPs) and others in active case management. There is no reason why non-adherence and drug gaps should not be fully integrated in Individualized Care Plans (ICPs) and aggressively worked.
  • Plans need to consider a new paradigm. In concert with medical care management and intervention, plans need to identify and stratify their members based on drug gaps and concerns and then place them in various escalating intervention programs: (1) health education and disease management due to drug non-adherence; (2) additional drug utilization and safety management if acetaminophen, opiate over-utilization, high-risk medication and other concerns are present; and (3) ongoing Comprehensive Medication Reconciliation (CMR) and Medication Therapy Management (MTM) for the most at risk.

Given high drug spending and the high costs of drug non-adherence and interactions, the Centers for Medicare and Medicaid Services (CMS) have continually added drug measures to the Star program. The CMS road map for Star continues this trend and may introduce even more complex and sophisticated drug measure suites. In addition, CMS is paying close attention to the moribund CMR measure and will again seek to overhaul MTMP. This will put even more pressure on plans to perform better on the drug side. And with the so-called Medicaid Uber rule bringing quality incentive and performance to all 50 states soon, drug measures should become a more important factor in how plans get rated in Medicaid as well. To succeed, plans need to pursue innovative strategies and technology to bring medical and pharmacy data together and coordinate all aspects of care management.

Marc Ryan

Marc S. Ryan serves as MedHOK’s Chief Strategy and Compliance Officer. During his career, Marc has served a number of health plans in executive-level regulatory, compliance, business development, and operations roles. He has launched and operated plans with Medicare, Medicaid, Commercial and Exchange lines of business. Marc was the Secretary of Policy and Management and State Budget Director of Connecticut, where he oversaw all aspects of state budgeting and management. In this role, Marc created the state’s Medicaid and SCHIP managed care programs and oversaw its state employee and retiree health plans. He also created the state’s long-term care continuum program. Marc was nominated by then HHS Secretary Tommy Thompson to serve on a panel of state program experts to advise CMS on aspects of Medicare Part D implementation. He also was nominated by Florida’s Medicaid Secretary to serve on the state’s Medicaid Reform advisory panel.

Marc graduated cum laude from the Edmund A. Walsh School of Foreign Service at Georgetown University with a Bachelor of Science in Foreign Service. He received a Master of Public Administration, specializing in local government management and managed healthcare, from the University of New Haven. He was inducted into Sigma Beta Delta, a national honor society for business, management, and administration.

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