1. Engaging the Community Pharmacy Team in Medicare Star Ratings
Mitzi Wasik, PharmD, BCPS
Director, Government Pharmacy Programs
October 24th, 2013
Renaye Phillips: Good evening and welcome to the Drugstore News Continuing Education Webinar, "Engaging the Community Pharmacy Team and Medicare Star Ratings" supported by Drugstore News. My name is Renaye Phillips, and I'll be your moderator. Our speaker this evening is Dr. Mitzi Wasik, Director of Government Pharmacy Programs at Coventry Health Care, where she oversees clinical pharmacy programs supporting star's measures and case management. Dr. Wasik received her Bachelor of Pharmacy and Doctor of Pharmacy degrees from Midwestern University, Chicago College of Pharmacy. She was involved for eight years in clinical practice at two different colleges of pharmacy in the ambulatory setting. And besides ambulatory care, Dr. Wasik's clinical experience includes internal medicine, family practice, women's health, anti-coagulation clinic, and community pharmacy. She is very involved in the Academy of Managed Care Pharmacy and currently sits on the Board of Directors.

2. Program Logistics Participation: asking questions and answering polls
Slide handout is available via “event resources” in the lower left of the screen
Process for CE credit – view entire program and complete evaluation
For assistance with technical problems click on the question mark in the right corner of the screen
Renaye: There's going to be some polling questions during the presentation that will ask for your participation, and following each question the results from the polling questions will appear on your screen. You will then need to click in the right-hand corner of the results box to close it, and then the presentation will continue to progress on its own.
If you would like to download a copy of Dr. Wasik's slide presentation, you can do this. All you have to do is click on the "Event Resources," and that's in the lower left part of your screen.  Please remember that to receive your credit, you must participate in the entire webinar and then complete a short program evaluation at the conclusion. Your statement of credit then will be available in your CE test history folder. That's on the Drugstore News Continuing Education website in approximately seven days.

3. Support
This lesson is supported by an education grant from Voice Port

4. Disclosures
Mitzi Wasik and the DSN Continuing Education team do not have any actual or potential conflicts of interest in relation to this CE activity

5. Objectives
Explain the Medicare Star ratings’ metrics related to the pharmacy benefit
Describe how Star ratings impact Medicare reimbursement
Identify changes to the Medicare Star ratings in 2013
Evaluate the engagement of consumer’s awareness of Medicare Star ratings
Formulate a method to support the Star ratings in community practice
Dr. Mitzi Wasik: Thank you for that introduction, Renaye. Good evening, everyone, and thanks for joining us on this beautiful Thursday evening. Hopefully, some of you are in warmer climates than I'm sitting right now.
What we're going to talk about today is the Medicare star ratings, and so just to go over the objectives very quickly, I am going to go into detail about what the Medicare star ratings are and how they relate to the pharmacy benefit; how they impact Medicare reimbursement; and then some of the star rating changes that we've seen over the past year and some that we might see going into the future.
We will also look at the engagement of consumers' awareness for the star ratings, and at the end and throughout the presentation, we'll talk about community pharmacy practice and supporting the star ratings.

6. Why STARS Ratings? Quality driven healthcare
Push for value and quality in the healthcare system
Putting the patient first
Overall goal: Improving value and quality while decreasing costs
So to begin -- why star ratings? And why did CMS put these ratings out and hold the health plans responsible for them? And I think what we're seeing in the industry, as a whole, is really that drive for quality health care, and it's starting on the Medicare side. And I think as the marketplace becomes bigger and gets launched, we're really going to see some of that quality filter over and be more accountable in the commercial side and, right now, to some extent, it is out there in the Medicaid line of business.
And so it's really pushing for that value and quality, and the main thing, if you look at the entire picture of stars, we are only going to get into the Part D stars today. But if you look at the entire picture, everything puts the patient first. And so it really relies on what does the patient think about their plan? Did the patient have any appeals or grievances to their plan? And so at the end of the year, there's a big calculation that kind of goes over everything, and it puts a rating next to our health plan.
So the overall goal that CMS has really turfed us with is to improve the value and quality that our patients receive while also decreasing our costs.

7. Medicare Ratings-Part D
Patient Safety Measures (PSM) have been adapted from
PQA (Pharmacy Quality Alliance)
The 5 triple weighted Patient Safety Measures have all been adapted from PQA
HEDIS
Consumer Assessment of Healthcare Providers and Systems survey (CAHPS)
Health of Seniors survey (HOS)
So just to start the basics of the Medicare rating, Part D, what we're going to talk about today are the patient safety measures. And these measures have been adapted from a few different sources. Many of you may be familiar with the Pharmacy Quality Alliance, and this is a group that, for the five triple-weighted pharmacy measures that I work on in a day-to-day basis, they have created those measures, and they continue to maintain them.
They're also a group that, you know, they have many workgroups. I sit on one of them, and they're constantly looking at health care and how can we drive quality further? And so they're identifying gaps in care in the industry and making measures around this and then they submit these to the NQS and then CMS can choose to adapt and hold the health plans responsible for these measures or take bits and pieces from it.
Other areas that patient safety measures are pulled from are HEDIS, and some of you may be familiar with HEDIS. On the commercial side with the NCQA, but the Part C measures that we won't talk about today but the other side of stars, these are really HEDIS-driven, so we think about osteoporosis, did a patient get a BMD, or starting osteoporosis therapy within six months of diagnosis?
The two last bullet points -- the CAPS and the HOS surveys -- this is really looking at how do consumers rate their plans? And CMS will actually send out surveys to members of our health plans, so at Coventry Health Care, CMS will pick a population of our members, and they'll send them surveys to say, you know, "How do you feel that you're getting treated?" "Do you have access to your provider networks?" And really take that back, and that's part of our overall rating at the end of the year.

8. Medicare Ratings – Part D
PDP and MA-PD Medicare plans are rated on overall on quality
Includes 4 domain scores with 15 individual measures
The first year a measure is included, it is weighted as a “1”
The next year the weight may be adjusted
Measures are weighted 1x, 1.5x, or 3x
Weight is dependent on category
All 5 Patient Safety Measures are 3x weight
For PDPs these measures account for ~30% of overall rating
For MA-PDs these measures account for 20% of overall rating
So just to kind of extrapolate a little bit more, PDP and MAPD Medicare plans are rated overall on quality. So a PDP plan, just to kind of level-set everyone, is a contract that only manages the pharmacy benefit, where the MAPD plans -- that manages the medical and the Part D benefit. So for my job, I oversee both PDP and MAPD but, really, the focus goes a lot to the MAPD with the medical and the pharmacy.
These ratings include four domains and 15 individual measures. In the first year, a "measure" is included in our rating. It's weighted as one. So if we get four stars, it's just weighted towards one aspect of the overall rating. The next year -- and usually it takes about two to three years -- CMS can either make that weighting a one and a half or a triple-time weights. And so we have the three different types of weights, and it depends on what category those measures fall into.
All five of the patient safety measures that are on the Part D, the drug benefit, are triple weighted, and, honestly, in the past two years, positions like mine within health plans at PBMs came about because these measures became triple-weighted. So if you look at the big picture, for a PDP plan that is only the drug benefit, just these five measures account for 30 percent of the overall rating.
And then the MAPD -- this accounts for about 20 percent of the overall rating. So, at the end of the day, when you look at all the measures that's taking a big chunk of the rating, and so we need to really focus on this, and these are really the outcomes-driven measures that -- I'm going to go into detail here in a few minutes.

9. STAR Ratings Ratings range from 1 to 5
5 is the goal, 1 is not!
Plans that perform overall less than 3 for 3 consecutive years are at risk for losing their contract
If a plan receives < 3 stars
There is an indicator online to alert the beneficiary
Beneficiaries may not enroll in these plans online, enrollment must be done via phone
Enrollment in 5 star plans can occur at any time (rolling AEP)
So what is the goal? The ratings for a stars measure is 1 to 5. Five is the goal, 1 is definitely not. Plans that get an overall score, less than 3 for three consecutive years can actually have their contract taken away by CMS. If they receive less than that three stars, there's actually a lot of barriers that are put up for members to enroll.
When patients go on the Medicare plan finder, there's an icon next to that contract to alert the beneficiary that this is a low-performing contract in regards to quality. Beneficiaries, patients, are not allowed to enroll in these contracts on line. They have to call the Medicare number. So as we see these younger older adults get into Medicare, you know, that's not really in how they function. They want to be able to enroll online, see all their options, and so that puts up a barrier for them.
One of the bonuses of being a five-star plan other than the reimbursement is members can enroll in your plan at any time. And many of you are probably familiar with the annual enrollment period, which we're currently in, where older adults have a certain timeframe to enroll into a plan, and once they're locked into that plan, they have to stay for the year, unless they're in a low-performing plan or a plan that's not five stars. A five-star plan can have a rolling enrollment of these beneficiaries. So it's definitely a benefit to them and their overall membership growth.

10. STAR Ratings PDP and MAPD are rated on separate curves
Each contract is individually rated on an overall score as well as individual scores per measure
The curves are set from a national perspective
There is no regional adjustment
For Part D Patient Safety 4 Star Thresholds have been given for 4 of 5 measures (new in 2013)
So when you look at the ratings, the ratings are done on separate curves. So I mentioned PDP's drug benefit only, MADP is medical and the prescription benefit. And so when you look at the two, they're calculated differently, and I'll kind of show you some examples of that later on in the presentation.
Each contract is individually rated as an overall score as well as individual scores per measure. So right now if I was enrolling into a Medicare plan, it's almost set up like Yelp or Amazon. I think that's probably what most of us are familiar with where there is a star category next to it. So that it will be one to five stars that are highlighted. The patient can click on those stars, and it breaks down every measure.
So if a patient is looking at the a plan in Pennsylvania -- if they have diabetes and hypertension, they can go into those measures that the plan is accountable for and see how the plan did. If the plan performed poorly, then that might deter that patient from enrolling.
Something that's new for this year is that CMS actually gave a four-star threshold. So we kind of have a point to get to when we're looking at these measures, and I'll talk about that a little bit later. But it's the first year that we've had that. Before we just had to forecast, do a lot of predictive modeling, and we never really knew where we were going to fall until the cutpoints were released from CMS.

11. Display Measures
Display Measures (not included in annual ratings reported to members) are also included in CMS review
2013 current patient safety display measures are
Drug-drug Interactions
Excessive doses of oral diabetes medications
Comprehensive Medication Reviews (CMRs)
Adherence to antiretroviral meds
Not an official display measure but currently tracked by CMS
Increases PDC (proportion of days covered) to 90%
2014 some Star measures being removed to display page:
Enrollment timeliness
Getting information from drug plans
Call center pharmacy hold times
One other thing to just kind of briefly go over is what we call display measures. And so I mentioned that the Pharmacy Quality Alliance are kind of the creators of the majority of these Part D measures. And what CMS will do is they will look at certain measures, and they'll put them on display so I can see how Coventry is doing on a month-to-month basis on some of these measures. But they're not counted towards my overall rating.
If CMS, after two to three years, identifies a gap in care industry-wide, they can move that display measure up to an actual rated measure. So some examples that are currently on display are drug/drug interactions, excessive doses of oral diabetes medications, so that one looks at the max dose of the oral diabetes medications and looks to see how many patients ages 65 years and older fall outside of that range.
Comprehensive Medication Review -- this one is semi-display measure. The jury is still out if CMS is going to hold this as part of the actual ratings for So we are tracking it, we're treating it like it's a measure, but it hasn't been officially announced that it's going to be part of our ratings yet. So we still have to report it as display.
Another one that's interesting is adherence to anti-retroviral medication -- so HIV medications. It's not an actual display measure, and it's not a measure that we're measured on, but CMS gives us our data every month and, unfortunately, I don't have the data here to share, but I will tell you, when you look at the national average of adherence to HIV medications, it's pretty low. I think the last national average I saw was in the 60 percent. And, as we know from clinical studies and just evidence-based medicine, you know, patients really need to have an adherence rate of 90 percent.
And then the next bullet point just goes over some of the star measures that are being removed to this display page. So these are more of the operational measures, and so it's not something that I would oversee, and so it's enrollment timeliness, getting information from drug plans, and call center pharmacy hold time.
But the reason I include this is because it does show the dedication of CMS and the health plan of the service to the patient. And so if we fall outside of these windows, we're really going to get dinged on our overall rating. So it's just something that we've never really been held accountable. The four-star ratings were deployed but now we actually get measured on that. So it is going back to display because everyone in the industry was doing well. But CMS will continue to track this to make sure that just because it got moved away from being measured, we're not just completely forgetting about it.

12. New Display Measures for 2014
Part C
Pharmacotherapy Management of COPD Exacerbation (PCE) *
Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (IET)
HEDIS Scores for Low Enrollment Contracts
Part D
Variation of MPF Price Accuracy
* Moves from display measure to measure in 2015
So some new measures for I added the Part C measures in here, so these are more in line with the HEDIS type -- the medical side. So a PDP plan where it's prescription benefit only would not be held accountable for this. But in my day-to-day with the MAPD side, we do get held accountable for this. So one of the new display measures is pharmacotherapy management of COPD exacerbation, initiation and engagement of alcohol and other drug dependence treatment, and then our HEDIS scores for low enrollment contracts.
And then a new measure for Part D is variation of Medicare -- Medicare plan finder price accuracy. So CMS will actually go out to all of our websites for any health plan PBM out there and make sure the files that we submitted to them and what we quote our prices are going to be for a current benefit year, match what our website says. And if there's any discrepancy there, then we get dinged on it. So, once again, really doing that QA check around everything that we post for the patient is accurate.

13. New Display Measures
Pharmacotherapy management of COPD exacerbations (PCE) for Part C for display in 2014 and inclusion in 2015
Percent of COPD exacerbations for members age 40 or older who had an acute inpatient discharge or ER encounter
Dispensed a systemic steroid within 14 days and
Dispensed a bronchodilator within 30 days
MTM Program completion rate for CMR for Part D
2014 display measure
2015 possible inclusion
So the pharmacotherapy management of the COPD -- this is a medical/prescription measure because it looks at any patient that's 40 years or older that had a diagnosis of an inpatient discharge or ER encounter for COPD, and then they look at their claims history to see if they got a systemic steroid within 14 days and a bronchodilator within 30 days. So really looking at the appropriate care in COPD patients and looking to see where the gaps in care are and what we need to close.
I mentioned the MTM program, the CMR rates for Part D -- for 2014, it's a display measure, and for 2015 it's a possible inclusion. And let me back up because I realized I didn't have a slide in here to explain why I'm talking in terms of 2014 and Some of the data that I'll share with you in a few minutes, I'm going to tell you is my 2014 stars ratings. And if you go out on the Medicare plan finder website right now, it will be reporting 2014 stars. That rating is actually based on our 2012 plan benefit year. But because it's used for enrollment for the 2014 benefit year, it's two years ahead.
So we're currently in the calendar year 2013, and so when I say 2015 possible inclusion that means that we're being measured on it right now, but it won't be reported until next year's annual enrollment. So I constantly have to remind myself what year I'm truly living in versus what year I work in. So when I go to write a date on a check, sometimes I write 2014 or 2015 because I'm so used to that lingo in my day-to-day job.

14. Medicare Ratings 2014
So Medicare ratings , these were just made public on Monday (Oct 15th) and, typically, we'll see it a little bit earlier but because of the government shutdown, everything was a little bit delayed this year. And so this was the first timeI can see how the industry did. I've always known how our contracts did, and ours were reported in September. But until annual enrollment opens, we really don't know how the industry did as a whole.
So I'd like to show this slide because it shows what percentage of patients in a health plan are in four stars or above contracts. So I like to carve out Kaiser because when you look to see 99.8 percent of their 1.1 million beneficiaries are in a 4+ star contract, it's actually 98.2 percent of their members are in a five-star contract.
But when you look at the public entities, Aetna, which includes Coventry, our million lives -- we have 61 percent, almost 62 percent of our membership in a 4+ plan. So for us that's huge. Our average star rating is 4. We've worked really hard over the past two years to kind of push them over the edge, and we're really -- you know, our feet are held to the fire to get these ratings up and really make sure that our patients are getting the best care and the best quality care possible.
So I'd just like to show here, you know, what plans really fell into that four-star and above contract, and this is something that we focus on and how we compare to the industry.
CMS Star Rating Fact Sheet, October 2013

15. So kind of adding to that, this next slide depicts is the green is the regions of the United States where there are 4+ star contracts.
So the first thing that should pop out to you on here is there's a lot of yellow in a lot of states. So what this means is patients do not have access to a four-star or above contract. Now, I think when we see that publication of this new map for this year, that green is going to filter out to a lot more states because the industry, as a whole, did very well.
One thing I'd like to highlight on this map is if you look down here at Puerto Rico, Puerto Rico is all yellow, and it's not just all yellow, but the majority of Puerto Rico had low-performing contracts, so less than three stars. So even though they had that option to opt out of a three-star plan and choose a higher star, they didn't have anything else to choose from. So I'm hoping that when we see this new map, and I haven't been able to dig into the data too deep, but we'll see that there are some new offerings in Puerto Rico as well as some of these other states, especially in the South where you see a lot of yellow.

16. 2014 Part D Measures Call Center – Foreign Language and TTY
Appeals Auto-Forward
Appeals Upheld
Complaints about the Drug Plan
Beneficiary Access and Performance Problems
Members Choosing to Leave the Plan
Drug Plan Quality Improvement
Rating of Drug Plan
Getting Needed Prescription Drugs
MPF Price Accuracy
The next slide is the 2014 Part D measures. I just listed these to kind of show you what else is out there. I'm not involved in these from a pharmacy perspective, but it's just other things that we're rated on and that stars includes from the Part D side. Like I said, I'm not going to highlight the Part C because that could be another two-hour presentation, and I'm going to try to get through all this is an hour, because there's a lot of it. But just, you know, they look to see how many members choose to leave our plan, and so if members leave our plan, we get dinged for it because, you know, we shouldn't have members opting out of our plan.

17. The Five Triple Weighted Patient Safety Measures
The Low Hanging Fruit for Pharmacy!
So getting to the meat of the presentation -- the five triple-rated patient safety measures in the Part D side -- so I put on here the low-hanging fruit for pharmacy because I really feel like this is where, as pharmacists, we can make the most impact, and this is where we have a front line to the patient even as me sitting behind a health plan managing a population. My team does a lot of clinical outreach at the patient level. So we're not always doing population, but we also need the front-facing pharmacists out there in the community that know the patients, they interact with them more than most health care providers do and really have that trust.

18. Weighted Measures
New measures receive a weight of “1” in the first year, and then assigned the weight per their weighting categories
So to start off with, I mentioned earlier when we see a new measure it receives a weight of 1 and then CMS can increase that weight. And these triple-weighted measures at the end of 2011, all of the measures that I'm going to review had a weighting of 1. And CMS put their call for comments out, and they put out there that they were going to triple-weight these. And when health plans saw what impact that was going to make on their overall star ratings, positions like mine quickly were created and new clinical teams were quickly assigned. And, since then, it's just -- the growth has been astronomical. So it's really a good story for pharmacy because not only in my health plan but other health plans that I -- I talk to my counterparts out there, you know, pharmacy really owns this space, and I think this is where we need to keep that ownership and create those partnerships with our pharmacies and with our providers.

19. Triple Weighted Patient Safety Measures
High Risk Medications (HRMs) - based on PQA list of high risk medications
60 medications as well as oral/transdermal estrogen products
5 agents with parameters other than 2 fills (dosage, >90 days of use)
Diabetic Treatment
1 fill of an oral anti-diabetic drug or insulin and a calcium channel block or beta-blocker and on and ACE/ARB/DRI
3 Adherence Drug Classes- Anti-diabetic drugs, RASA (renin-angiotensin- receptor antagonists) and statins
2 fills of one drugs in above class
Goal of 80% Proportion of Days Covered (PDC)
So the triple-weighted measures are high-risk medications, diabetic treatment, and then there's three measures that are around adherence. So I'm going to go over each of those in detail on the next few slides.
ACE-Angiotensin Converting Enzyme Inhibitor, ARB-Angiotensin Receptor Blocker, DRI-Direct Renin Inhibitor

20. Current Pharmacy STARS Measurements
High Risk Medications (HRM)
Based on 2 fills of same HRM
Meds pulled from PQA supported list derived from the Inappropriate Medication Use in the Elderly (referred to as Beers list)
Prior to 4/12, the last update to Beers was 2002
Now published by the American Geriatrics Society
Sample of meds included in the HRM measure
cyclobenzaprine, carisoprodol, conjugated estrogens, nitrofurantoin, antihistamines, antiemetics, etc
So to start off with, we have high-risk medications. Everyone is probably familiar with the Beers List, and this is where these drugs are pulled from. But you're also probably aware that there is a few hundred if not even maybe a close to 1,000 drugs on that list with the new update that we saw in 2012 from the American Geriatric Society. And so what PQA did, the Pharmacy Quality Alliance, is when the new update was released in April of 2012, they looked at that list, and they said what are the highest-risk medications when you look at the population older than 65?
And so they updated their list, and there was a lot of new medications added. So the way this measure works is if a member fills a high-risk med two times for the same drug, that counts against the health plan. And so this is a very short window of time that we have to make an impact on this. 1/1 every year this is the first thing that's on my radar because that first fill of that high-risk med, we have to give attention to that, and we have to figure out how we're going to avoid that second high-risk med from being filled.
So if you haven't visited the American Geriatric Society, they do have a lot of good resources that I'll highlight on the next slide. But some sample of the medications that we see as our highest utilized medications in our population are the cyclobenzaprine, carisoprodol, the conjugated estrogens, nitrofurantoin, antihistamines, and antiemetics. Probably the number-one utilized medication is zolpidem, and so that's really been one of our biggest struggles. You know, when I see an 80-year-old patient on zolpidem, and they're also being treated for osteoporosis I just get chills down my spine because, you know, that's just the perfect storm for a fall and a fracture to happen, and we know the mortality rate after a fall and fracture, you know, with any year is about 50 percent.
So this is something at the community pharmacy level that, you know, as soon as those first fills are seen, you know, education to the patient about side effects, you know, this is really meant for short term. We shouldn't be using these drugs long term, and really having that engagement with the provider to remind them, you know, that this patient has been on this drug for a while and it's probably not in their best interest.

21. BEERS/PQA Update Published April 2012 with American Geriatric Society
Website has many resources for providers and patients
***Pocket cards for providers***
App available for free
Important additions
Glyburide – renal insufficiency caution
Digoxin > 0.125mg average daily dose
Non-benzo hypnotics > 90 days
Deletions
Older drugs that are no longer in use
Daily fluoxetine
I mentioned the American Geriatric Society has a lot of great resources. Everyone today has a smart phone. They have a fantastic app that -- it's free. I've actually downloaded it and used it myself. They have a pocket card similar to what the Beers update used to have. It is a little bit cumbersome and, you know, we don't wear white jackets with books and pocket cards stuffed in our pockets anymore because everything is on our smart phone, but I would highly recommend for you to check out the app. And then the Beers list, the actual report, the full report, is available online at their website for free. And then the PQA list is available on the PQA website as well.
Some important additions that we saw on the 2012 update was glyburide and so because of renal insufficiency that increases our patients' risks of having hypoglycemia, and I think sometimes we overlook that because we're just looking at is their hemoglobin A1C controlled, you know, how are their daily blood sugars, and you know, there's so much going on with a diabetic patient that sometimes it just gets missed that, wait a minute, should this patient be on a safer alternative -- glipizide, glimepiride, that doesn't have that renal issue.
Digoxin with an average daily dose greater than 1.25 is on there, and this is one that I struggle with because there's so much data out there to show that when you discontinue digoxin that you can actually cause more harm to the patient. So that's one that, you know, at a pharmacy level, probably you have a better interaction than I would with a health plan with a provider to come up with a plan on how to manage that.
And then I mentioned zolpidem as our highest utilized high-risk medication. So, really, it's any non-benzohypnotic for accumulative use of greater than 90 days. And so you look at the high-risk meds, and for the most part when providers ask me for alternatives, it's really hard to identify alternatives because they all cause that dizziness, drowsiness, the anticholinergic side effects profile that puts them at risk for falls and fractures. So we have to kind of really look at the non-pharmacotherapy options that are there.
Some deletions that they took off -- propoxyphene was still on there, daily fluoxetine got taken off, but really, overall, it was the additions that they put on there, and that list hadn't been updated in 10 years, so it was a big overhaul that they took on to do that.

22. High Risk Medications Difficult to measure to manage
Removal of drugs, utilization management
Cannot remove patient from the numerator after 2 fills
Current National Averages (through 7/13/13)
MAPD – 7.78%
PDP – 10.17%
So from a health plan perspective and even from a community pharmacy perspective, this is a really difficult measure to manage. From a health plan perspective, we've removed a lot of medications, or we've put prior authorizations in place for members that are older than 65. And once that patient has filled that second fill, there's nothing we can do to remove them, and I say numerator here. So the way the measure works is how many patients are included in our contract, and how many have filled that high-risk medication at least twice.
So if you look at the current national average, and this is actually through July 31, 2013, it was about 8 percent for MAPD. Now, to put that in perspective, two years ago the average was 20 percent. So we've made a lot of ground in this area, and a lot of that comes from the partnerships that we've had with community with our providers, some utilization management criteria that we use within the formulary development. But we still have a lot of work to do, and I think this is definitely an opportunity for community pharmacists and staff to really kind of jump in and take the lead on that.

23. Current Pharmacy STARS Measurements
Diabetic Treatment
Any patient that has 1 or more fill or an oral diabetes medication or insulin as well as to a beta blocker or calcium channel blocker are included in the measure
The measure assesses how many of these patients are also on an ACE/ARB/DRI
Only requires one fill!
The next measurement is called the Diabetes Treatment Measure. And so this is really looking at any patient that has diabetes, so they either have a claim for an oral diabetes medication or insulin, as well as a claim for beta blocker, calcium channel blocker. And so what the identifies is that patient with diabetes and hypertension, and it looks at how many patients are also on an ACE or an ARB -- so your lisinopril, your losartan. And so we get dinged for those patients that are not on it.
And I'll tell you, we do a lot of outreach to our providers on this, and the most common response that we get back is the patient's hypertension is controlled with a calcium channel blocker, so I'm not going to change their medication. And when we remind them that that's not really our main concern but, really, we're looking for that prevention of nephropathy, and so it's really renal protection. It's kind of like the light bulb goes off of, oh, right, and we actually get a lot of providers that prescribe it after we talk to them. But, again, this is the low-hanging fruit for community pharmacy to really drive that percentage up to make sure patients are on that appropriate therapy.
I think back to my ambulatory care days, and the family medicine physician would see the diabetic hypertensive, high cholesterol patient and have 15 minutes to go over everything and then turf them to the pharmacy team to really go over the details because you can't identify all of these nuances in that 15-minute setting. So, again, pharmacy really shows and kind of shines through right there on what their role is.
This is another measure that we struggle with. There's a lot of regional disparities when you look at the map for this. One of them that jumps out is Pennsylvania. Our contracts do not do well there, and other contracts that are in that market do not do well also. It only requires one fill of the ACE or the ARB, so it's surprising that we do so poorly in some regions. So as a health plan we're trying to understand is it prescribing practices of the providers? Is it the relationship between the pharmacist and the provider? Is it pushback from that member population, like, really, what's driving that deficiency in that region? And there are other regions out there that have a disparity.
And then you look at Utah, and our plan in Utah, we don't do anything for them, and they get five stars every year. So it's kind of mind-boggling to figure out what are the differences regionally.

24. Current Pharmacy STARS Measurements
Barriers
Cash Claims
Many plans struggle with this measure
Coordination of care
Opportunity?
So some of the barriers that we've identified are the cash claims program. You know, most of the retailers have the $4 programs or whatever the cost may be. There's some out there that has the lisinopril for free, and we've done a lot of education around this because we're finding that Medicare is hard to keep up with on the year-to-year changes and, honestly, some pharmacy staff are still kind of operating in that model where this gap was this huge hole that a member was going to fall into, and it was really easy to reach. And so that's where these cash claims programs were born from.
But if a patient -- let's say they take their Coventry Part D insurance card to the pharmacy, and they are at a retailer that has a $4 program, and they submit that same drug through their Part D insurance, it's only $4 because I think, for the most part, the retailers have passed along that cost to the health plans, so it's really not saving the patient any money. Even if they had a $10 Care One co-pay, we couldn't charge them any more than $4 with the benefit.
So we find that some patients are trying to kind of save their pennies every month and use those $4 programs when, if they're going to hit the gap, they're on an expensive drug that eventually is going to push them over and by using those cash claims it's not really helping them avoid it.
There's also coordination of care where we do our outreaches for this. We find that, you know, we'll call the endocrinologist and say, you know, you need to add an ACE inhibitor, and they'll say, oh, call the cardiologist, and the cardiologist will say, well, call the PCP. So -- you know, the coordination of care on the provider side is a little iffy sometimes as well -- who is going to actually take responsibility? So, again, the pharmacist is the key person that really could take that and run with it. And, for the most part, I think, in most situations, you know, they do.

25. Current Pharmacy STARS Measurements
Adherence
Patients with 2 or more fills of an adherence medication fall into the measure
Current measures include 3 drug class
ACE/ARB/DRI’s, Statins, Diabetes Medications (except insulin)
Updated in 2012 to include inpatient hospital stays
Goal is 80% adherence calculated by PDC
So the next measurements that we are held accountable for is adherence and, like I said, there's three adherence measures for the (inaudible) to the Lisinoprils, Losartans, and then the diabetes medications. So the oral diabetes medications and then the incretin mimetics. If a patient is on insulin, they are excluded from this because insulin is hard to do a true day's supply and so can throw off the adherence rate.
One thing that CMS did in 2012 is they included inpatient hospital stays to count towards the days because we assume when a patient is in the hospital that they are adherent. And the goal is 80 percent calculated by PDC. So I'm sure that's probably not a term that most people are familiar with. It's pretty new in the industry, honestly, since CMS started measuring stars. So I just wanted to go over that very quickly.

26. Proportion of Days Covered (PDC) vs. Medication Possession Ratio (MPR)
MPR tends to overestimate true adherence
Does not have safety nets built in for early fills, duplication in therapy classes, etc.
PDC is a more sophisticated measurement to account for days supply on hand, and above issues
What everyone on the call is probably more familiar with is the MPR, or the Medication Possession Ratio, and so there's a really good article on the Pharmacy Quality Alliance website that kind of goes over the exact differences written by David Nau that's -- if anybody's interested in getting more into the weeds of the difference. But we measure everything in PDC. It's a much more sophisticated measurement. It accounts for day's supply on hand, it doesn't over-estimate adherence, and it has -- MPR doesn't have safety nets built in for early fills where PDC does. So it's really something that, you know, in the beginning we kind of struggled with how to use the technical notes and calculate it, but now we're experts at it and can do it in our sleep.
But I did want to just go over that quickly in case you guys are wondering why we're going to this PDC, and it's kind of new terminology.
So we're going to stop here quickly for a polling question, so, Renaye, I'll let you take this over for the polling question.

27. Self-Assessment
Polling Question 1
In your current practice, what do you routinely check during the quality assurance process?
A. I only check the prescription for safety and accuracy
B. I review the profile at each fill (new and refills) to ensure all necessary medications are being taken
C. I check the profile for gaps in therapy when dispensing new prescriptions

28. Self-Assessment
Polling Question 1
In your current practice, what do you routinely check during the quality assurance process?
A. I only check the prescription for safety and accuracy
B. I review the profile at each fill (new and refills) to ensure all necessary medications are being taken
C. I check the profile for gaps in therapy when dispensing new prescriptions
Okay, it looks like we have most of the results, and it looks like we have 52 percent of B and 35 percent for A, and then the others bringing up the 12 percent for C. Great, thank you.
So that was kind of a little bit of the mix that I was expecting. B being the overall winner in the overall winner in the polling question, "I review the profile at each fill, new and refills." You know, in the perfect world of pharmacy, I think this is what we would all like to do but, of course, understanding that, you know, there's 100 different things going on at the pharmacy at all times, you know, sometimes we don't always get a chance to do that. But as you do get the opportunity to review the profile, kind of intermittently through the patient's time with the pharmacy and as they bring on new prescriptions, you know, it is important to make sure that everything onboard matches up and duplicate of therapy and then really just looking quality-wise with the gaps in care.
I know there's a lot of automation going on in the industry, so hopefully that will free up the pharmacist more to do the clinical job that we were trained for.

29. Patient Discussion – Applying Skills
Mrs. Curry, 66 year old female, presents to your pharmacy for a refill on her glyburide
She has no new complaints and reports she is doing well per today’s doctor check up
Her current medication list consists of 4 meds:
Glyburide
Metformin
Metoprolol
Keflex
Moving on to the next slide, we do have another polling question come up, so, Mrs. Curry, a 66-year-old female presents to your pharmacy for a refill on her Glyburide. She has no new complaints and reports she's doing well per today's doctor checkup. Her current medication list consists of the four medications below -- Glyburide, Metformin, Metoprolol and Keflex. So for our polling question, what medication should the pharmacist consider recommending to Mrs. Curry's prescriber to be considered for addition to her medication regimen and, really, based on the case discussion above? So we'll go ahead and let you answer that polling question.

30. Case Discussion
Polling Question 2
What medication(s) should the pharmacist consider recommending to Mrs. Curry’s prescriber to be considered for addition to her medication regimen?
A. None
B. Aspirin, ACE/ARB/DRI and Statin
C. ACE/ARB/DRI
D. Insulin

31. Case Discussion
Polling Question 2
What medication(s) should the pharmacist consider recommending to Mrs. Curry’s prescriber to be considered for addition to her medication regimen?
A. None
B. Aspirin, ACE/ARB/DRI and Statin
C. ACE/ARB/DRI
D. Insulin
we have about 52 percent for C and second is B with about 25 percent.
Great, thank you. So, really, the answer I was looking for here, I knew we'd have a split between B and C because if you further looked into the profile, then for B aspirin and a statin could be indicated in the diabetic hypertensive patient. But just looking at face value of the diabetic patient with hypertension and really looking for that renal effect, definitely, C would be the answer, but B absolutely a possibility depending on the rest of the patient's profile.

32. New Cut Points Released for 2014 STARS (based on 2012 data)!
2nd preview period was sent to plans on 9/4
5 Star cut points (compared with previous year):
2013
2014
PDC-Diabetes
79.0 %
77 %
PDC - RASA
79.7 %
79 %
PDC - Statins
75.4 %
75 %
Diabetes – HT Treatment
87.8 %
87 %
HRM
< 5.0 %
< 3 %
So moving along, I wanted to kind of share this slide and, you know, in the retail side, you're probably not used to a lot of this cutpoints and the terminology that I'm using, and I do understand that. And, you know, for us, it's just second nature because we are, you know, feet held to the fire on a daily basis.
But I wanted to kind of show you some of the cutpoints that we're held accountable for, and we had a little bit of a shock this year. We had our preview period for our Coventry Aetna contract sent to us on September 4th, so we knew what our stars ratings were. And we met our goals, exceeded our goals, and were ecstatic. So when we looked at the five-star cutpoints, one thing I want to point out is when you look at the PDC, so remember that's the adherence to the diabetes medications -- from the 2011 data, which was reported as 2013 to the 2012 data, which was reported as 2014, CMS actually lowered that by 2 percent.
We had forecasted that to be above based on some of their call letter language that they had sent out to us. And then the other one that kind of hurt us was the high-risk medication. The previous year, less than 5 percent was a five-star cutpoint, which is always our goal, and they lowered it to less than 3 percent. So if you remember, on the previous slides I told you that our current national average is at 7.8 percent, and so that's industry-wide, that's every health plan out there.
So to be below a 3 percent is really an elite group of contracts, and I'll tell you, Kaiser is up there, and I will tell you we are not, as Coventry, that's no secret. But so -- you know, they really kind of hold us to really high standards in what our contracts can be.

33. Increasing STAR ratings – who is the patient/beneficiary?
Baby Boomers are making their entrance
10,000 older adults turn 65 years of age….EVERYDAY
About 3% per year age-ins
A 65 year old patient is not a 75 year old
Differences in
Technology
Education levels
So I also want to talk about who is the patient or the beneficiary? You'll probably notice that I don't use the word "seniors," I use the word "older adults," because having parents in their 60s I almost got kicked out of the house when I explained what I did for my job, and I threw out the word "senior," so I now am very careful around that.
And so when you look at the baby boomers, they've made their entrance into Medicare and an astonishing fact that I share with every presentation I do -- every day 10,000 people turn 65. So 10,000 people potentially enter Medicare every day. When I look at my outreaches that I do for our clinical programs, my 65-year-old patient is not my 75-year-old patient. They have differences in technology and educational levels. You know, I think about my father-in-law who could still probably outrun me and is more technologically advanced than my grandmother, and I know that I can't do the same outreach to them. I can send text messages or s to one and a letter in sixth-grade level to the other.
So we've really had to kind of dive deep into our populations and start to filter that out to see what are we doing and are we making the right outreach to the right patient?

34. Opportunities? Community pharmacy
The front line to the patient and provider
Trusted health care professional
Engaging the patient in their healthcare
The missing link?
Partnering with providers
Better educate and partner with providers on gaps in care
Some opportunities that I kind of discussed throughout the presentation for community pharmacy -- like I said, community pharmacy is really the front line to the patient and the provider. Pharmacists definitely have a better relationship with the providers than the health plans do. You know, we do clinical outreach calls, I've actually had providers say to my clinical staff, "You're the insurance company, why do you care?" You know, and you actually want patients to take medications, because that will drive your costs up?
And so it's kind of a new mindset that insurance companies are really putting a lot of budget towards these outreaches that we're doing.
The missing link to all of this is the patients. And everyone on this call, I'm sure you have a million stories that could speak to this -- really getting that patient to understand that they are responsible for their health care, and the reason they need to take their medications every day and the importance. I think -- you know, I've heard it a million times, pharmacists are the most non-adherent patients, so how do we expect our patients to take their medications and how do we get that message to them and how do we really get them engaged?
And so, like I said, being the front line to that patient, you have that trust, you have that relationship, and I think you have that opportunity to engage the patient in how important it is and, you know, they don't just need to stand in line at a pharmacy, get their prescription, and we'll see you in 30 days.
We are partnering with providers more than we ever have done before. We've done a lot of education to our providers on gaps and care, and we share adherence data with them and, you know, they'll say, "Well, my patient tells me they never miss a dose of medication," and then when we send them our data, they're pretty shell-shocked.

35. Do STARS Make a Difference to the Patients?

36. JAMA Article Analyzed patient behavior in 2011
952k first time enrollees and 323k “switchers”
Statistical significance found with star ratings and plan chosen
STAR ratings were less likely to influence, youngest, black, low income, rural and mid-west enrollees
So next I wanted to highlight an article that was published in JAMA in January of this year, and it was the first time that it was looked at to see is there an association between the Medicare Advantage Plan star ratings and the enrollment. If anyone is interested in this article, I'd be happy to share it. It's a pretty interesting article, and I'm sure when we see this data again in two years it will be even more robust.
So it looked at patients in 2011, and it looked at about 950,000 first-time enrollees and 320,000 switchers that were switching from plan to plan. They actually found a statistical significance for those plans that had higher star ratings and the plan that was chosen. So it is working, it is getting the bandwidth. You know, when you look at your 65- to 70-year-old population, they know what an Amazon star rating is, they know what Yelp is, and so they're going to click on those stars and see what their health plans are doing, and they're going to be engaged in rating their health plan.

37. Impact of CMS’ Outreach
Beginning last fall, notices were sent to enrollees in LPI contracts to consider better performing plans
From 2012 to 2013, more patients switched out of low performing contracts
Of those in LPI contracts
that switched in 2013
The ratings were less likely to influence the youngest, which, that was a little bit shocking to me -- black, low-income, and Midwest enrollees. So one thing that CMS does, if a plan gets a low-performing icon, so they perform less than three stars, CMS will send them a nice little letter saying, "Hey, by the way, your health plan is not up to par when it comes to quality, and you have the opportunity to opt out of that health plan and choose a new one."
And when you look on the right-hand side --but we looked at patients that were in low-performing icon contracts to see what do they switch to? And if a -- say a member was in a two-and-half-star contract, if you look right in the middle, 52 percent of members that received those low-performing icon letters, they switched to a three-star contract and, more than likely, on that map that I showed, they didn't have anything available to them, and a lot of these are probably from Puerto Rico.
So there wasn't a lot of opportunity, and so I think with this new year plan ratings, the industry went up astronomically, I think we'll see this -- a little bit of a switch and have more bandwidth for members and patients to choose a higher-rated quality plan.

38. Future of STARS? More outcomes based measures to be added
Quality will be at the forefront of the exchanges, future of healthcare
Weed out the low performing plans and ensure health plans are offering high quality health care
The “young” older adults will rely more on ratings to choose health care which will increase the competitiveness
So what's the future of stars? You know, there's going to be more outcomes-based measures added. I was shocked this year that they didn't add anything. You know, I talked about the display measures earlier. I'm just waiting for those to get lifted up to a regular measure and really hold the plans accountable.
And we've made some significant investments from the health plan side, you know, like I said earlier, to make sure that we are performing at the highest quality because that shows our patients that we are vested for them and the higher stars we get the more reimbursement we get from CMS, and that reimbursement doesn't go to my pocket, it doesn't go to my boss's pocket, but it has to be reinvested back into that contract. So it allows us to add enhanced benefits to lower co-pays, to lower premiums, add vision services, you know, whatever it might be. So the more reimbursement we get, the more we offer our patients. So it does indirectly go back to our patients' pockets.
As the exchanges in the marketplace start to get on the ground, quality will be at the forefront. They're going to be held liable. And the star ratings are going to start weeding out the low-performing plans. There was one health plan that got 11 low-performing icons this year, and I didn't put that slide up because I didn't want to call anybody out, but it is out there in the public domain if someone is interested. But it's really going to push those contracts and make them either invest in quality or get out of the Medicare game.
Like I mentioned earlier, the young older adults rely more on these ratings to choose their health care and that's -- you know, it's already increased our competitiveness when you look across the board.

39. Summary
STAR ratings are pushing health plans to drive for higher quality and older adults are noticing the changes
Quality measurement has been a part of healthcare for many years but in recent years is tied to reimbursement
STARS will continue to evolve and more outcome measures expected to be added to the STARS overall rating
So, in summary, kind of a repeat of what I just said, but quality is not only going to drive health care -- or health plan reimbursement, but it's getting pushed down to the provider side. It's getting pushed down to the pharmacy side, and reimbursement is going to revolve around quality. In the next five to 10 years, I think we're going to see a huge landscape shift, and it's not -- you know, pharmacists won't be there just to fill a prescription. They're really going to be relied on for their clinical expertise and how to close gaps in care.

40. QUESTIONs
One of the first questions was what does star stand for? And it actually doesn't stand for anything. I know we capitalize it, and so that -- to us, in pharmacy, everything is an acronym, but it actually doesn't stand for anything. It's just the stars, you know, that's how they rate us and that's how they showcase us on the Medicare plan finder. So, for the first time in health care, I don't have an acronym to give you.
Another question that came through -- for the high-risk medication measure, why do you change the specs when they are released midyear from CMS rather than waiting for a new measurement year to begin? And this is a great question, and something that, as a health plan, we have no control over. CMS did change the list last September and, at that time, they made that retrospective. But because that was unfair to us, to the pharmacies, to the providers, to hold us accountable, they, in the call letter this year, they refuted that, and they went with the original list, and they started the new list in So that was -- I think that was a one-time issue because of that major change in the Beers criteria. So, hopefully, going forward, right now, in October, I guess that everything is a little bit delayed because of the government shutdown, but we'll get a call for comments, and CMS allows us multiple times to comment on what we think about their proposed new measures, changes to the measures, the calculations, and we get an opportunity to comment. So as Coventry we send out one document of comments and, I should say Aetna now, I apologize, and then CMS takes all those comments from all the health plans, and then they put out their final call letter with the final rules in April. So that's really what we have to live by.
So in April, I kind of knew it was coming. There was only one shock on how they calculated the measures, which was to our benefit compared to the original draft comments. So if you have any interest in this, there's a lot of stuff in the public domain -- the call letter is in the public domain. You know, sometimes I laugh and joke that I really should have learned how to read Greek when it comes to some of these measures, because it takes me a few times. An average call letter is 120 pages, so, as you can imagine, you know, we should just start recommending for our members to read a call letter and get off the result of them. That could be a non-pharmacotherapeutic way to manage their insomnia.
Another question in regards to high-risk medications is in regards to the benzodiazepines -- as of January 1, 2013, CMS did require health plans to cover barbiturates and benzos, and initially the benzodiazepines were on the high-risk medication list, but with the PQ update, they were taken off. So the barbiturates are still on there, and we struggle with this one. You know, it's only indicated for either epilepsy, cancer, or mental health. So for our plan we have PAs around all of our barbiturates.
So we go through that risk-versus-benefits discussion with the provider. If we approve the PA because of the correct indication we still get dinged for it on a high-risk medication list. And, to be fair, when I do outreach to the pharmacies or providers, I take that off my list, and I don't hold them accountable because if the patient is filling it, we've already went through that song and dance of, you know, it is appropriately indicated. I'm not going to send more information out there to contradict what we initially had said.
So we do try to take that into consideration when we are doing communication with pharmacies and providers.
Another question that came in -- does the ACE inhibitor get prescribed at low doses mainly for renal protection? For those providers that tell us, it took us a long time to get this patient's hypertension controlled, so I don't want to change the medication, and then we have the clinical conversation about the renal protection. They typically do start a very low dose. So it's something onboard. It's not really going to touch their hypertension, but it does give that renal protection. So I'd say we're pretty successful with that argument, or I will say "discussion" with our providers.
Honestly, they'll admit to us, you know, "Oh, gosh, we overlooked that because there's so much going on with this patient, it's hard to manage that sometimes things just go to the wayside." So, you know, some providers don't want our input and others are appreciative of it.
Let's see, so another question came through in regards to some of the cash programs, and there is a chain in Florida that has free Lisinopril, and it's interesting because it comes down to member education. My contracts in Florida have a tier 1 zero dollar co-pay. And we found last year a few hundred members that were getting their Lisinopril through this free program when that was their pharmacy benefit.
So it does count against us. It will make us look like our patients are non-adherent because we can't claim cash claims to CMS. The only thing that counts on the Part D measures are adjudicated claims. So if the Part D benefit card is not used, we don't get credit for that, and the third party vendor acumen that reconciles the data for CMS will not have access to it. So we are trying to do a lot around that with education with pharmacies, providers, as well as members.
And last question-- what guarantees that the plans are not fidgeting the numbers to get better stars? You know, we actually -- there is nothing we can do to do the numbers because, like I said, everything is claims adjudicated. If CMS even has the inkling that we are providing erroneous data, that contract automatically gets one star. So it is in our best interest -- everything I do, everything anybody that has involvement with stars, we have a compliance department we have to go through. We have a legal department. There is nothing we can do to manipulate our numbers on the Part D side. It's claims adjudicated, so we're really held accountable, and it's a sound process in that way, but we do kind of miss out because of some of the cash claims programs.

41. CE Credit Complete evaluation at the end of the webinar
Statement of credit available in CE/Test history folder
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