Medicare Star Research Articles

Variation in Screening Mammography Rates Among Medicare Advantage Plans

PurposePrior studies have shown higher screening mammography rates for beneficiaries in capitated managed care Medicare Advantage (MA) plans compared with traditional fee-for-service Medicare. The aim of this study was to explore variation in screening mammography rates at the level of MA managed care plans. MethodsUsing the 2016 MA Healthcare Effectiveness Data and Information Set Public Use File, screening mammography rates were identified for all 385 reporting MA plans. Associations were explored with a range of plan characteristics from this file, as well as from the CMS Part C and Part D Medicare Star Ratings Data File, Medicare Advantage Plan Directory, and Medicare Monthly Enrollment by Plan File. ResultsOverall MA plan screening rates were high (mean, 72.6 ± 9.4%) but varied substantially among plans (range, 14.3%-91.8%). Screening rates were higher in nonprofit versus for-profit plans (77.3% versus 71.8%, P < .001), as well as in health maintenance organization or local preferred provider organization plans versus private fee-for-service or regional preferred provider organization plans (71.9%-73.2% versus 65.5%-66.8%, P = .001). Among parent organizations with five or more plans, screening rates were highest for Kaiser Foundation (median, 88.4%) and lowest for Molina Healthcare (median, 65.3%). Screening rates showed small but significant associations with plans’ contract lengths, enrolled populations, and counties served. Screening rates showed strong associations (r = 0.796-0.798) with colorectal cancer screening and annual flu vaccine rates and showed moderate associations (r = 0.283-0.365) with ambulatory and preventive care visits, osteoporosis screenings, body mass index assessments, and nonrecommended prostate-specific antigen screenings after age 70. ConclusionsScreening mammography rates vary considerably among MA plans. With increased federal interest in promoting the MA program, enhanced transparency will be necessary to ensure appropriate Medicare beneficiary participation decision making.

An Analysis of Quality Improvement Education at US Colleges of Pharmacy

Objective. Analyze quality improvement (QI) education across US pharmacy programs. Methods. This was a two stage cross-sectional study that inspected each accredited school website for published QI curriculum or related content, and e-mailed a questionnaire to each school asking about QI curriculum or content. T-test and chi square were used for analysis with an alpha a priori set at .05. Results. Sixty responses (47% response rate) revealed the least-covered QI topics: quality dashboards /sentinel systems (30%); six-sigma or other QI methodologies (45%); safety and quality measures (57%); Medicare Star measures and payment incentives (58%); and how to implement changes to improve quality (60%). More private institutions covered Adverse Drug Events than public institutions and required a dedicated QI class; however, required QI projects were more often reported by public institutions. Conclusion. Despite the need for pharmacists to understand QI, it is not covered well in school curricula.

Patient perceptions of a pharmacy star rating model

ObjectivesTo identify patients’ understanding of what constitutes a “quality pharmacy” and to obtain their feedback regarding the development and use of the pharmacy star rating model, a pharmacy-specific aggregate performance score based on the Centers for Medicare and Medicaid Services’ Medicare Star Rating. DesignProspective cross-sectional study. Setting and participantsFocus groups were conducted in Arizona, California, Mississippi, Maryland, and the District of Columbia, and one-on-one interviews were conducted in Indiana. Eligible patients were required to routinely use a community pharmacy. Main outcome measuresConsumer insights on their experiences with their pharmacies and their input on the pharmacy star rating model were attained. Key themes from the focus groups and interviews were obtained through the use of qualitative data analyses. ResultsForty-nine subjects from 5 states and DC participated in 6 focus groups and 4 one-on-one interviews. Eighty-eight percent of participants reported currently taking at least 1 medication, and 87% reported having at least 1 health condition. The 7 themes identified during qualitative analysis included patient care, relational factors for choosing a pharmacy, physical factors for choosing a pharmacy, factors related to use of the pharmacy star rating model, reliability of the pharmacy star rating model, trust in pharmacists, and measures of pharmacy quality. Most participants agreed that the ratings would be useful and could aid in selecting a pharmacy, especially if they were moving to a new place or if they were dissatisfied with their current pharmacy. ConclusionPharmacy quality measures are new to patients. Therefore, training and education will need to be provided to patients, as pharmacies begin to offer additional clinical services, such as medication therapy management and diabetes education. The use of the pharmacy star rating model was dependent on the participants’ situation when choosing a pharmacy.

Association Between Medicare Star Ratings for Patient Experience and Medicare Spending per Beneficiary for US Hospitals.

Objective:To test the association between patient experience and Centers for Medicare and Medicaid Services (CMS) spending at the hospital level.Methods:Using CMS Hospital Compare data set, we analyzed 2014 data for CMS patient experience star ratings and the hospital Medicare Spending per Beneficiary (MSPB) Measure, which assesses price-standardized, risk-adjusted payments for services provided to Medicare beneficiaries for an episode of care from 3 days before hospital admission to 30 days following discharge. We tested the association using linear regression, adjusting for complexity of care using hospital Case Mix Index (CMI) and for socioeconomic status of the hospital patient population using Disproportionate Share Hospital (DSH) status.Results:The MSPB decreased with increasing hospital patient experience ratings. After adjustment for CMI and DSH, better hospital patient experience was associated with lower spending per episode (5.6% decrease from the lowest to highest patient experience star rating).Conclusion:We found that better hospital patient experience was associated with lower health-care spending. Further research is needed to define what specific elements and phases of the episode of care are driving the association.

Statin Adherence Rates in Patients Utilizing a Patient-Centered Medical Home-Based Pharmacy

Background: Medication nonadherence contributes to approximately US$290 billion per year in avoidable health-care spending. Statins are of particular interest because of their importance to patient outcomes, costs of treatment failure, and categorization as a Medicare star measure linked to financial reimbursement. Objective: To evaluate statin adherence as defined by the proportion of days covered (PDC) among patients who use an embedded dispensing pharmacy in a patient-centered medical home (PCMH). Methods: This study is a retrospective chart review of Lifetime Health Medical Group’s electronic health record and third-party prescription claims data of statin therapy. Statin adherence is reported using PDC, with 0.8 or greater considered adherent for statin therapy. Statistics used include 2-sample unpaired t test to compare PDC between gender and age, and analysis of variance was used to determine differences in PDC among different insurance types. Results: One hundred ninety-three patients were included, and 917 statin prescriptions were filled. PDC for statin medications in the population was 0.92 ± 0.20. Eighty-six percent of patients were considered adherent, with a PDC ≥80%. The average insurance and patient costs for brand prescriptions (n = 106) were US$233 ± US$143 and US$31 ± US$27, respectively, and costs for generic prescriptions (n = 811) were US$8 ± US$13 and US$7 ± US$6, respectively. Conclusion: Statin adherence rates for patients utilizing a dispensing pharmacy embedded in a large PCMH exceed the national average of 40% to 50% adherence.

Delivering on quality measures: Six new CMS SNF quality measures

Data on skilled nursing facility utilization among patients undergoing pancreatic surgery remain scarce. We sought to define the incidence of utilization of skilled nursing facilities and determine the impact of skilled nursing facility quality markers on postoperative outcomes among patients who underwent pancreatic surgery.Medicare Standard Analytic Files were used to identify patients who underwent pancreatic resection during 2013–2015. Nursing Home Compare datasets were used to examine the influence of skilled nursing facility quality as estimated by quality markers (Medicare star ratings) on postoperative outcomes.Among 13,018 patients who underwent pancreatectomy, 2,247 (17.3%) were discharged to a skilled nursing facility. Compared with patients discharged home, patients discharged to a skilled nursing facility were older (median age: 72 [interquartile range 68–76] vs 76 [interquartile range 71–80]), more likely female (44.4% vs 56.8%), and had greater Charlson comorbidity index scores (median score: 3 [interquartile range 2–8] vs 4 [interquartile range 2–8]) (all P < .001). Most patients were discharged to an above-average skilled nursing facility (N = 1,463, 65.1%), and a lesser subset was discharged to a skilled nursing facility with a below-average (N = 490, 21.8%) or average (N = 294, 13.1%) star rating. The 30-day hospital readmission was greatest among patients discharged to a below-average skilled nursing facility (below average N = 217, 44.3%; average N = 110, 37.4%; above average N = 517, 35.3%; P = .002). On multivariate analysis, patients discharged to below-average skilled nursing facilities remained 64% more likely to be readmitted within 30 days (OR 1.64, 1.29–2.02, P < .001). In contrast, 30-day mortality was comparable across the skilled nursing facility star rating categories (P = .08).Roughly 1 in 6 patients undergoing pancreatic surgery were discharged to a skilled nursing facility. Patients discharged to a below-average skilled nursing facility were more likely to be readmitted compared with patients discharged to an above-average skilled nursing facility.

Impact of Environmental Factors on Differences in Quality of Medication Use: An Insight for the Medicare Star Rating System.

The Medicare star ratings system incentivizes health plan sponsors based on their performance across a measurement system that contains quality measures related to medication use. As health plan sponsors seek to further engage their network providers, specifically network pharmacies, to improve performance on these measures, it is important to consider the effect of environmental factors on the performance of network pharmacies. To determine the effect of environmental factors on pharmacy quality as measured by (a) medication adherence for noninsulin diabetes medications, (b) medication adherence for renin angiotensin receptor antagonists (RASA), (c) medication adherence for cholesterol medications (statins), and (d) use of high-risk medications (HRM) in the elderly. The EQuIPP database, which contains performance information for pharmacies for a nationwide sample of Medicare beneficiaries, was used for this analysis. Environmental factors included regions or characteristics of a community or county. County-level data was obtained from the Area Health Resource Files, a resource product available from the Health Resources & Service Administration. A logistic regression model was developed with performance as the dependent variable and regions and environmental factors as independent variables. Performance and county characteristics, such as proportion of patients in an age group, race, income, or number of outpatient visits, were classified as high and low based on a median cutoff of nationwide performance scores. A total of 28,950 pharmacies were included in this analysis. For most measures, the proportion of low-performing pharmacies was significantly higher in the East South Central, Mid-Atlantic, Mountain, Pacific, and West South Central regions. Pharmacies in counties with high median income, high proportion of elderly population (aged > 84 years), high proportion of elderly patients who were white or Hispanic, high proportion of elderly males, and high proportion of elderly urban patients were less likely to have low performance, whereas those with high proportion of elderly African Americans and high density of independent pharmacies were more likely to have low performance (P < 0.05-0.0001). This study found that environmental characteristics of a region, including pharmacy and sociodemographic characteristics, explained regional variation in quality measures related to medication use for patient populations served by pharmacies. This evaluation serves to further inform the discussion regarding case-mix adjustment of quality measures and provides information that may be important to further refine intervention strategies for pharmacies and pharmacists who serve certain regional populations. Additionally, pharmacies in greatest need of support for quality improvement may be those who serve populations that are predominantly low income and elderly African American. Desai's postdoctoral fellowship was funded by Pharmacy Quality Solutions for conducting this study and writing the manuscript. Nau and Conklin are employed by Pharmacy Quality Solutions. An earlier version of this research was presented as a poster at the Annual Meeting of the Academy of Managed Care Pharmacy; San Diego, CA; April 7-10, 2015. Study concept and design were contributed by Conklin, Nau, Desai, and Heaton. Desai and Conklin took the lead in data collection, assisted by Nau and Heaton. The manuscript was primarily written by Desai and Heaton, with assistance from Conklin and Nau. All authors contributed to data interpretation and manuscript revision.

A pharmacist's contribution within a patient-centered medical home

ObjectivesTo evaluate the impact of a pharmacist embedded in a primary care physician (PCP) group practice to assist in achieving patient-centered medical home (PCMH) accreditation by increasing chronic care measures through the use of angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB) medications in patients with concomitant diabetes mellitus (DM) and hypertension (HTN). SettingPCP practice in Pittsburgh, PA. Practice description16 decentralized PCPs linked by electronic health record system. Practice innovationAn academically based pharmacist provided medication management services to the PCP group for patients with DM and HTN using criteria developed by the quality committee of the practice. InterventionsUsing the electronic health records and inclusion criteria, a list of patients with concomitant DM and HTN and not currently taking ACEI or ARB medications was obtained. Patients were excluded based on predetermined criteria. Electronic messages were sent to PCPs responsible for the remaining patients. ResultsAcross the 16 participating office locations, 5,258 patients were diagnosed with DM and HTN. Of these, 4,304 were already being treated with an ACEI or ARB medication (81.9%). Of the remaining 954 patients, the pharmacist determined that 784 met at least one of the exclusion criteria (82.2%). Recommendations were sent for the remaining 170 patients, and the pharmacist received 150 responses (88.2%). Physicians agreed with the recommendation to initiate therapy in 82 patients (54.7%), and therapy was started in 56 of those patients (68.3%). ConclusionThis project showed the positive effect of a pharmacist in helping a PCP group address quality projects relating to PCMH accreditation and improvements in care that can affect Medicare star ratings.

Health care system-level factors associated with performance on Medicare STAR adherence metrics in a large, integrated delivery system.

Background:The Centers for Medicare and Medicaid Services provide significant incentives to health plans that score well on Medicare STAR metrics for cardiovascular disease risk factor medication adherence. Information on modifiable health system-level predictors of adherence can help clinicians and health plans develop strategies for improving Medicare STAR scores, and potentially improve cardiovascular disease outcomes.Objective:To examine the association of Medicare STAR adherence metrics with system-level factors.Research Design:A cross-sectional study.Subjects:A total of 129,040 diabetes patients aged 65 years and above in 2010 from 3 Kaiser Permanente regions.Measures:Adherence to antihypertensive, antihyperlipidemic, and oral antihyperglycemic medications in 2010, defined by Medicare STAR as the proportion of days covered ≥80%.Results:After controlling for individual-level factors, the strongest predictor of achieving STAR-defined medication adherence was a mean prescribed medication days’ supply of >90 days (RR=1.61 for antihypertensives, oral antihyperglycemics, and statins; all P<0.001). Using mail order pharmacy to fill medications >50% of the time was independently associated with better adherence with these medications (RR=1.07, 1.06, 1.07; P<0.001); mail order use had an increased positive association among black and Hispanic patients. Medication copayments ≤$10 for 30 days’ supply (RR=1.02, 1.02, 1.02; P<0.01) and annual individual out-of-pocket maximums ≤$2000 (RR=1.02, 1.01, 1.02; P<0.01) were also significantly associated with higher adherence for all 3 therapeutic groupings.Conclusions:Greater medication days’ supply and mail order pharmacy use, and lower copayments and out-of-pocket maximums, are associated with better Medicare STAR adherence. Initiatives to improve adherence should focus on modifiable health system-level barriers to obtaining evidence-based medications.

Everybody Is a Star

Everybody Is a Star

Dancing with the star ratings: Pharmacy groups publish jointly in JAPhA

I March 2013, APhA and the Academy of Managed Care Pharmacy (AMCP) convened 15 thought leaders—representatives of independent and chain pharmacies, managed care organizations, pharmacy associations, and CMS—at a conference, CMS Star Ratings: A Stakeholder Discussion. The May/June 2014 Journal of the American Pharmacists Association published a free-access special feature by the two pharmacy associations, “Medicare star ratings: Stakeholder proceedings on community pharmacy and managed care partnerships in quality.”

Potentially inappropriate medications in older adults: A review of the 2012 Beers Criteria and the implications in persons with dementia

In 2012, the American Geriatrics Society (AGS), along with a panel of 11 experts, updated the Beers Criteria which has evolved significantly since its inception in 1991. The Beers Criteria, in general, classifies medications/medication classes as: (1) potentially inappropriate for use in all older adults, (2) potentially inappropriate for older adults with certain diseases or symptoms and (3) requiring extra caution when used in older adults. Although each patient must be evaluated individually, the Beers Criteria is a useful clinical tool that can be used when initiating pharmacologic agents in both ambulatory and institutionalized patients. The concept behind use of the Beers Criteria is that it allows prescribers to readily identify, and avoid, medications associated with negative outcomes in older adults therefore decreasing the risk of adverse drug events (ADEs). Within this review article, there will be a highlight of potentially inappropriate medications (PIMs) commonly seen in clinical practice settings such as antipsychotics, benzodiazepines, non-benzodiazepine sedative-hypnotics, anticholinergics and sliding scale insulin. The focus will be to outline the risk-benefits of these drug classes within the context of persons with dementia. Furthermore, the use of PIMs has both clinical and financial implications in Medicare Star ratings and Healthcare Effectiveness Data and Information Set (HEDIS) measures.

Medicare star ratings: Stakeholder proceedings on community pharmacy and managed care partnerships in quality: American Pharmacists Association and Academy of Managed Care Pharmacy

ObjectivesTo describe the Medicare star rating system, created by the Centers for Medicare & Medicaid Services (CMS) in 2007; identify quality measures that can potentially be improved through collaboration between health plans and community pharmacy; provide examples of current collaboration between health plans and community pharmacy; and identify collaboration goals, challenges, components, and strategies. Data sourcesNational thought leaders at a conference titled CMS Star Ratings: A Stakeholder Discussion, held on March 21, 2013, supplemented with related information from the literature. SummaryThe Medicare star rating system is part of CMS's efforts to define, measure, and reward quality health care. Approximately one-half of the star rating performance measures can be influenced directly by community pharmacists working in conjunction with payers that must meet the quality measures. In 2012, a weighting system for star ratings was implemented. Of 10 triple-weighted ratings, 8 are related directly and indirectly to medication therapy and thus have the potential to be improved by pharmacist intervention. Plan ratings can have a substantial impact on beneficiary enrollment. Since very small improvements in performance measures can translate into large effects on star ratings, concerted efforts to improve pharmacy-related measures could move a plan to a higher star rating; conversely, inattention to areas such as high-risk medications, antidiabetic pharmacotherapy, and medication adherence could lower a plan's star rating. Topics discussed in this article include the Electronic Quality Improvement Platform for Plans and Pharmacies, or EQUIPP, the payer perspective on pharmacies, programs currently under way in community pharmacies, and ways plans and pharmacies can better collaborate with each other. ConclusionThe pharmacist's ability to work directly with patients to improve medication use is a critical factor in improving health plan Medicare star ratings. Health plans and community pharmacies must forge partnerships based on well-defined goals and innovative tactics to ensure care quality consistent with evolving public and private payment models.

Few health plans cover MTM services because pharmacists lack Medicare provider status

Few health plans cover MTM services because pharmacists lack Medicare provider status

Be a ‘star’: Get older patients off high-risk meds

Be a ‘star’: Get older patients off high-risk meds

Pharmacists can improve Medicare plan star ratings

What are Medicare star ratings, and why do they matter to pharmacists? CMS assigns Medicare Advantage and Part D prescription drug plans an overall star rating of one to five stars based on the plans' performance on quality measures, many of which are affected by pharmacists' patient care services.

Early Detection of Poor Adherers to Statins: Applying Individualized Surveillance to Pay for Performance

BackgroundMedication nonadherence costs $300 billion annually in the US. Medicare Advantage plans have a financial incentive to increase medication adherence among members because the Centers for Medicare and Medicaid Services (CMS) now awards substantive bonus payments to such plans, based in part on population adherence to chronic medications. We sought to build an individualized surveillance model that detects early which beneficiaries will fall below the CMS adherence threshold.MethodsThis was a retrospective study of over 210,000 beneficiaries initiating statins, in a database of private insurance claims, from 2008-2011. A logistic regression model was constructed to use statin adherence from initiation to day 90 to predict beneficiaries who would not meet the CMS measure of proportion of days covered 0.8 or above, from day 91 to 365. The model controlled for 15 additional characteristics. In a sensitivity analysis, we varied the number of days of adherence data used for prediction.ResultsLower adherence in the first 90 days was the strongest predictor of one-year nonadherence, with an odds ratio of 25.0 (95% confidence interval 23.7-26.5) for poor adherence at one year. The model had an area under the receiver operating characteristic curve of 0.80. Sensitivity analysis revealed that predictions of comparable accuracy could be made only 40 days after statin initiation. When members with 30-day supplies for their first statin fill had predictions made at 40 days, and members with 90-day supplies for their first fill had predictions made at 100 days, poor adherence could be predicted with 86% positive predictive value.ConclusionsTo preserve their Medicare Star ratings, plan managers should identify or develop effective programs to improve adherence. An individualized surveillance approach can be used to target members who would most benefit, recognizing the tradeoff between improved model performance over time and the advantage of earlier detection.