Editor’s Note: This article originally appeared on Cardinal Health’s website.
There has been a lot of talk about “Star Ratings” in recent months, after the Centers for Medicare & Medicaid Services (CMS) released its Overall Hospital Quality Star Rating program this summer. Although CMS doesn’t issue star ratings for pharmacies, we know that health plans are increasingly looking at pharmacy performance based on specific quality metrics when making network decisions.
That’s because, like hospitals, health plans ─ specifically Medicare Advantage plans ─ are subject to CMS’ “Star Ratings” quality system. They are rated through these measurements just like a five-star restaurant or hotel. Based on their performance they receive bonus payments – a monetary incentive for performing well. Conversely, CMS can shut down plans that receive less than a three-star rating for three consecutive years. That means health plans are placing more focus on how pharmacies contribute to Star Ratings through quality of medication use. One key area of focus is medication adherence, particularly in the categories of diabetes, statins for cholesterol and anti-hypertensive medications to treat high blood pressure.
In addition, plans are looking at the extent to which pharmacies are identifying gaps in care – specific to patients with diabetes using a statin and avoiding high risk medications in the elderly – which can be improved with proper intervention. Pharmacies that are not able to demonstrate their performance on these specific pharmacy-related metrics may risk being left behind, and ultimately losing access or money via incremental Direct and Indirect Remuneration (DIR) fees. Click here to continue >>
