STAR RATINGS PBM PARTNERSHIP, MAXIMUM RESULTS. Michelle Juhanson, CHC, CHPC Director of Compliance and Quality PerformRx
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1 STAR RATINGS PBM PARTNERSHIP, MAXIMUM RESULTS Michelle Juhanson, CHC, CHPC Director of Compliance and Quality PerformRx
2 Agenda History & Timeline Quality Bonus Payment CMS Changes The PBM Role Best Practices We, CMS, are trying to push plans that continue to have low star ratings to not offer products to beneficiaries. Jonathan Blum, Former CMS Deputy Administrator & Director 2
3 History of Ratings Beneficiary tool on Medicare Plan Finder 2010 CMS changes scope Patient Protection & Affordable Care Act (PPACA) creates Quality Bonus Payment (QBP) Low performing icon introduced 2011 CMS announces Quality Bonus Payment (QBP) demonstration 5 star plans unlimited marketing and enrollment High Performing icon introduced Overall Rating introduced 3
4 History of Ratings QBP demonstration period Automatic 1 star deductions for gaming MMP Demonstration Quality Withhold 2015 First year of PPACA QBP 2018 Ratings codified CMS F (the Final Rule) 4
5 Two-Tier Eligibility QBP & Quality Withhold Eligibility by Plan Plan Type QBP QW PDP No No 1876 Cost No No MAPD Yes No MMP No Yes MAPD QBP Demo = 3 stars PPACA QBP = 4 stars after MMP 3 stars 1 Part D measure 5
6 QBP Use CMS Rules Prohibit Reinvesting QBP on Quality Improvement (b) Form of rebate. The rebate must be provided by crediting the rebate amount to one or more of the following: (1) Supplemental health care benefits. (2) Payment of premium for prescription drug coverage. (3) Payment toward Part B premium.* This means: The QBP cannot be spent on s *42 C.F.R (b) 6
7 QBP Timeline 4-Year Data Collection to QBP Cycle QBP Timeline Measurement Period Report Card Release Report Card Year QBP Payment Year 1/1/12-12/31/12 October 2013 CY (PPACA Yr 1) 1/1/13-12/31/13 October 2014 CY (PPACA Yr 2) 1/1/14-12/31/14 October 2015 CY (PPACA Yr 3) 1/1/15-12/31/15 October 2016 CY (PPACA Yr 4) 1/1/16-12/31/16 October 2017 CY (PPACA Yr 5) 1/1/17-12/31/17 October 2018 CY (PPACA Yr 6) 7
8 QBP Timeline Evaluation of the Medicare Quality Bonus Payment Demonstration 8
9 Government Accountability Office 2012 Report Senate Finance Committee commissioned GAO audit 2012 $8 billion in spending over 10 yrs Average plans get most payments CMS research goals undermined 9
10 Estimate vs Actual CMS commissioned study by L&M Policy Research 2016 Average Ratings improved in QBP demo QBP demo impact positive to neutral QBP demo payments lowered beneficiary OOP costs 10
11 QBP Payments The Medicare program paid Medicare Advantage organizations an estimated $10.96 billion under the QBP Demonstration Evaluation of the Medicare Quality Bonus Payment Demonstration 11
12 Estimate vs Actual GAO Estimate Actual Difference $8 billion $10.96 billion $(2.96) Billion Majority QBP will be paid to average plans 84% paid to average plans + 33% s Total QBP by Year 3 $1,018,910, $846,706, $527,948, $2,393,565, $1,180,660, $1,678,383, $1,836,673, $4,695,716, Sum (3+3.5) $2,199,570, $2,525,090, ,364,621, $7,089,282, Total QBP 3-5 Plans Percentage of total paid to average plans $3,813,133, $3,717,028, ,432,168, $10,962,330, % 94% 81% 84% 12
13 Source Documents CY 2019 Part C & D Call Letter CY 2019 Final Rule 13
14 QBP Updates Call Letter No major changes announced Final Rule PDPs and 1876 cost plans remain excluded CMS wants beneficiaries enrolled in QBP plans Data suggests that enrollees switch from non-qbp plans to QBP plans 14
15 Rating Updates Call Letter Measure Changes Statin Use in Persons w/ Diabetes (SUSPD) Part D 1 to 4 star reduction for IRE data issues Appeals Auto-Forward & Appeals Upheld Timeliness Monitoring Project (TMP) data Final Rule Codified most of existing Ratings program CMS will seek comments for new measures New measures added will be Display measures for at least 2 years Non-substantive changes addressed in Call Letter Initial substantive change feedback sought in Call Letter Scaled reductions for IRE measures. 15
16 The PBM Role What s missing? Traditional PBM Delegation Utilization Management Pricing Pharmacy network admin Claims processing MTM Traditional Pharmacy Delegation Fill Prescription *Appeals Auto- Forward Medicare Plan Finder Price Accuracy Medication Adherence for Hypertension Medication Adherence for Diabetes Medications Appeals Upheld MTM CMR Completion Rate Adherence for Cholesterol (Statins) Statins Use in Persons with Diabetes 16
17 Plan PBM Partnership MTM supplements Medical Management Communicate Effectively & Often Weekly huddles Portals/SharePoint Trouble reaching beneficiaries Consider Shared Goal Setting Do you strive for 5, but 3 is in the budget? Are goals aligned? Is there an annual work plan/strategy? Are your goals on a per measure, per client, basis? Example, plan A delegates MTM Is there a program evaluation? Are there barrier analyses? 17
18 Influence The art of argument Tell a story Provide examples Provide data Be polite Tone (no whining) 1. Regulations 2. Call Letter (Sub regulatory) 3. CMS Conferences Join the Pharmacy Quality Alliance (PQA) Measure Development Plan Preview Periods Data / Process May - August (Acumen) Data/Process Missing PDEs 18
19 Best Practices Measurement Look at your data Trend over time Benchmark yourself Look backwards Barrier analysis Cut point anticipation analysis. Monitor Display Measures Measure even if CMS does not Example: MMP plans only currently evaluated for one Part D measure [Medical] Provider incentive programs are the only QI activity associated with changes in Ratings from 2013 to 2015 * Evaluation of the Medicare Quality Bonus Payment Demonstration 19
20 Seeing s Cut Point Analysis 2018 CMS Part Report Card (10/2017 Goal: CMS cut point once the final report card is released 50% measures: at or above CMS (D02, D10, and D15) D02 and D15 far exceeded industry performance 50% measures: below final CMS (D12, D13, and D14) 3% - Average variance for 5-star cut point thresholds 5% - Average variance for 4-star cut point thresholds 20
21 CONTRACT ID Org Type Contract Name H1234 Local CCP Perfect Plan 1 H4567 Local CCP Perfect Plan 2 D02: Appeals Auto Forward No data available No data available Results CY2018 CMS Part D Report Card Data Collection Period: 1/1/16-12/31/16 D10: MPF Price Accuracy D12: Medication Adherence for Diabetes Medications D13: Medication Adherence for Hypertension (RAS antagonists) Seeing s D14: Medication Adherence for Cholesterol (Statins) D15: MTM Program Completion Rate for CMR No data available No data available No data available No data available No data available No data available No data available No data available No data available No data available H9999 Local CCP Perfect Plan Perfect Plan, Inc. & PBM Averages vs. National MAPD Averages Measure Measure Title Perfect Plan, Inc. PBM MA-PD D02 Appeals Auto Forward D10 MPF Price Accuracy D12 D13 D14 Medication Adherence for Diabetes Medications Medication Adherence for Hypertension(RAS antagonists) Medication Adherence for Cholesterol (Statins) D15 MTM Program Completion Rate for CMR
22 Seeing s CY2019 Anticipated Report Card Results Example Contract D02: Appeals Auto- Forward Rating MPF Price Accuracy Rating CY2017 Part D Report Card Data Collection Period: 1/1/17-12/31/17 D12: Part D Medication Adherence for Oral Diabetes Medication Score Rating D13: Part D Medication Adherence for Hypertension (RAS Antagonists) Score Rating D14: Medication Adherence for Cholesterol (Statins) Score Rating D15:MTM Program Completion Rate Score Score Score H % % % % % 4 H % % % % % 4 H % % % % % 5 Rating 22
23 Seeing s Q vs. Q Contract Appeals Auto-Forward MPF Price Accuracy Medication Adherence for Diabetes Medication SUPD: Statin Use in Persons with Diabetes Q Q Q Q Q Q Q (New) Rating Rating Rating Rating Rating Rating Score Rating Score Score Score Score Score Score H % 5 98% 4 86 % 5 89% 5 75% 3 H % 4 99% 5 89.% 5 92% 5 71% 3 H % 4 98% 4 89 % 5 91% 5 72% 3 Q vs. Q Contract Part D Medication Adherence for Hypertension (RAS Antagonists Q1 Year-to-Year Trend Example Medication Adherence for Cholesterol (Statins) Comprehensive Medication Review Completion Rate Q Q Q Q Q Q Rating Rating Score Rating Score Rating Score Rating Score Rating Score Score H % 5 89% 5 87 % 5 87% % 1 12% 1 H % 5 91% 5 88% 5 88% % 2 12% 1 H % 5 91% 5 88% 5 90% % 2 20% 1 23
24 Reference Materials n-finalevalrpt.pdf FirstEvalRpt.pdf 24
25 QUESTIONS?
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