Medicare star ratings: stakeholder proceedings on community pharmacy and managed care partnerships in quality

Abstract

Objectives: To 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 sources: National thought leaders at a conference titled CMS Star Ratings: A Stakeholder Discussion, held on March 21, 2013, supplemented with related information from the literature.

Summary: The 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.

Conclusion: The 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.