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Medication adherence a big factor in Medicare Advantage star ratings

The bonus pool size in 2018 was $6.3 billion, which goes to 4-star and above plans as $500 per member, per year.

Susan Morse, Senior Editor

Medicare Advantage plans that do well in star ratings must do well with medication adherence.

This is because 50% of star ratings are weighted on medication adherence, according to Jason Rose, CEO of AdhereHealth, a company focused on helping plans achieve adherence. Medication adherence includes measures such as blood sugar glucose, biometric screening and other factors affected by whether members take their prescribed drugs.

In the star ratings, the Centers for Medicare and Medicaid Services has moved from giving credit for reporting measures to improvement in results, Rose said. It's not enough that plans show patients picked up their drugs from the pharmacy.  They must show that a patient is taking the drug 80-percent of the time in a given year.

"Numbers have shown CMS has pushed on quality of care, with the types of things they're weighting," Rose said.

Adhere works with several dozen MA plans to help them move the needle on star ratings, taking 100 percent risk, according to Rose.

WHY THIS MATTERS

Star ratings are important to MA plans because of bonuses that help improve medical benefits, the competitive edge this creates, and as a tool in promoting the plans to beneficiaries.

CMS has an annual pool of money for plans rated 4 stars and above, to be used to improve the quality of care. The mandate is 100% of the money must go to improve the medical benefit.

The pool size from 2018 was $6.3 billion, according to Rose, which goes to the higher rated plans as $500 per member, per year, on top of the premium.

"They should have enough funding to have a more competitive product," Rose said.

But it's like grading on a curve, because there's a finite pool of money.

"It's not possible for every plan to get to four stars," Rose said, "because everything is graded against each other."

Approximately 52 percent of contracts for Medicare Advantage plans offering Part D coverage earned 4 stars or higher, compared to about 45% in 2019, according to CMS.

Open enrollment starts today.

THE LARGER TREND

At least a third of all Medicare beneficiaries are in MA plans and this number is expected to climb to 70% by 2030. The estimate is that, by 2030, there will be 55 million members based on the total number of those eligible that year, which is 79 million. 

There's an estimated 1,200 more MA plans being offered for 2020 as opposed to 2018.

SOCIAL DETERMINANTS

Adhere gets, on a daily basis, data from hospital discharges, claims, and other information to identify gaps and to do comparative benchmarking. Then it prioritizes which consumers need to be getting attention for the next day.

A clinical workflow team reaches out to these beneficiaries. Only about half of Americans are taking their medications as prescribed, Rose said.

The social determinants of health is often a factor, which the company addresses through contact with community services such as food pantries,  health plan formularies to lower co-pays to zero and through its own pharmacy company, AdhereRx.

One consumer was choosing feeding her dog versus taking her medication, Rose said. The company contacted the dog food company to get her free dog food.

"We take each case one at a time," Rose said.

Twitter: @SusanJMorse
Email the writer: susan.morse@himssmedia.com