Five-star ratings systems aren’t just for hotels anymore


Elie M. Bahou, PharmD, MBA

Vice President
Managed Care and Business Development
Pharmaceutical Distribution
Cardinal Health

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.

So what can pharmacies do to improve their performance?

1. See how you measure up

It is important for pharmacies to be aware of how they are performing monthly so they know whether they need to make improvements. In an effort to create transparency, Pharmacy Quality Solutions (PQS) created EQuIPP™, an unbiased pharmacy benchmarking tool using current CMS Star Rating pharmacy-related measures. All pharmacies have access to EQuIPP and can see how their pharmacy is performing related to the quality measures on a monthly basis. A number of health plans use EQuIPP to measure pharmacy performance and implement the performance component of their contracts through this tool.

Additionally, pharmacies should be aware of how they are performing with health plans that do not use EQuIPP as their main pharmacy performance resource as this may impact their reimbursements. Health plans that do not use EQuIPP provide pharmacy performance reports through a retail independent pharmacy’s Pharmacy Services Administrative Organization (PSAO) or directly to the pharmacy itself.

2. Identify who needs your help

It is important to identify those patients who are negatively impacting your pharmacy’s performance. With the majority of pharmacy-related measures focused on medication adherence, a few patients can make a great impact on performance, for better or worse. EQuIPP offers Patient Outlier Reporting that allows pharmacies to see which patients are non-adherent to their medications by health plan. Pharmacies should identify these patients and consider ways to increase patient engagement and targeted interventions to address better medication adherence.

Learn more about how your independent pharmacy can elevate patient care and pharmacy performance, and grow your business, in this video:

3. Provide personalized patient care solutions

Retail independent pharmacies understand each patient faces unique challenges to medication adherence, which uniquely positions them to provide personalized care to their patients. OutcomesMTM and Mirixa assign pharmacies Medication Therapy Management (MTM) cases they can complete to help their patients improve their overall wellness, which may also help to improve the pharmacy’s performance measures. Additionally, by syncing medications for high priority patients identified through the EQuIPP Patient Outliers Report, pharmacies will see improved medication adherence as their patients will be more likely to fill their prescriptions with less visits to the pharmacy.

The “Star Ratings” quality ratings system is part of an overall effort by CMS to provide more quality ratings with the goal of creating a more accountable, reliable, and transparent CMS. Furthermore, we know that quality measures will only continue to gain more prominence as healthcare continues to evolve more toward quality driven care. Each of these steps is critical to a pharmacy’s success in “reaching for the stars.”