Project #38: Securing High Performance for HAP Medicare 5-Star Program through Collaboration with Pharmacy Advantage and Medication Therapy Management Team

Project #38: Securing High Performance for HAP Medicare 5-Star Program through Collaboration with Pharmacy Advantage and Medication Therapy Management Team

Description

Across the US, health plans are given a Star rating of 1 through 5 (5 is best) by the Centers for Medicare & Medicaid Services (CMS) for their combined performance on quality, member experience and plan operations. Health plans that achieve four (4) stars or higher qualify for federal bonus payments that equate to an extra 5% per member per year. For health plans that earn a bonus payment, this bonus is applied towards enhancing the benefits offered to its Medicare beneficiaries. enhancing benefits creates a competitive advantage and attracts, more members to join the health plan’s Medicare plans. For Health Alliance Plan (HAP), achieving four (4) stars equate to over $40M bonus payment for reinvestment into its Medicare members.Medication adherence in key drug classes, based on evidence-based guideline recommendations, to treat chronic disease states such as Diabetes, Hypertension and Coronary Artery Disease is associated with improved clinical outcomes. Ultimately, greater medication adherence rates tend to lead to improved management of multiple chronic conditions. As such, the Medicare Stars Program has placed the highest weight available, 3, on all three of the drug adherence metrics included in its overall Star rating of payers: 1. Diabetes drugs, 2. ACEI/ARBs (drug class used for blood pressure management and kidney protection in those with diabetes), and 3. Statins (drug class used for cholesterol management). To ensure Medicare beneficiaries have an adequate supply of medication on hand to manage their health conditions, CMS announced a policy change in 2019, with an effective date of 1/1/2020, allowing mail-order pharmacies to auto-ship medications to Medicare beneficiaries. For Health Alliance Plan (HAP) to maintain an overall four (4) star or higher rating for the Medicare Stars program, our processes are continuously evaluated for improvement in patient experience, plan operations and quality metrics. Since HAP’s Medicare population use of mail order pharmacy use in 2019 was 6% and national average was estimated to be approximately 15% to 20%. Understanding this, HAP needed to increase use of its mail order pharmacy to maintain a competitive advantage for its Medicare Star performance of the three drug adherence metrics (due to new auto-shipment policy). Our goal was to increase overall adoption of mail order pharmacy usage to 20%. To achieve this goal, a collaborative partnership with Community Care Service – Pharmacy Advantage (Henry Ford Health System (HFHS) Mail order Pharmacy) and HAP Health Care Management was expanded to include promotion of Free In-Home Delivery Medication Service through Pharmacy Advantage (Pharm Adv) for the Medicare Advantage population. Through this partnership the HAP/HFHS Ambulatory Clinical Pharmacy Programs worked closely with Pharm Adv for sharing past lessons learned on drug adherence best practices, sharing timely prescription claims data, stratifying patients for drug adherence outreaches to assure HAP Medicare member experience remained high with no duplicative outreaches made by the Medication Therapy Management (MTM) technicians, and proactively identifying opportunities to move patients to Pharm Adv for improved outcomes. The overall aim of this project was to assure HAP’s Medicare 5-Star adherence metrics remain competitive considering CMS’s new auto-shipment policy by increasing use of Pharm Adv’s Free In-Home Medication Delivery service in collaboration with the HAP/HFHS MTM team.

Publication Date

3-16-2021

Project #38: Securing High Performance for HAP Medicare 5-Star Program through Collaboration with Pharmacy Advantage and Medication Therapy Management Team

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