It is no secret for health plans that providing quality clinical pharmacy services often comes with a high cost.
However, medication-related services – like comprehensive medication management (CMM) – impact nearly 50% of Medicare Star Rating categories. This is due, in large part, to the multiple studies that show how CMM and related services help patients manage chronic diseases (e.g. diabetes, hypertension).
Conversely, effectively providing clinical pharmacy services often comes with a high price tag. And, frequently, the tradeoff comes down to the quality of care and profitability of the program. Often, health plans are left wondering whether providing clinical pharmacy services is financially feasible.
Ultimately, the decision requires a thorough cost analysis before deciding whether clinical pharmacy services should be built and delivered in-house or outsourced pharmacy services are a better route. When making this decision, it’s vital to consider the larger impact on quality improvement measures, including Star Ratings.
What are Star Ratings?
The Star Rating system was introduced more than a decade ago as a way for CMS and consumers to compare different health plans based upon metrics other than cost. A Star Rating is reported for each individual component of a health plan. A five-star rating shows that a health plan delivers exceptional member care and has high member satisfaction.
A health plan Star Rating goes up and down, depending on the quality of the services provided. According to studies, failure to complete comprehensive medication reviews (CMRs) or improve CMM metrics can significantly reduce Star Ratings. Achieving a five-star rating in all three categories – Medicare Advantage, Part D, and Overall Care – is extremely difficult to achieve with in-house resources, even in the best-staffed health plans.
How Star Ratings impact health plan member enrollment & bonus payments
Health plan ratings are measured in nine different categories:
- How many members comply with preventive care and screening recommendations.
- What the health plan does to help with chronic condition management.
- How responsive the plan is, what’s the users’ access to care, and overall care quality.
- The number of complaints and appeals the health plan gets.
- Health plan customer service.
- Medication plan customer service.
- Member complaints and changes in the medication plan’s performance.
- Member experience with the medication plan.
- Accuracy and clarity of prescription drug information as well as pricing.
Star Ratings will affect a plan’s member enrollment numbers. The logic behind this is simple: if a health plan doesn’t maintain a high rating, other potential members will choose a better-performing option. If a plan begins to see a decline in members, they’ll begin to lose money in more ways than one.
CMS Star Ratings are a way for healthcare payers to get bonus funding, based on more than 50 criteria that derive from quality measures like HEDIS. If a health plan has a rating with a minimum of three stars, it will be eligible for bonus payments at the end of the year. However, if the plan has a Star Rating below three, it can potentially get flagged for termination.
Comprehensive medication review completion rate and its impact on Star Ratings
A comprehensive medication review – or CMR for short – gives clinical pharmacists an opportunity to perform services for health plan members. However, due to time constraints related to retail pharmacy environments, most community pharmacists can’t perform CMRs.
Unsurprisingly, a low CMR completion rate can have an impact on a health plan’s Star Rating. In fact, The Centers for Medicare & Medicaid Services (CMS) now includes CMR completion for patients as an element of the overall Star Rating system.
One way to affect the CMR completion rate is to incorporate additional staff, including clinical pharmacists, into the workflow. In a recent study, a team of pharmacists was able to increase the number of completed CMRs from 29 to 158 by adding staff members. However, for most health plans, simply increasing headcount isn’t feasible. They need a more nuanced and technology-enabled solution to boost their CMR completion rates.
How outsourced pharmacy services can cut costs and improve care
Since the COVID-19 pandemic, telemedicine services have become a convenient way for healthcare consumers to connect with their healthcare providers. And for providers, telemedicine technology has enabled practices to increase the population they can serve and the speed at which they can serve them.
It’s not a stretch to see how similar technologies can be used to deliver clinical pharmacy services. Ultimately, the question is whether the investment in this technology would increase profitability. While the exact “profitability” may be hard to measure, there are clear benefits.
First, if health plan members enjoy their experience receiving clinical pharmacy services virtually with a remote pharmacist matched to them, it will have a positive effect on the Star Rating and, in turn, a positive effect on the profitability of the program.
Additionally, technology can enable more efficient touchpoints between members and pharmacists, leading not only to improved relationships but also to improved medication adherence rates. This results in fewer emergency room visits, decreased healthcare costs, and improved patient care and outcomes.
Often, medication nonadherence occurs because members don’t have someone consistently monitoring and advising them on their prescriptions and medication regimens.
There are two primary areas where telemedicine technology can significantly improve the quality of the relationship between member and provider – diversity and area of expertise.
Outsourced pharmacy services can help make the right connections
Every member is unique, as is every clinical pharmacist. Finding a trusted partner with the technology provide outsourced pharmacy services that enhance relationships between members and pharmacists is paramount to improving health outcomes and satisfaction. Often, it can be as simple as aligning patient and pharmacist demographics to make significant improvements.
With more than 20% of people in the United States speaking a language other than English in their households, health plans need to meet non-native English speakers where they are.
Demographics such as language are key factors in how likely a member is to remain adherent, manage their conditions, and take an active role in their health.
Aspen RxHealth pharmacists are matched to health plan members based on clinical and social factors, including:
- Language
- Geographic location
- Pharmacist specialty
- Member disease state
Creating these curated connections allows pharmacists to utilize their full clinical expertise and provide personalized care to each member. Making the best possible connection every time ensures that every consultation is personal, empathetic, and rooted in a desire to improve health outcomes.
Benefits of outsourced pharmacy services
From improving care and relationships to lowering costs, outsourcing clinical pharmacy services can help health plans improve member satisfaction and health outcomes as well as elevate Star Ratings.
Beyond the immediate financial and health benefits, outsourced pharmacy services can help create and maintain long-term relationships with health plan members, boosting your bottom line and member health.
Further, the flexible nature of outsourcing enables health plans to design unique engagement strategies for members while taking on less risk and improving outcomes. It’s a win for members, pharmacists, and health plans.
Explore all the solutions Aspen RxHealth can provide as your clinical pharmacy services partner.