The healthcare industry has made its verdict: value-based care is the future. But in a system where payments are tied to performance, how do we prove value? How do we translate better patient health into a language that regulators, members, and stakeholders can all understand?
The answer lies within the structured framework of CMS quality measures. Acting as the framework for modern healthcare initiatives, these measures provide the data-informed structure for delivering care that’s both high-quality and high-value.
What are CMS quality measures?
CMS quality measures are standardized tools that the Centers for Medicare & Medicaid Services (CMS) use to quantify the quality of healthcare. Far more than a simple checklist, these measures evaluate the entire care journey, including:
- Clinical processes: Are providers following evidence-based practices for prevention and treatment, such as prescribing statins for cardiovascular disease?
- Patient outcomes: Are patients’ health conditions, like diabetes or hypertension, improving as a result of the care they receive?
- Patient perceptions: Do patients feel heard, respected, and engaged in their own care decisions?
- System efficiency and safety: Is care being delivered in a coordinated, safe, and timely manner, reducing hospital readmissions and medication errors?
Ultimately, these measures are the building blocks of clinical quality improvement. They transform abstract goals like "better care" into tangible data points. Further, these measures are the engine behind the CMS National Quality Strategy, which aims to create a more equitable, safe, and patient-centered system for all.
By focusing on metrics that matter, like medication adherence and the management of chronic conditions, CMS quality measures push the entire industry toward a future where healthier patient outcomes define value.
Key CMS quality programs and measures impacting pharmacy
Pharmacists are no longer just dispensers of medication; they are critical access points for care, uniquely positioned to influence the very metrics that define a plan's success. For health plans seeking to thrive in a value-based landscape, it’s essential to understand there’s a direct line between pharmacy services and quality scores.
Key programs like the CMS star ratings and performance on HEDIS measures are deeply intertwined with the quality of pharmacy care members receive, making an integrated pharmacy solution a cornerstone of any successful clinical quality improvement strategy.
CMS Star Ratings
The five-star quality rating system is one of the most visible indicators of a Medicare Advantage plan's performance. For members, it’s a guide to choosing a high-quality plan. For health plans, it’s a direct driver of enrollment and revenue. A significant portion of these ratings is tied to medication-related measures, placing pharmacists on the front lines of star performance.
The most heavily weighted CMS star measures revolve around medication adherence for chronic conditions such as diabetes, hypertension, and high cholesterol. When a member adheres to their prescribed medication, it is a powerful indicator of effective disease management and positive patient outcomes. Pharmacists, through consistent, high-touch engagement, can:
- Identify and resolve barriers: Address social determinants of health (SDOH), healthcare disparities, cost concerns, or side effects that prevent medication adherence.
- Provide targeted patient education: Reinforce the importance of a medication regimen, ensuring patients feel empowered and understood.
- Improve medication safety: Conduct comprehensive medication reviews (CMRs) and targeted medication reviews (TMRs) to prevent adverse drug events, a key component of patient safety and experience measures.
HEDIS scores
The Healthcare Effectiveness Data and Information Set (HEDIS) is another critical tool used by the vast majority of American health plans to measure performance on important dimensions of care and service. Many HEDIS scores are directly influenced by pharmacy-related activities, making pharmacists invaluable partners in closing care gaps.
Similar to star ratings, HEDIS heavily emphasizes medication adherence as a marker of effective care for chronic diseases. A plan's ability to demonstrate high adherence rates is fundamental to achieving a strong HEDIS score. Beyond adherence, pharmacists contribute by supporting other HEDIS measures, such as ensuring patients receive persistent medication therapy after a cardiovascular event or managing blood pressure.
By integrating pharmacists into a collaborative care model, health plans can leverage their expertise to drive significant improvements. Through targeted outreach and clear communication, pharmacists ensure members not only have their medications but also understand how to use them to achieve the best possible health. This collaborative effort transforms performance on paper into a tangible reality of improved patient health and stronger, more competitive HEDIS scores.
The importance of prioritizing CMS quality measures
As part of the greater healthcare ecosystem, health plans and remote pharmacists aim to accomplish the same goal: provide high-quality, patient-focused, and value-centric care. This model redefines success by shifting focus to the quality of patient outcomes rather than the quantity of services performed. As a critical framework for value-based care, CMS quality measures are a blueprint for fostering a healthier population that reaches more people.
Actively focusing on these metrics creates a powerful ripple effect, delivering distinct, tangible benefits not only for health plans but also for the clinical professionals. For health plans and remote pharmacists alike, embracing a strategy centered on quality is a strategic imperative to achieve the mission of improving lives through value-based care.
Benefits for health plans
For health plans, a proactive and sophisticated approach to CMS quality measures is the key to market leadership and long-term viability. The advantages of embedding clinical quality improvement into the core of your operations are clear and compelling:
- Enhanced financial performance: Higher CMS star measures and HEDIS scores lead directly to increased quality bonus payments (QBPs) and rebates from CMS. This financial upside can be reinvested into member benefits, technology, and further care improvement initiatives, creating a cycle of continuous growth.
- Increased member enrollment and retention: Top-tier star ratings are a powerful marketing tool, attracting discerning members who seek the best possible care. Delivering consistently high-quality experiences and positive patient outcomes builds loyalty and reduces member churn, securing a stable membership base.
- Reduced system costs: A focus on preventative care and medication adherence naturally leads to fewer costly downstream events like emergency room visits and hospital readmissions. In fact, improving medication adherence can reduce annual healthcare costs in the U.S. by more than $100 billion. Effective management of chronic diseases isn’t just good care; it's good economics.
- Strengthened provider partnerships: When health plans provide the right pharmacy technology and data-driven insights, they empower their network providers and pharmacists to succeed. This collaborative approach strengthens relationships and creates a more integrated, effective, and efficient care delivery system.
Benefits for remote pharmacists
For pharmacists, the shift toward value-based care and the focus on CMS quality measures represent a profound opportunity to elevate their role and expand their clinical impact. A modern pharmacy solution equips remote pharmacists to move beyond dispensing and become central figures in a patient's health journey.
- Demonstrate tangible value: The right pharmacy technology allows pharmacists to meticulously track their interventions and link them directly to improvements in medication adherence, HEDIS scores, and star ratings. This data-driven approach makes their clinical and financial contributions visible and undeniable.
- Greater job satisfaction and flexibility: Contributing to meaningful, measurable improvements in patient health provides immense professional satisfaction. A digital pharmacy framework offers the flexibility to provide this high-impact care from anywhere, fostering a better work-life balance and reducing pharmacist burnout.
- Become an indispensable partner: As health plans increasingly prioritize quality scores, pharmacists who are adept at navigating and improving these metrics become indispensable partners. This expertise solidifies their position as a vital part of the collaborative care team, essential to achieving shared success.
The connection between a pharmacist’s clinical skill and the power of technology is precisely where meaningful, scalable clinical quality improvement occurs. While a pharmacist’s expertise is the catalyst, the right pharmacy technology provides the engine to drive results across an entire member population.
How pharmacy technology aids in clinical quality improvement
Understanding the importance of CMS quality measures is the first step. Actively improving them requires moving from insight to action, and that action is powered by modern pharmacy technology. To succeed in a value-based care environment, health plans and pharmacists need intelligent, intuitive tools designed to facilitate high-quality patient interactions at scale.
How Aspen RxHealth supports CMS Quality Performance
Through innovative pharmacy solutions, Aspen RxHealth empowers both health plans and pharmacists to not only meet but exceed CMS quality standards. Our innovative platforms are purpose-built to bridge the gap between quality goals and patient outcomes.
BeWell by Aspen RxHealth is the technology platform that powers Aspen RxHealth’s nationwide network of pharmacists. Using BeWell, our pharmacists deliver high-quality, personalized clinical services, from medication therapy management (MTM) to adherence counseling and chronic condition support. With the BeWell platform, teams can streamline MTM across devices for efficient and patient-focused services. BeWell enables:
- Scalable, one-on-one consults with licensed pharmacists
- Targeted outreach based on member needs, language, and geography
- Real-time tracking of interventions and outcomes tied to CMS quality measures
- Resolution of real-world adherence barriers like cost, confusion, or side effects
For health plans with in-house clinical teams, Alliance by Aspen RxHealth offers access to the same powerful platform our pharmacists use, tailored for your internal use.
Alliance equips your team with:
- A streamlined interface for conducting and documenting clinical consults
- Built-in workflows to support MTM, adherence monitoring, and patient follow-ups
- Seamless integration of clinical protocols aligned with CMS quality programs
- Data capture and analytics to demonstrate ROI and quality impact
Both Alliance and BeWell are designed to tackle the most heavily weighted and challenging component of quality scores: medication adherence. By enabling personalized, consistent, and empathetic patient engagement, our solutions help uncover and resolve the real-world barriers that prevent patients from taking their medications as prescribed. This targeted approach is fundamental to improving CMS star measures and HEDIS scores.
We believe in preparing our partners for the future of quality care. While comprehensive medication therapy management (MTM) isn’t a current star measure, it’s expected to be included in 2027. With that in mind, the best time to prepare for upcoming CMS changes is to start today. By developing these workflows and demonstrating their value now, your organization will be positioned to excel when the standards evolve, turning future requirements into current strengths.
Ultimately, achieving excellence in a value-based world demands a streamlined strategy, clinical expertise, and powerful telepharmacy solutions. With Aspen RxHealth, health plans and remote pharmacists gain an indispensable partner, equipped with the innovative solutions needed to improve quality, enhance patient lives, and lead the future of care. Book a demo today to get started!
