Changes to 2021 Star Rating Cut Points Require Innovative Solutions Centers for Medicare and Medicaid Services (CMS) recently released the latest cut points for 2021 Star Ratings for Medicare plans. Many of the 46 Star measures saw increases, including the Medication Adherence and Statin Use in Persons with Diabetes (SUPD) measures, which now make up 15% of the overall Star Rating. The SUPD measure saw the most dramatic increase in cut points. What used to constitute as a 4 Star Rating for this measure (81% of diabetic members using a statin) now only earns 3 Stars.

With 14 measures tied to the Part D ratings—including the heavily weighted adherence measures—they influence 30% of a plan's overall Star Rating. A pharmacy benefit manager (PBM) can be a valued partner in helping to improve scores. PBMs collect a vast amount of data on Medicare members’ prescription filling habits. By sharing that data in a concise and easy-to-use reporting system, Medicare plans can make a measurable difference in their Stars scores.

A Five Point Solution to Achieving Stellar Stars Scores

Elixir has developed the multifaceted Stars Targeted Analytics & Reporting (STAR) solution to help Medicare clients improve Part D Star measures. Using the latest guidance from CMS, this self-service solution provides clients with on-demand actionable data. It is an interactive analytics tool that provides information on five different key areas to help Medicare plans analyze their standings and determine if targeted member interventions or plan improvements are needed to increase Star Ratings.

The STAR solution consists of the following five tools:

  1. Stars Estimator – The Stars Estimator helps clients track their Stars scores based on CMS cut points. It provides estimates on how many members need to be impacted for a particular measure in order to move up a Star Rating or, conversely, the number of members who would need to adversely change their behavior in order to lower the plan’s Star Rating. This allows plans to play out what-if scenarios with performance and flexible cut point targets.

    The tool also calculates a percentage for individual measures and an overall rating. Estimating Star Ratings in real time allows clients to make mid-year changes to prioritize and positively affect performance and quality scores.

  1. Member Fill Rate Monitoring – This tool tracks the potential over- and under-utilization of medications by drug classification using member adherence data. With the ability to drill down for a holistic view, clients can detect patterns and determine if interventions may be needed to improve care.
  1. Pain Management and Opioid Utilization Monitoring – While the Use of Opioids at High Dosage and from Multiple Providers is only a display measure at this point, we anticipate that it will be a Star measure in the future. Also, with the current epidemic of opioid misuse and abuse in our country, it is an important area for plans to manage.

    The Pain Management tool specifically tracks potential over utilization of opioids to identify members at risk for misuse or abuse. With the Opioid Monitoring tool, clients can also determine patterns of potential doctor or pharmacy shopping. With this data, plan sponsors can decide if interventions are needed to improve care, deter fraud and protect the member.
  1. Prescription Drug Event (PDE) – This tool reviews claims compared to operational and financial PDE results and tracks claim aging and rejections. It helps plans determine what to expect in reimbursements from CMS and provides information on any outstanding reimbursements.

    Clients also receive information as soon as a PDE happens in order to make any necessary adjustments in a timely manner. With PDE acceptance tied to Medicare reimbursement and reinsurance subsidies, this data can help with oversight to improve processes.
  1. Part D Adherence Member Outcomes Reporting – Using data from claims history to track actual member behavior, this tool provides information on the highly weighted medication adherence and SUPD measures. With this data, clients can view member utilization patterns, in real time, and identify gaps.

    Clients can even drill down to get information by member, prescriber and pharmacy in order to perform meaningful outreach that impacts adherence. The valuable insight from the Part D Adherence Member Outcomes tool can help clients determine if interventions are needed that can both improve care and substantially increase their Star Ratings.

This mix of data can provide Medicare plans with the insights they need to make improvements that increase member care and Stars scores. The STAR tools put the solution to achieving stellar Star scores for 2022 and beyond right at clients’ fingertips!