Mastering Drug Measures: Best Practices for Higher Star Ratings

Drug measures and performance

In our November 25, 2024 blog — The Importance and Challenge of Drug Measures in Medicare Advantage Stars  — we discussed the importance and challenges of drug measures in the MA Star program. The ratings for drug measures are low and have dropped on a majority of the five measures for Star Year (SY) 2025. As you can see below, these measures weigh down on overall and Part D summary rating achievement. They are in the low 3s and high 2s.

Of note is that the three Medication Adherence measures were all 3.2 or 3.3 and they are each 3x weighted. What’s more, the adherence measures will see a major change in Measure Year (MY) 2026 (SY 2028). A risk-adjustment methodology is applied and there will be the removal of Inpatient Hospital and Skilled Nursing Facility positive adjustments. While the measures drop to 1 weight that Star Year, they return to three weighting in SY 2029.

Complicating drug measure performance further is the fact that there are two new measures coming in for MY 2025/SY 2027 and these are different types of measures than in Star now. 

• Concurrent Use of Opioids and Benzodiazepines (COB) (1x for SY 2027) – This measure determines the percentage of individuals ≥18 years with concurrent use of prescription opioids and benzodiazepines for ≥30 cumulative days.
• Use of Multiple Anticholinergic Medications in Older Adults (Poly-ACH) (1x for SY 2027) – This measure determines the percentage of individuals ≥65 years of age older adults with concurrent use of ≥2 unique anticholinergic medications.

Drug measure attainment challenges

Data Lags – First, the earlier drug measure blog discussed the complications unique to drug measures versus those of clinical measures. CMS calculates the drug measures using a Pharmacy Quality Alliance (PQA) base measure and then applies various CMS-specific parameters.  While CMS provides patient safety and adherence reports, the data and calculations lag actual service dates significantly. As an example, the first 2024 reports were released on April 30, 2024 and contained PDE data for dates of service between January 1, 2024, and March 31, 2024. This amounts to a 120-day lag at the beginning of the year and up to a 60-day lag thereafter. 

Continuous Nature – Second, unlike most clinical measures which are “one-and-done” (you become compliant with one hit), medication adherence and drug safety measures need year-round tracking and remediation. Many plans lose critical time to close medication adherence gaps. Further, it is not enough to get to an adherence rate like 80% to get a high score on a medication adherence measure. The drug safety measures allow only a 30-day overlap before someone is deemed non-compliant. 

Data Complexity – Third, the measures need accurate eligibility, medical claims, and pharmacy claims to ensure correct calculation by CMS. Eligibility for a measure, exclusion from a measure, and adjustments to a measure all need to be calculated. Medical claims are submitted by plans via a complex encounter submission process. Pharmacy claims are submitted via an equally complex PDE process.) 

Remediation Variation –  Last, as alluded to above, current drug measures actually have three sub-types, which complicates remediation activities as each type must be approached somewhat differently. (Go to the earlier blog to understand the differences and complexities)

Drug measure best practices

Drug measures are challenging due to all the complexities noted above. But there are some best practices plans can implement to move their performance up. 

Do not rely alone on Acumen patient safety reports — Relying just on Acumen reports will likely mean poor measure scores given the significant lag noted above. A plan or a PBM should license and build (or at the very least seek to proxy) the PQA measures used and take into account any CMS modifications. 

Reduce or eliminate the claims and reporting lag – The Acumen lag is related to the time for PDE submission, a claims submission cutoff for each report, and the time it takes Acumen to assemble data and issue the report. Plans or PBMs should use pharmacy claims instead of PDEs and update gaps as often as daily. This will super-charge your efforts to drive drug measure improvement. 

Some may question why you should use pharmacy claims vs. PDEs as PDEs appear to be the source of truth for CMS. Yes, but when you are seeking to close gaps with members and providers, the PBM claim is the fastest way to identify gaps. This should be your source of truth for care gap remediation. You can reconcile where you are between pharmacy claims and PDEs separately (see below).

Intervene on medication adherence measures as often as daily – Refresh each of the three adherence measures over night for the previous days’ claims. Look at upcoming fills and whether these fills are overdue. Use AI agents or IVRs to send out electronic calls to remind members of upcoming refills or if they are overdue. Overdue calls might have a human touch through an adherence team or call center. The same daily lists could also be shared with provider groups if desired. These reminders and overdue calls are a best practice to reduce the number of gaps days in the proportion of days covered (PDC) formula.

Intervene on all drug measures weekly — Refresh each drug measure over night for the previous days’ claims. Each week produce internal refreshed care gaps lists for health plan departments as well as panel lists for providers. These should give the latest picture of compliance and adherence for each member. Include critical information to help health plan associates and providers remediate care gaps, including the following:

• Member eligibility 
• Member demographics
• Social risk factor information 
• Language
• Drug and other clinical information
• Measure status, including key medication gaps, fill dates, fill duration, and PDC info for medication adherence
• Prescriber information
• PCP information

Target at-risk individuals on drug safety measures – The new COB and POLY-ACH drug safety measures are extremely complex. Because most scripts are 30 day fills or more, by the time someone hits the drug measure algorithm, the vast majority are classified as non-recoverable for the entire year. 

It is important to attack these measures in two ways: (1) Ensure doctors remediate those that are non-recoverable so they don’t count against you in the following year. Earlier intervention, the better. (2) Track individuals each month that are at-risk of becoming non-recoverable. For example, track folks that have a history of opioid or benzodiazepine use but have not yet met the fill requirements of the measure. Stratify the risk of these individuals based on their prescription history and conduct outreach to providers.

Multi-modal communication based on member profile and engagement history analysis – Each member may respond differently to communication from the plan. Outreach to improve drug measure compliance has to be done in a culturally competent manner, meet member preferences, and use targeted modes that meet the profile (including barriers) identified. Special attention to language is also key.

Member health education and monthly campaigns – High-performing plans are building out health education campaigns performed as often as monthly. These campaign focus on healthy behaviors, disease state education, social determinant barriers education, benefit and supplemental benefit education, the importance of medication adherence and drug compliance, drug safety, and flu and other vaccine reminders. In addition, targeted campaigns for members in the measure denominator are important, including disease state education. Member newsletters should also educate on drug compliance, safety, and adherence.

Links to other health plan departments – Ensuring appropriate linkages to other health plan departments is critical for high performance on drug measures. If a member is chronically non-compliant or non-adherent, it makes sense to assign drug measure remediation to a given department. In other cases, departments could be an escalation point to solve temporary issues. And overall, drug measure performance should be shared with various departments so they can solve issues as part of their daily tasks. 

Examples of departments that can own or solve drug measure compliance problems include:

• Special Needs Plan (SNP) units
• Medication adherence and therapy management departments
• Prior authorization and utilization management departments
• Case and disease management departments
• Other care management 
• Health education
• Member services

HRAs and care plans — Another best practice is ensuring SNP and disease state health risk assessments question enrollees on drug affordability and prescription drug access or barriers. As well, putting ongoing drug compliance and adherence in SNP, case management, and disease management care plans is essential.

Integrate with care transitions – When it comes to non-compliance and low adherence, members can have two types of drug gaps – short and long. Short gaps tend to be throughout the years and usually represent overdue or missed fills. Long gaps can be a period of weeks or months when a chronic drug regimen is not reactivated after a hospitalization. It is important to integrate gap lists with care transition units to ensure that patient engagement and medication review occurs after an inpatient stay and that chronic medications are reactivated timely and safely during recovery.

Provider education – To maximize performance, it is also critical to educate providers on the purpose and complexity of the Star program. Educating providers on how a member qualifies for a given measure, how they may be excluded, and medications needed to be compliant are also critical. Coordinating between multiple providers is a must for the new drug safety measures. 

Provider incentives — As with clinical measures, drug measure achievement should be incentivized with quality bonuses or factors within applicable value-based care (VBC) payments. Plans should also adopt provider report cards for all measures, disclosing the provider’s panel results for each measure and overall as well as against peer groups.

Validate PDEs – It is always good to validate your PDE submissions separate and apart from the delegation to your PBM. Compare your finalized pharmacy claims to PDEs regularly and assess rejections and remediations of PDEs each month. Plans have until June 30 of the following year to submit and remediate PDEs for the previous year. Plans often lose critical drug measure credit because some claims were never submitted and others not successfully remediated. Rejections occur for both clinical and eligibility reasons. 

Plan vs. CMS data analysis and reconciliation – We believe that the biggest improvement comes with closing the lag that often exists in data. But ratings for given drug measures can be incrementally improved as well by reconciling CMS Acumen patient safety reports and core plan data for any discrepancies. It is not unusual that plan data and CMS Acumen data may be different for eligibility, exclusions, adjustments, compliance, and adherence ratios. Plans should take core plan data and compare it against Acumen reports by month. While the plan will have more detailed data than Acumen, you should be able to hone in on discrepancies by member. 

Sometimes, errors are on the plan side and can be remediated – inaccurate eligibility records, PDEs that failed, or medical encounters that failed. But errors can also be found within CMS and Acumen. Plans should be ready to report such discrepancies to CMS when issues are found.

Conclusion

The above can be overwhelming. And a plan may not be able to tackle all of these best practices at once. But research them, create an achievable phase-in of best practices, and implement them. The best practices outlined should help improve measure results over time. Forecast desired improvement in each measure and gauge how you are doing along the way.

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About Lilac

Are you one of the many plans struggling with drug measure achievement? Lilac Software has created a state-of-the-art technology platform aimed at high drug measure achievement. Our PQA-licensed engine has been specifically designed to help you implement the best practices above, including:

• Closing the time gap by using pharmacy claims
• Running measures as often as daily
• Publishing daily and weekly gap lists for research, plan departments, and providers.
• Validating PDEs
• Reconciling CMS Acumen and Plan drug data for each measure

Learn more by visiting our MA Drug Measure Solution page or start a conversation by filling out the form in this link.