With an Eye on 2012 Quality Ratings, PBMs Help MA Plans Fire Up Their Star Power
Reprinted from DRUG BENEFIT NEWS, biweekly news, proven cost management strategies and unique data for health plans, PBMs, pharma companies and employers.
By Steve Davolt, Editor
March 4, 2011Volume 12Issue 5
Medicare Advantage plans have only from now until June of this year to make changes that can help them enhance their star quality ratings for 2012, and the clock is ticking. PBMs are discovering ways they can make themselves indispensable allies to MA plans in this effort, helping them to boost their ratings and become eligible for coveted bonus payments.
“The primary data that PBMs can provide revolves around drug utilization and through a PBM’s MTM [i.e., medication therapy management] programs,” Miryam Frieder, a senior manager in Avalere Health LLC’s health reform practice, tells DBN. “A PBM can even marry drug and medical claims data if a plan wants to share that data.”
By supplying a host of data, Colorado-based PBM HealthTrans is turning out to be an ideal partner to MA plans seeking to up their quality ratings. “Our experience with the data being integrated into care management programs assists in providing interventional care and retrospective review into quality management programs,” Jon Andrews, director of product and sales strategies for HealthTrans, tells DBN.
HealthTrans provides prescription-level claims information that offers both a qualitative and quantitative view of patient and physician activity. The claims data can help an MA plan review disease states and supports disease management and MTM programs. The incorporation of the data into medical records or as a stand-alone offering provides an immediate view of the patient and assists in achieving improved health outcomes.
To provide MA plans with additional informational support, HealthTrans identifies metrics that cross domains, e.g. enrollment and clinical. “We assist MAs with their data but also with their overarching processes, which helps to ensure high star ratings,” Andrews says. “Moreover, our industry experts deliver consultation and pharmacy expertise to support our health plans.”
Similarly, Philadelphia-based PBM PerformRx, LLC, a division of the AmeriHealth Mercy Family of Companies, is making itself useful to MA plans aspiring to boost their CMS quality rankings. “PerformRx’s star rating improvement strategy is a systematic, measured and unified approach,” Mesfin Tegenu, president of PerformRx, explains to DBN. “We replicate CMS star ratings methodology. We identify and correct low-performing measures and assist in maintaining high-rated measures. We utilize our unique technology to provide enhanced drug therapy management services.”
Invaluable Partners
Tegenu points out that PerformRx can help an MA plan partner boost its quality through the PBM’s direct impact in the areas of pharmacy and prescriber customer service, coverage determination via such means as prior authorizations and appeals, drug pricing, patient safety and audit findings. But those are only the most obvious methods. “An important indirect way to impact an MA plan’s star rating positively is providing an enhanced member complaints resolution method, which improves overall member experience and also enhances MA plans’ CAHPS [i.e., Consumer Assessment of Healthcare Provider and Systems] survey results,” Tegenu says.
To become invaluable partners to MA plans in their quest for quality improvement, PBMs need to become intimately familiar with the star rating system, Tegenu observes. “PBMs must develop expertise in understanding and meeting goals outlined by CMS to boost their client’s star rating,” he says. “Expertise such as having controls in place to assure data quality and integrity, appropriate claims processing, TrOOP [i.e., true out-of-pocket] facilitation and reporting — all of which contribute to the plan’s star ratings — should be primary focus points.”
To that end, PerformRx has implemented monitoring and auditing processes to identify areas for improvement. “Our collaborative approach with MA plan sponsors includes meeting shared star rating measures by applying PerformRx-developed methodology and best practices,” Tegenu says. Some of those activities include:
· Call center support: PerformRx closely monitors call center performance and conducts self-audits using the same methodology that CMS uses. The PBM tracks time on hold, disconnect rate, call answer time and accuracy of information given.
· Enhanced drug therapy management: Using the PBM’s integrated data warehouse and portal technology, PerformRx’s clinical pharmacists obtain both pharmacy and medical data (if provided by the plan) to design enhanced drug therapy management programs to minimize drug interactions, potential therapeutic failures and duplicate therapy. In addition, PerformRx’s drug therapy management team coordinates with the MA plan to augment its care management.
· Plan finder/pricing: PerformRx routinely monitors pricing submitted to CMS for accuracy, making sure that prices submitted to CMS for a specific time period are the same as in the claim submitted for that period.
· Patient safety: PerformRx reviews Acumen reports provided by CMS to MA plans, using the information to conduct targeted prescriber outreach to influence prescribing patterns. The reviews enable PerformRx to head off such patient risk factors as the prescription of high-risk medications for the elderly or certain blood pressure drugs that can adversely affect patients with diabetes.
Improving Patient Safety
HealthTrans has also put in place programs that can help MA plan partners expand on their patient safety scores. The PBM conducts comprehensive drug use review reports, coordinates clinical rules and edits to ensure correct implementation and ongoing management, and audits plan designs to ensure that rules are set up appropriately. HealthTrans’s tight policing of every phase of its processes includes double-checking itself. “We regularly review criteria to make sure we are taking the appropriate steps from a prior-authorization standpoint,” Andrews says.
To assist MA plans in their goal of improving star ratings, PBMs are not merely providing data, Avalere’s Frieder says. “Rather, it’s the implementation of enhanced clinical management control” and all the quality assurance measures that entails.
In terms of what PBMs can expect to get in return for rendering such vital assistance to MA plans, an age-old symbiosis applies. “In exchange for assisting clients with improving their star ratings, HealthTrans anticipates high rates of client and member satisfaction, which in turn will lead to high client and member retention rates,” Andrews says.
No comments:
Post a Comment