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CONTRIBUTOR: MEDICATION ADHERENCE IS A “FORCE MULTIPLIER” FOR MEDICARE ADVANTAGE
PROFITABILITY, ENROLLMENT, STAR RATINGS

Jan 9, 2023
Jason Z. Rose, MHSA



Medication adherence is a key part of Medicare Advantage, and its importance to
improving Star Ratings necessitate a renewed focus on the measure.

There’s never been a more critical time for Medicare Advantage (MA) plans to
focus on improving medication adherence. It’s a key component of the overall
strategy for the MA plan to improve Star Ratings, competitiveness for the annual
enrollment period (AEP), and overall plan profitability.

With the COVID-19 public health crisis tapering off, CMS is demanding plans
refocus on outcomes by ending critical Star Rating performance safeguards
designed to protect plans during the crisis. As a result, 2022 Star Ratings
performances that rose to all-time highs have now dropped back down to Earth.
CMS notes nearly 70% of MA prescription drug plans earned a rating of 4.0 Stars
or higher in the 2022 Star Ratings compared with 49% for 2023.



Improving and/or maintaining high-performing MA Star Ratings can be challenging,
even for plans that excel each year. Rising cut point thresholds make it even
harder to move the needle and reach or exceed 4.0 Stars, the point when plans
can start to capture Quality Bonus Payment (QBP) distributions. The infusion of
these performance-based revenues improves member benefits, ultimately attracting
more enrollees. Between the QBP and approximately 3 million new members being
added annually to MA, as well as lower voluntary attrition, health plans stand
to gain a portion of the approximately $50 billion in available revenues each
year.

Medication adherence is a “force multiplier” directly related to many other
heavily weighted and influential components of the Star Ratings system. What
plans should be aware of is the influence of triple-weighted medication
adherence measures, along with their cascading impact to related Healthcare
Effectiveness Data and Information Set (HEDIS) and Consumer Assessment of
Healthcare Providers and Systems (CAHPS) measures. Fortunately, there is a path
to be a step ahead of the curve— maximizing year-round medication adherence
performance.

There is no dispute that medication adherence is critical for plans to achieve
the Triple Aim of health care: better outcomes, improved patient experience, and
lower cost of care.



The Star Ratings system continues to get more challenging

The Star Ratings rubric constantly evolves to keep MA plans on their toes.

Among the 34% of measures whose cut points got harder to achieve for 2023, Star
Ratings are some of the most historically challenging for health plans. The cut
points for key medication adherence measures, including hypertension
renin-angiotensin-system (RAS)-acting agents adherence, medication for
cholesterol (statin) adherence, and statin use in persons with diabetes, have
all become harder for plans to reach higher performance. These measures are also
triple weighted and heavily influence overall Stars performance for plans.

MA plans must find new strategies to navigate an increasingly challenging
environment for members whoi are perpetually nonadherent. Focusing on areas that
have the highest impact on the Star Ratings, such as medication adherence, will
help ensure plans can earn their maximum performance. In turn, MA plans can
successfully achieve exponentially greater success, which results in more QBP
dollars, better member benefit offerings, and the key prize: increased
membership enrollment revenues.

Darwinism in health care: Star Ratings' impact on “plan survival”

The aggregate Star Rating a plan achieves is imperative to its profitability and
growth. Further, without QBP funding from CMS, the health plan can’t afford
competitive member benefits and lower premiums. These facts directly impact plan
selection during the Medicare AEP, where beneficiaries choose their insurance
option. Moreover, after the beneficiary inputs their ZIP code and prescription
drugs into the Medicare enrollment website, CMS automatically custom sorts MA
plans with the best benefits, lowest premiums, and highest Star Rating.

With an average of about 40 MA plans to choose from on multiple screens to click
through, the first few plans displayed can automatically gain preference for
member selection. On the other hand, plans with fewer benefits, higher premiums,
and lower Star Ratings are sequenced in the latter pages of plans to select. For
members already enrolled in MA plans that score less than 3.0 Stars for 3 years
in a row, CMS can send a letter to the member, encouraging them to immediately
change to a health plan with a higher Star Rating. Also, beginning this year,
CMS now restricts membership enrollment growth for plans scoring 2.5 Stars or
lower.

It’s also important to note that in the 2023 Star Ratings, average voluntary
member attrition rose to 17.15% (up almost 2.5 points from 2022)—reflecting
members who chose to leave their MA plan and enroll in a different plan. This is
critical to plan survival, given that revenue lost through member attrition
($15,250 per covered person per a recent report from the Kaiser Family
Foundation) will need to be made up by plans through member enrollment.

To summarize the overall impact of Star Ratings, plans with more Stars lead
toward more revenue through increased member enrollment. A landmark Guidehouse
study found that plans earning 1 additional Star can expect an enrollment bump
between 8% and 12%. Those findings validated prior research published in JAMA
linking the Star Rating system’s association with beneficiary enrollment
decisions to an increase of 9.5% enrollment growth. But this isn’t the only
consideration for plans looking to improve their Star Rating.

The Guidehouse study went further, documenting that plans improving from a
3.0-Star to 4.0-Star Rating would increase plan revenues between 13.4% and 17.6%
through increased enrollment revenue and QBP. In effect, Star Ratings scores
direct approximately $50 billion in revenue for MA plans.



For example, consider an MA plan with 50,000 enrolled members. By moving from
3.0 to 4.0 Stars, the plan would earn a combination of bonuses and rebates that
would affect average annual revenue per member (growing estimated benchmark of
$15,000). Along with anticipated enrollment growth of 6000 new members per
year—a 12% increase based on the Guidehouse study assertions of increased
enrollment—the plan could expect to see an estimated $134 million in revenue
growth (more membership and higher revenue per member), all stemming from higher
performance on the all-important Star Ratings.

Medication adherence: the compounding catalyst

In and of itself, medication adherence has a direct impact on the 2023 Star
Ratings:

 * Medication adherence (3x weighting; ~9% of overall Star Rating)
   * Medication adherence for hypertension (RAS antagonists)
   * Medication adherence for cholesterol (statins)
   * Medication adherence for diabetes medications


Medication adherence is also a transformative influence permeating every Star
Ratings framework layer. It’s a force multiplier directly related to many other
heavily weighted and influential components of the system, including:

 * CAHPS patient experience (33% of overall Star Rating): Medication adherence
   improvement is a pathway to overall engagement improvement; thus, the tactics
   used in the adherence program inherently impact CAHPS patient experience
   measures.
 * Drug plan quality improvement (5.2% of overall Star Rating): The quality
   improvement factor comprises year-over-year measure momentum across Part D,
   heavily influenced by medication adherence and CAHPS measures.
 * Part C blood sugar and pressure control measures (4.2% of overall Star
   Rating): Diabetes blood sugar control and controlling blood pressure measure
   outcomes directly tie to medication adherence—after all, this control is the
   direct target of these prescriptions.
 * Statin use in persons with diabetes and statin use in persons with
   cardiovascular disease (2.1% of Star Ratings);: Statin compliance is the
   cornerstone of these condition-specific measures. Getting overall statin
   utilization patterns on track directly influences these scores.


As a reflection of behavioral persistence, a proxy for experience and
satisfaction, a lever for normal laboratory results, an ingredient in trend
measurement, and an important corollary of retention, medication adherence
carries so much weight that it warrants significant attention. Forward-thinking
plans must invest in proactive and comprehensive year-round medication adherence
engagement programs, particularly for the complex, high-risk members who
typically struggle with managing their medications.

Reviewing the 2023 Star Ratings results (released in October 2022 for 2021 plan
year results), medication adherence measure performance had a profound impact on
the overall Star Rating. Per the summary below, the following perspectives
clearly convey how impactful medication adherence measures (including the
triple-weighted RAS, statin, and diabetes measures) are to the overall MA Star
Rating:





Further details are described in the following table:





Developing and deploying a robust, year-round medication adherence strategy will
help plans achieve their Triple Aim goals for upcoming performance periods and
achieve higher Star Ratings in an increasingly competitive environment.


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