CMS Star Ratings are here

Prime Therapeutics (Prime) announced that a record 17 of its clients’ Medicare contracts earned a quality bonus payment. This is based on 2020 Star ratings recently released by the Centers for Medicare and Medicaid Services (CMS).

“The quality bonus payments will equate to hundreds of millions of dollars that our health plan clients will use to offer incremental benefits and/or reduce costs to their members,” says Ben Poehling, vice president, quality and performance programs. “This is another example of how Prime supports making health care more affordable for Medicare members across the country.”

Furthermore, 86 percent of Prime’s MAPD membership is in contracts that earned 4 or more Stars for the Part D rating.

Stars are made up of many elements

Dozens of individual measures roll up into a plan’s overall Star rating. Part C measures relate primarily to the health plan and medical benefit. Part D measures relate primarily to the drug benefit. As a pharmacy benefit manager, Prime influences many of the 13 Part D measures reflecting operations, customer experience and medication adherence. Prime also impacts a handful of the Part C measures.

“There is a lot of interaction between Part C and Part D measures,” explains Kim Kishel-Geiger, senior director, quality management. “The data-driven, partnering approach that Prime deploys with clients is showing results through improved ratings,” added Kim.

Challenged by continuous improvement

The star rating system is designed to continually improve the quality of care provided through Medicare. To do that, CMS evaluates performance data each year; they may adjust the cut points for metrics. This can make it difficult to earn higher Star ratings.

Prime programs like GuidedHealth, SmartAdherence and Quality Based Networks have helped improve adherence rates. These receive more weight than other metrics in determining ratings.

“The 4- and 5-Star cut points continue to be more and more challenging to achieve,” says Kim. Prime continually innovates, particularly in the areas of data and analytics, clinical programming and provider partnering, to stay ahead of the curve.”

“CMS had foresight when designing the Star rating system,” says Ben. “The agency rewards plans that deliver higher quality across both the medical and drug benefit. This is 100 percent aligned with our goal at Prime to lead the market in total drug management solutions that put people first.”