Pharmacy Star Ratings Changes Coming in 2023

Last updated Nov 21, 2022 | Pharmacy Management, Pharmacy Marketing

On October 7th, 2022 the U.S. Food and Drug Administration (FDA) announced its approval of the Boostrix vaccine, commonly known as Tdap (combination of Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis) for immunization administration during the third trimester of pregnancy to prevent pertussis in infants younger than two months of age.

Background

The Star Ratings program was developed by CMS to assess how satisfied Medicare beneficiaries are with their health plan and the healthcare system.1 The Star Ratings program is also known as the Five Star quality rating system in which healthcare is ranked on a scale of 1 to 5, with 5 being the highest and 1 being the lowest.1 The Star Ratings program’s goal is to make it easier for customers, and caregivers to compare nursing facilities and pinpoint areas individuals might want to inquire about.2

Changes made to Medicare Part D:

CMS is releasing further changes with the aim of increasing access to affordable healthcare and enhancing health equity in Medicare Advantage (MA) and Part D by lowering out-of-pocket costs for prescription drugs as well as enhancing customers’ safety. Here are some of the changes that were made to Medicare part D:

a) Lowering Beneficiary Cost-sharing at the Pharmacy Counter

A policy being finalized by CMS will require Part D plans to add any price reductions they obtain from network pharmacies to the negotiated price at the time of sale, allowing the beneficiary to benefit from the savings as well.

b) Marketing and Communications Oversight

Medicare beneficiaries will be secured by CMS’s finalization of revisions to marketing and communications regulations that will guarantee they get accurate and understandable information about their coverage. These regulations include:

  • Strengthening control over third-party marketing companies to identify and prohibit the use of imprecise activities when enrolling beneficiaries in Medicare Advantage and Part D plans.
  • Returning to the requirement that all necessary papers have a multilingual insert informing clients of the availability of interpreting services and information about how to appoint a representative from the plan’s website.

c) Beneficiary Access to Care During Emergencies 

To guarantee that beneficiaries have continuous access to the services they require, the final rule will make sure that when there is an emergency (including a public health emergency) and an interruption in access to healthcare in the MA plan’s service region, the MA plan must adhere to the special criteria.

d) Plans Must Comply With MA Network Adequacy Rules When Applying

Before CMS will accept an application for a new or extended MA contract, MA applicants must show they have a sufficient network of contracted providers to care for beneficiaries. This is done to tighten up application criteria and supervision.

e) D-SNP Operations

For each state where the Dual Special Needs Plans (D-SNP) is provided, CMS is finalizing a requirement that all D-SNPs maintain 1 or more enrollee advisory groups. They must also confer with these committees on a variety of topics, such as how to enhance health equality for underserved communities.

f) Social Factors That Influence Health

Certain social risk factors can influence individual access to healthcare as well as health outcomes such as food insecurity, lack of access to transportation, housing insecurity, and poor health literacy levels. To address this problem, health risk assessments (HRAs) for enrollees must be completed upon enrollment and on a yearly basis by all SNPs. Using HRAs will make it possible for MA SNPs to better detect the risk factors that could prevent enrollees from receiving the treatment they need. This will also allow MA SNPs to consider these risk factors in enrollee care plans.

g) Star rating specific based on Local D-SNP Performance

Medicare Advantage Star Ratings are a crucial tool for beneficiaries to compare plans. CMS is approving a pathway that will enable some states with integrated care programs to mandate that Medicare Advantage organizations create contracts that only contain 1 or more D-SNPs, allowing the contract’s Star Ratings to reflect the local performance of the D-SNPs.

Road Towards Approval

a) Pandemic Factors:

Health plans had previously been allowed to apply carryover quality criteria from 2021 and 2022. However, in 2023, health plans should improve member engagement by scheduling a visit for preventative care or completing a missed screening. Doing this will result in better engagement and may lead to higher member satisfaction scores.

b) Patient Experience Rating:

When determining Star Ratings starting in 2023, patient experience ratings will be quadruple weighted. To keep patients satisfied, health plans should foster a personalized welcome and onboarding experience as well as communicate effectively with members. Some of the following factors health plans should look for:

  • Interacting with participants to address inquiries and/or resolve issues
  • Make sure patients are aware of their out-of-pocket expenses
  • Provide health information
  • Remind patient regarding preventive services and other communications
  • Ensure patients can communicate and connect with health plan staff members

c) A Focus on Health Equity:

The CMS intends to develop a health equity index in the future, this would integrate performance indicators for health equity across Medicare Advantage and Part D plans into a single score. The goal of this index is to evaluate how well plans screen for social factors that might affect a patient’s ability to get medical attention. These social factors include food insecurity, housing instability, and transportation issues which have been mentioned above.

Health plans may act immediately to improve patient data collection and documentation related to these discrepancies by considering the following:

  • Community collaboration:
    Health plans should consider collaborating with community outreach programs and enhancing incentives to promote community cooperation. By doing this, health plans can help identify the disparities in access to healthcare.
  • Intelligent Data Collection:
    Health plans must reconsider how they gather and record member data. For instance, data on housing security, food security, and transportation issues. Enhancements to Health Risk Assessments, Application Data, and other data gathering possibilities throughout the continuum of a member’s journey with the plan are being considered by innovative health plans.

 

Overall, many changes are expected to be implemented in 2023 with the vision in mind of expanding access to affordable health care and improving health equity.

Resources:
https://www.cms.gov/newsroom/fact-sheets/cy-2023-medicare-advantage-and-part-d-final-rule-cms-4192-f
https://www.ibx.com/documents/35221/56671/cms-star-rating-provider-guide.pdf/4522db52-d921-6156-db05-f392f9e08da6?t=1580918398627#:~:text=The%20Centers%20for%20Medicare%20%26%20Medicaid,with%205%20being%20the%20highest
https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/FSQRS
https://www.tdsclinical.com/blog/the-biggest-changes-to-star-ratings
https://www.prosphire.com/issue-briefs/star-ratings-impact-2023-medicare-advantage-and-part-d-rate-announcement/

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