Optimizing Medicare Advantage (MA) Star Ratings in the pharmacy setting

Care management plays a critical role in optimizing health outcomes for Medicare members and Star Ratings for Medicare Advantage (MA) plans. Below is a breakdown of some key insights and strategies MA plans should consider if not doing so already. 

Pharmacy: The most frequently used benefit

Whether it’s managing chronic conditions, preventing adverse drug events, or ensuring adherence, pharmacies are at the forefront of patient care for Medicare members, especially given the frequency of interactions. According to a nationwide cross-sectional study, the median number of visits to community pharmacies by active Medicare members was significantly higher than encounters with primary care physicians, 13, compared to 7 encounters respectively.

Star Ratings: A critical metric

Plans with higher Star Ratings receive financial bonuses from the Centers for Medicare & Medicaid Services (CMS), leading to a positive impact on plan revenue which can contribute to the overall financial success of the plan. Higher Star Ratings indicate better health care quality and outcomes for members. A report observed 22 clinical quality of care measures to compare outcomes between MA and fee-for-service Medicare. For 77 percent of the clinical quality of care measures (17 of the 22 measures), MA populations achieved better results. This linkage between quality performance and financial rewards underscores the pivotal role of Star Ratings in steering the focus of MA plans towards continuous quality improvement initiatives. As plans endeavor to elevate their Star Ratings, they are compelled to invest in innovative care management strategies, enhance provider networks, and implement comprehensive interventions aimed at promoting better health outcomes for members.

Challenges in maintaining high Star Ratings

Overall, average Star Ratings continued to decline in 2023 to 4.15, down from 4.37 in 2022. The methodology continues to evolve, and, with the introduction of the Health Equity Index, plans will now be rewarded for improving the care of members with complex needs. So maintaining high Star Ratings is increasingly complex and Part D plays a big role in plans’ Stars success since it contributes ~30% of a plans’ overall rating. This creates a valuable and significant opportunity to engage with a plan’s most complex members through pharmacies to increase Part D quality scores. Notably, Express Scripts clients consistently score higher than the industry average on Part D measures: In 2024, 57% of Express Scripts MA Part D contracts received >4 Stars, compared to 42% of the industry. 

Diverse Medicare consumers

Our market research amongst the general population identified 6 types of senior consumers based on their differences in overall health, health care engagement, behaviors, and socioeconomic status. Each consumer group’s needs are dramatically different: from those with above average health who are engaged, proactive and stable, using more of a self-service approach; to those who tend to have high medical and behavioral health needs and are vulnerable patient populations at risk for health disparities. The more vulnerable patients could potentially benefit from a high-touch approach. While we found that most seniors are generally satisfied with their pharmacy services and benefits, there are sizable segments such as the vulnerable patient population who remain much less satisfied. Tailoring services to each of these distinct groups is crucial to improving overall engagement and satisfaction, especially for those in need of a high-touch approach. 

The vulnerable patient population

Opportunities exist to improve satisfaction among vulnerable patient populations such as the chronically ill or disabled, high risk, underserved populations that face significant challenges, including: 

• High incidence of physical and mental health issues
• Stress and limited financial resources
• Delayed health care despite high utilization
• Potentially a sense of hopelessness about their inability to affect change in their health

This population is the primary focus of CMS’s Health Equity Index, a tool to reward plans for improving the care and outcomes of this group. When plans try to improve their services for this population, they align with CMS goals, support higher rates of satisfaction and Star Ratings, and increase their quality bonus potential.

Holistic pharmacy services

Plans should consider taking a holistic, high-touch approach to pharmacy services when dealing with this population. This involves educating patients on holistic condition management rather than just medication specifics, tapping into early detection and treatment services, collaborating with other providers for a comprehensive care plan, and connecting patients to medical and social services when needed.

Community pharmacies, especially independent pharmacies, play a vital role in this process: They help patients stay on track with their medications; they leverage the frequency of patient interactions in order to provide timely education; and they bridge the gaps in care between doctor visits.

MA Plans should also consider identifying and connecting vulnerable patients to holistic service models involving community pharmacies. By doing so, they can better influence satisfaction & adherence measures as well as the Health Equity Index critical to Plan revenue.