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As Medicare Advantage continues to get more popular among consumers, CMS is sharply focused on ensuring that quality and service remain as high as possible. Using the Star Ratings—and its quality bonus payments (QBP)—as a strong lever to encourage continual improvement among MA plans, the agency is rolling out plenty of big, challenging changes for 2024 and 2025.
Two important Star measures are at the top of the list: medication reconciliation post discharge (MRP) and plan all-cause readmission (PCR). To remain competitive and retain access to crucial QBP funding, health plan leaders must be aware of how these measures are changing and what they can do to perform well on these requirements.
“The pressure is on for MA plans to keep up their performance in 2024 and beyond,” said Cyndi Alexander, Chief Adherence Officer at AdhereHealth. “High Stars performance is critical for many reasons: there are expanded financial, marketing and member enrollment opportunities associated with achieving 4 or more Stars, which plans cannot afford to let slip by.”
“But there are also issues of health equity at stake,” she continued. “The Star Ratings, taking into consideration the SDOH survey as an influence on all measures, are designed to guide health plans toward closing gaps in care and reducing disparities. This can improve overall outcomes and produce a net good for the entire healthcare system. The MRP and PCR measures are important guideposts for health equity among the MA population, which is one reason why CMS is making adjustments at this point in time.”
Here’s what’s changing for these measures and what MA plans can do to maximize their Star Ratings in 2024 and beyond.
Medication reconciliation post discharge (MRP)
Medication reconciliation is one of the most important pieces of the care coordination process. More than 80% of U.S. adults age 65 and older take at least one medication, and more than half take four or more. Reviewing and adjusting these medications as required after a hospital stay can significantly reduce the likelihood of an adverse drug event (40% of which are tied to transitions of care) that could lead to a potentially avoidable readmission.
With the Medicare readmission rate still hovering around 20% and the associated costs exceeding $17.4 billion for Medicare annually, there is a strong incentive to ensure that members are taking the right medications once they get home from the hospital.
Plans should be familiar with basic principles of medication reconciliation after a qualifying discharge event, as the metric has been a part of Stars for quite some time as a stand-alone measure. In essence, the MRP measure assesses whether plan members who were discharged from an inpatient facility had their medications reconciled within 30 days of discharge.
CMS is not changing this fundamental requirement. However, with the launch of the new four-in-one transitions of care (TRC) measure, the stand-alone MRP requirement has become duplicative and will now be retired.
Going forward, plans will need to complete all of the following to meet the TRC measure:
- Notification of inpatient admission: Documentation in the medical record of receipt of notification of inpatient admission on the day of admission or within the following 2 calendar days
- Receipt of discharge information: Documentation in the medical record of receipt of discharge information on the day of discharge or within the following 2 calendar days
- Patient engagement after inpatient discharge: Evidence of contact with the patient within 30 days of discharge, including an office visit, telehealth visit, or home visit
- Medication reconciliation post discharge: Medication reconciliation conducted on the date of discharge through 30 days after discharge (31 total days)
For health plans, this means rolling traditional MRP activities into a much more coordinated and comprehensive effort to prevent readmissions for members. Doing so will require enhanced technical infrastructure and member engagement techniques.
Plan all-cause readmission (PCR)
Plans that perform well on the updated TRC measure are also likely to see better scores on the plan all-cause readmission metric, which is essentially the outcome measure paired with TRC process measure.
PCR assesses the percentage of hospital stays during the measurement year that were followed by an unplanned readmission within 30 days. Plans must also report a predicted probability of readmission for members to help calculate whether or not the plan had greater or fewer readmissions compared to what should be expected for the population’s health status.
PCR had been retired from Stars, but will now be returned as a measure to the 2024 Star Ratings and beyond. This further reinforces CMS’s emphasis on member experiences and outcomes, particularly among higher-risk, more complex members who may have a history of transitioning in and out of the hospital.
With medication reconciliation so closely tied to readmission prevention, health plans will need to carefully consider how to incorporate holistic, data-driven approaches to the entire transitions of care process.
How to enhance Stars performance with seamless medication services for members
Oftentimes, transitions of care are marked by confusion about treatment plans, missed follow-up appointments, patient dissatisfaction and muddled medications, all of which can easily lead to a preventable readmission. These issues can be particularly problematic for populations struggling with the social determinants of health (SDOH), such as pharmacy deserts, lack of transportation and low health literacy, leading to increased readmissions in these vulnerable groups.
To achieve the goals of the MRP and PCR measures—including reduced spending, better member experiences and a reduction in health disparities—MA plans need to reexamine their current transition of care processes:
- Improve understanding of members at risk of readmissions.
Plans can start by gaining greater visibility into their post-discharge populations. Patient management tools with predictive analytics can capture and surface the most accurate, timely data from all providers involved in a member’s care, allowing plans to take swift action to close gaps and facilitate communication. By analyzing a member’s detailed clinical history, medical and prescription claims and other data sources in real time, plans can be more proactive in their outreach and address potential medication concerns before they turn into readmission-worthy problems. - Implement well-rounded healthcare technology.
In the same vein, technology is instrumental in conducting comprehensive medication reviews (CMRs) in a timely, thorough, cost-effective manner.
The use of telepharmacy, supported by intelligent clinical workflows, allows pharmacy experts to work one-on-one with patients to identify potential concerns, offer personalized medication education and provide instructions for adhering to their prescriptions. By leveraging automation and smart analytics tools, plans can reach more members more quickly while maximizing their existing staffing resources. - Provide empathy and improved member relationships.
Plans should consider MRP and PCR as part of their larger member engagement and health equity plans. As such, they need to have strategies in place to work with members who are experiencing challenges with their post-discharge self-management. Culturally sensitive, empathetic and supportive motivational interviewing can help uncover and address these factors, particularly those that overlap with the social determinants of health. Establishing personal relationships with members and maintaining these relationships all year long through regular outreach activities can build trust and keep lines of communication open when a member is experiencing a difficult health event. This makes it easier to conduct honest and transparent medication reviews and get to the root causes of why a member may not be fully adherent to their medications and other care activities. - Offer valuable post-discharge resources.
Lastly, plans should provide post-discharge resources for members who are experiencing challenges, such as medication synchronization or compliance packaging to make it easier to take medications as prescribed, meal delivery services to ensure nutrition while reacclimating to the home environment, or transportation services to post-discharge appointments to avoid rising risks from turning into a readmission. As CMS continues to make changes to the Star Ratings, plans will need to stay on their toes and adopt data-driven, person-focused strategies to streamline transitions of care, avoid preventable readmissions and meet the industry’s health equity goals.
To learn more about how AdhereHealth can help Medicare Advantage plans like yours improve transitions of care, reduce readmissions and maximize Star Ratings performance, request a consultation today.
