On March 26, 2020, the Centers for Medicare and Medicaid Services (CMS) published an Interim Final Rule with comment period (IFC) on policy and regulatory revisions in response to the COVID-19 pandemic. Payers, PBMs and pharmacies need to be aware of significant changes to quality rating calculations covered in this IFC.
COVID-19’s effect on 2021 and 2022 Star ratings
CMS is concerned that the pandemic will affect the collection of HEDIS, CAHPS and HOS data, used to calculate the 2021 and 2022 Star ratings. The CAHPS survey efforts are ongoing through the end of May 2020, while the HEDIS data collection is due to CMS by June 15, 2020 and both are used for the 2021 Star Ratings. The HOS data is also scheduled to be collected later in 2020 for use in the 2022 Star ratings calculations. CMS is concerned that MA organizations and Part D plan sponsors will not be able to complete this year’s data collection. Additionally, if CMS is unable to complete HOS data collection in 2020 (for the 2022 Star ratings), the IFC will substitute the measures based on HOS data collections with earlier values that are not affected by COVID-19.
To address these concerns, the IFC modified the calculation of the 2021 and 2022 Part C and D Star Ratings. CMS will replace the 2021 Star ratings measures based on HEDIS and Medicare CAHPS survey data with earlier values from the 2020 Star ratings. And if other 2021 measures have a data quality issue due to COVID-19, CMS will replace them with the equivalent Star ratings and scores from 2020
CMS will also remove the guardrails for the 2022 Star Ratings cutpoints so that if plans have a decline in performance due to COVID, they won’t be penalized by a lower STAR level. Additionally, CMS will expand the existing hold harmless provision for the Part C and D Improvement measures to include all contracts, regardless of their ratings, for the 2022 Star Ratings. With this hold harmless expansion, if the inclusion of the improvement measure(s) reduces the contract’s overall Star Rating, the Part C and D improvement measures will be excluded from the calculation for that particular contract.
Looking ahead to 2022 Part D Quality Star ratings
Looking ahead, how will the pandemic effect the 2022 payer Part D Quality Star ratings, since the virus will unquestionably affect these measures? Dr. Linda Schultz, VP of Customer Success at AllazoHealth, suspects CMS will wait to determine how it plans to handle these measures. “It will be interesting to see just how COVID-19 affects the gap-in-care and other medication measures, like adherence. I think that CMS will wait until they have the data to decide the COVID-19 impact and best way of addressing the Part D measures.”
The big picture
Measures that are calculated by using actual pharmacy claims data, such as adherence, are less likely to impacted by COVID-19, so they are less likely to be substantially changed by CMS.
Since many parts of the country have imposed stay-at-home orders, the pandemic offers payers a unique opportunity to reach out to patients by phone,.The potential disruptions to patient behavior offers a window for payers to engage their membership to address both near-term and long-term challenges to staying medically adherent. Targeting the most optimal patients for positive outcomes will be key.
An opportunity for pharmacies
The IFC expands telehealth/telecommunication services for Medicare patients, paying for many more services when furnished via telehealth, such as emergency department visits, initial nursing facility and discharge visits, and home visits.
Dr. Schultz does have a recommendation for AllazoHealth’s pharmacy and payer/PBM clients: provide comments to CMS about including pharmacists in the list of healthcare providers that should be paid by CMS for their telehealth/telecommunication services.
“If I were in the leadership shoes of payers, PBMs and pharmacies, this would be something I would be sending input on, especially because pharmacists have been effectively doing this already as a valuable contribution to patients’ quality outcomes,” she says.
AllazoHealth uses artificial intelligence to make a positive impact on individual patient adherence. We help pharmacies, payers and PBMs increase the effectiveness of patient engagement programs that focus on quality ratings. Improving patient adherence can have a dramatic effect on Star ratings, HEDIS scores, DIR contracts, QRS ratings, and Medicaid quality measures.
Find out how AI benefits patient adherence and improves quality ratings.
Dr. Linda Schultz
VP of Customer Success
(888) 464-2776 x715