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PQA Measures Used By CMS in the Star Ratings
PQA Measures

Update on Medication Quality Measures in
Medicare Part D Plan Star Ratings-2016

Understanding the CMS Quality Evaluation System

There are multiple components to CMS’ evaluation of medication-related quality across Medicare Parts C and D. CMS creates plan ratings that indicate the quality of Medicare plans on a scale of 1 to 5 stars with 5 stars being the highest rating. The overall star rating is determined through numerous performance measures across several domains of performance. Each measure is awarded a star rating and the individual measure stars are then aggregated at the domain and summary level. Only a small number of plans receive a 5-star summary rating from CMS, with most plans receiving 3 to 4 stars.

Medicare Advantage plans that include drug benefits (MA-PDs) are rated on performance measures for Parts C and D. For Part C, a subset of the HEDIS measure set from NCQA is used for evaluation. Medicare Part D stars are applicable to MA-PDs and stand-alone PDPs. The stars are assigned based on performance measures across four domains. The four Part D domains are:

1. Drug Plan Customer Service
2. Member Complaints, Problems Getting Services, and Choosing to Leave the Plan
3. Member Experience with Drug Plan
4. Drug Pricing & Patient Safety

There are 15 individual measures of quality in the 2016 Part D ratings based on 2014 prescription drug claims). Medication safety and adherence measures are in the domain of Drug Pricing & Patient Safety. Five PQA measures are included in this domain for the 2016 Star Ratings. These include three of PQA’s medication adherence measures in the following therapeutic categories: HMG-CoA inhibitors (statins), Renin Angiotensin System Antagonists, and Oral Diabetes Medications. Two measures of medications safety or MTM are also included, High risk medications in the elderly and Comprehensive Medication Review (CMR) Completion Rate. The CMR Completion Rate measure is new for 2016. Each measure is assigned a weighting factor. Outcomes and Intermediate outcomes are weighted higher. The PQA measures in the plan ratings and their respective weighting are described on the following page.

In addition to the plan ratings, CMS also uses the “Display Measures” to provide further evaluation of Part D plans. The Display Measures are not included in the plan ratings, but are used to facilitate quality improvement by the plans. The Display Measures include three PQA-supported measures of medication safety (drug-drug interactions; excessive doses of oral diabetes medications; Statin Use in Persons with Diabetes). An additional measure, HIV antiretroviral medication adherence, is reported to plans in their Safety Reports. CMS maintains a “Patient Safety website” that provides the benchmarks and scores to the plans across both the Display Measure and Plan Ratings Measures.

Who Manages the Star Ratings System?

CMS manages the star ratings system and uses contractor support for this effort. For example, CMS contracts with Acumen, LLC for the analyses of Medicare data to generate the rates for the medication measures. PQA maintains the PQA-supported performance measures and updates the technical specifications and drug-code lists for the measures every six months. PQA also shares new measures that are endorsed by PQA with CMS and provides some technical guidance on the use of the measures within the plan ratings. CMS tests updates to the PQA-supported measure specifications and drug-code lists and implements these as they deem appropriate.

A Look at the PQA-supported Medication Measures Included in the Part D Plan Ratings

High-risk medications in the elderly (HRM). This NQF-endorsed measure was adapted from the HEDIS measure known as Drugs to be Avoided in the Elderly (DAE). The HRM/DAE measures identify the percentage of older adults (>65yo) who receive a medication that is considered to put the patient at high-risk for an adverse drug-related event. The list of medications in this measure was derived from the Beers’ List that was originally developed in the 1990s, but updated in 2002. The American Geriatrics Society (AGS) provided updated recommendations for the Beer’s List in 2012 and again in 2015. NCQA and PQA considered the AGS recommendations when updating their performance measures in 2012 and plan a measure update in 2016. 

Proportion of Days Covered (PDC). PDC is the PQA-recommended methodology for estimation of medication adherence for patients using chronic medications. This metric is also endorsed by the National Quality Forum (NQF). The metric identifies the percentage of patients taking medications in a particular drug class that have high adherence (PDC > 80% for the individual). There are three rates reported in the Star Ratings. One for blood pressure medications (renin angiotensin system antagonists [RASA]); one for statin medications, and one for diabetes medications (not including insulin).

Medication Therapy Management (MTM) Program Completion Rate for Comprehensive Medication Review (CMR) (new for 2016). CMS added this measure to the Star Rating after reporting it to plans as a display measure for several years. The measure calculates the percentage of beneficiaries who met eligibility criteria for the MTM program and who received a CMR with a written summary in the CMS standardized format. Currently this measure is assigned a weight of “1” since it is a new process measure.

Prepared by: 
Julie Kuhle, BS Pharm
Vice President, Measure Operations
Pharmacy Quality Alliance
Email:  jkuhle@PQAalliance.org



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