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PQA Measures Used By CMS in the Star Ratings
PQA Measures

Executive Update on Medication Quality Measures in Medicare Part D Plan Ratings 2013

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 3.5 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 18 individual measures of quality in the 2013 Part D ratings. Medication safety and adherence measures are in the domain of Drug Pricing & Patient Safety.  Prior to 2012, there were 2 PQA-supported measures within the Part D ratings measure set, but this expanded for the 2012 ratings with the addition of three of PQAs medication adherence measures in the following therapeutic categories:  HMG-CoA inhibitors (statins), Renin Angiotensin System Antagonists, and Oral Diabetes Medications.  Another change for 2012 was the addition of weighting factors for the measures. The PQA measures in the plan ratings 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; completion rate of Comprehensive Medication Reviews). 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 (all of which are PQA-supported).  PQA maintains the PQA-supported performance measures and updates the drug-code lists for the measures every six months. PQA provides the updated technical specifications and drug-code lists to CMS when updates are completed. 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 implement as they deem appropriate.

Tying the Star Ratings to Quality Bonus Payments (QBPs)

In 2012, CMS started a three-year demonstration project for Medicare Advantage plans wherein CMS awards quality bonus payments (QBPs) to plans based on the plans star ratings. Under the demonstration, plans must receive at least 3 stars to be eligible for QBPs. The amount of QBP is determined by the star rating wherein higher stars equate to higher payments to the plans. For example, 3-star plans will receive a 3% QBP, 4-star plans receive a 4% QBP, and 5-star plans receive a 5% QBP. Assuming that the base payments for Medicare Advantage plans will not increase in future years, the QBPs may be the lynchpin to continued profitability for those plans.

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 Beers List in 2012.  NCQA and PQA considered the AGS recommendations when updating their performance measures in 2012. 

Appropriate Treatment of Hypertension in Persons with Diabetes.  This measure includes patients who have received a medication for diabetes as well as any drug that could be used for treatment of hypertension. Thus, the drugs serve as proxies for a diagnosis of diabetes and hypertension.  The measure indicates the percentage of these diabetes-hypertension patients who receive and ACEI or ARB.

 

Proportion of Days Covered (PDC). PDC is the PQA-recommended metric 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).  When the PDC was used in the Display Measures, it was only reported as a composite score across all of the aforementioned drug classes. For the 2012 plan ratings, the public can see three rates; one for blood pressure medications (renin angiotensin system antagonists [RASA]); one for cholesterol medications (statins); and one for diabetes medications (roll-up across 4 classes of oral diabetes drugs).

 ___________________________________

Prepared by: Jackie Green
Director, Business Development & Operations
Pharmacy Quality Alliance (PQA), Inc.
Email:  jgreen@PQAalliance.org


                                                                                       2013 Plan Ratings Weighting for Part D Measures

Measure ID

Measure Name

Weight in Part D Summary Stars

D01

Call Center Pharmacy Hold Time

1.5

D02

Call Center Foreign Language

Interpreter and TTY/TDD Available

1.5

D03

Appeals Auto–Forward

1.5

D04

Appeals Upheld

1.5

D05

Enrollment Timeliness

1.0

D06

Complaints about the Drug Plan

1.5

D07

Beneficiary Access; Performance

Problem

1.5

D08

Members Choosing to Leave the Plan

1.5

D09

Getting Information From Drug Plan

1.5

D10

Rating of Drug Plan

1.5

D11

Getting Needed Prescription Drugs

1.5

D12

MPF Composite

1.0

D13

High Risk Medication

3

D14

Diabetes Treatment

3

D15

Medication Adherence for Oral

Diabetes Medications

3

D16

Medication Adherence for

Hypertension (RASA)

3

D17

Medication Adherence for

Cholesterol (Statins)

3

                                                  Medicare Part D 2013 Average Rates for PQA-endorsed Measures

 

Part D Plan Rating

MA-PD

PDP

 

 

 

PDC Diabetes

73.7 %

75.8 %

 

 

 

PDC - Hypertension

73.9 %

76.8 %

 

 

 

PDC Cholesterol

69.0 %

71.0 %

 

 

 

Diabetes RASA Use

84.3 %

82.3 %

 

 

 

High-Risk Medications

7.8 %

8.8 %

                                        PDC = Proportion of Days Covered; the rate indicates the percent of
                                        persons on the target drugs who are highly adherent to the drug regimen.




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