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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-2018


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 and Changes in the Drug Plan’s Performance
3.  Member Experience with Drug Plan
4.  Drug Safety and Accuracy of Drug Pricing

There are 15 individual measures of quality in the 2018 Part D ratings based on 2016 prescription drug claims). Medication safety and adherence measures are in the domain of Drug Safety and Accuracy of Drug Pricing. Four PQA measures are included in this domain for the 2018 Star Ratings. These include three of PQA’s medication adherence measures in the following therapeutic categories: Cholesterol (Statins), Hypertension (Renin Angiotensin System Antagonists), and Diabetes Medications. One MTM measure is also included, MTM Program Completion Rate for Comprehensive Medication Review (CMR). 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 below.

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 2018 Display Measures include five PQA-endorsed measures:  Drug-Drug Interactions, Diabetes Medication Dosing, Statin Use in Persons with Diabetes, High Risk Medications in the Elderly, and Antipsychotic Use in Persons with Dementia. Additional measures, including HIV Antiretroviral Medication Adherence, Use of Opioids at High Dosage in Persons without Cancer, Use of Opioids from Multiple Providers in Persons without Cancer, and Use of Opioids at High Dosage and from Multiple Providers in Persons without Cancer are 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 Measures 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-endorsed performance measures and updates the technical specifications and drug-code lists for the measures twice annually. 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-endorsed measure specifications and drug-code lists and implements these as they deem appropriate. 

A Look at the PQA-endorsed Medication Measures Included in the Part D Star Ratings

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 hypertension medications (renin angiotensin system antagonists); one for cholesterol medications (statins), and one for diabetes medications (not including insulin).

Completion Rate for Comprehensive Medication Review (CMR). 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.


2018 Plan Ratings Weighting for Part D Measures

 
Measure ID  Measure Name Weights in Part D
Summary Stars
D01  Call Center - Foreign Lanuage
Interpreter and TTY Availability
1.5
D02 Appeals Auto-Forward 1.5
D03 Appeals Upheld 1.5
D04 Complaints about the Drug Plan 1.5
D05 Members Choosing to Leave the Plan 1.5
D06 Beneficiary Access and Performance Problems 1.5
D07 Drug Plan Quality Improvement 5
D08 Rating of Drug Plan 1.5
D09 Getting Needed Prescription Drugs 1.5
D10 MFP Price Accuracy 1
D11
Medication Adherence for Diabetes Medications 3
D12 Medication Adherence for 
Hypertension (RAS antagonists)
3
D13 Medication Adherence for
Cholesterol (Statins)
3
D14 MTM Program Completion Rate for CMR 1


Note:  Bold text
indicates PQA-endorsed medication measures included in the Part D Star Ratings

For contracts that solely serve the population of beneficiaries in Puerto Rico, the weights for D11, D12, and D13 will be zero in the summary and overall rating calculations and maintain the weight of three for the improvement measure calculations.


For more information, contact:  Lynn Pezzullo at LPezzullo@PQAalliance.org.



 
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