The COVID-19 pandemic derailed much of what was once standard in healthcare, and quality measures are no exception. On March 26, 2020, the Centers for Medicare and Medicaid Services (CMS) published their response document, outlining regulatory revisions that would change quality ratings for Medicare and Medicaid. Medicare Part C and D Star Ratings take into account these changes, offering a slightly different ratings rubric. Understanding the interim approach during the COVID-19 crisis is critical for payers, PBMs, and pharmacies.
How COVID-19 Changed 2021 and 2022 Medicare Quality Measures
Citing concerns that the pandemic would undermine the collection of HOS, CAHPS, and HEDIS data, CMS temporarily changed its guidelines for the collection of Star Ratings data. Some of the changes include:
- Removing guardrails cutpoints. Plans with a decline in performance due to COVID will not face penalties with a lower level and will not see their ratings change by more than five percentage points.
- Expansions of the existing hold harmless provision. This expansion includes all contracts, regardless of rating. If the inclusion of the improvement measure(s) reduces the contract’s Star Rating, the Part C and D improvement measures will be excluded from the calculation for the contract.
- Disaster adjustment qualifications. All Part C and D contracts now qualify for disaster adjustment qualifications.
- Published data on score changes. CMS Is also publishing data on average shifts in scores during the COVID pandemic.
The Future of Part D Quality Star Ratings
Medicare Part D quality Star Ratings play a key role in which plans are available, as well as how consumers select their plans. So how will the pandemic affect quality ratings?
Dr. Linda Schultz, VP of Customer Success at AllazoHealth, said, “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.”
Measures that use pharmacy claims data, such as adherence, are less directly impacted by COVID-19. As more providers move to telehealth, the pandemic poses a powerful opportunity to reach consumers via phone. This may help overcome disruptions in compliance and ensure patients stay healthy and medically compliant. Critically, payers must identify the patients most likely to struggle with compliance during the pandemic. As hospital beds fill with each new disease surge, compliance can prevent taxing the health system to its breaking point and prevent more deaths.
The COVID-19 Opportunity
Businesses that have acted flexibly and creatively during the pandemic have grown, profited, and helped others. Healthcare entities are no exception. The interim final rule expands telehealth and telecommunication services for Medicare recipients, paying for numerous telehealth services, even emergency visits. Providers that can pivot toward this new approach can reach more patients and save money.
Dr. Schultz recommends staying ahead of the curve by providing comments to CMS about including pharmacists in the list of healthcare providers whose payment is partially related to their telehealth and telecommunication services.
“If I were in the leadership shoes of payers, PBMs, and pharmacies,” she said, “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.”
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 while reducing needless healthcare spending. These effects are even more pronounced during the pandemic, as healthcare systems continue to strain under the weight of each COVID surge.
About the Author
Dr. Linda Schultz
Dr. Linda Schultz is a results-oriented Healthcare Pharmacy Executive who excels at leading transformational, top-notch, interdisciplinary healthcare teams to create and execute outcomes driven clinical operations and account management initiatives. Dynamic and knowledgeable in all healthcare business segments, most passionately within the complex Medicare, Duals and Medicaid markets, she is an accomplished, creative motivator and driver of innovative quality and cost of care pharmacy interventions. Dr. Schultz is currently VP, Customer Success at AllazoHealth, a cutting-edge, healthcare artificial intelligence company. Prior to her leadership role at Allazo, Linda founded and led RxHorizons, LLC., an international healthcare consulting group. Her expertise stems from over 25 years of experience within the Managed Care industry, with a focus on leading, strategizing, developing and implementing pharmacy benefit management activities within national PBMs and health plans.