Jim Riopelle, MD, CPE
A 2020 Stars Performance review: What are you doing to keep up?
The 2020 Star ratings were released in the 4th quarter and you probably saw that ~52% of MAPD plans earned 4 Stars or higher and ~81% of MAPD enrollees are now in contracts with 4 Stars or more. PDPs didn’t fare quite as well with only 30% of contracts achieving 4 Stars, representing ~28% of of PDP enrollees.
There were 9 new entrants to the elusive “High-Performing” club for their achievement of 5 Stars in 2020. With only 23, 5 Star plans across the country, this represents a 64% increase in High Performance plans in 2020 alone. The obvious questions for most plans is what are you doing to keep up and how can you ensure you don’t get lost in the middle of the pack, as CMS continues to move the goal posts to incentivize stronger and stronger performance?
Our leadership team spent some time studying the 2020 Stars performance reports with a particular interest in how these top plans are achieving superior performance. Across the board, plans are getting better at blocking and tackling. That is to say, those administrative measures that largely rely on operational processes and infrastructure are consistently above 4 Stars. What is more challenging for most plans is achieving 4 or 5 Star status on those measures that require patients and/or providers to change their behavior. This shouldn’t be surprising to anyone.
As a physician, I can tell you that the royal “We” don’t like to be told what to do or how to do it. In fact, when I was practicing in my younger years, I witnessed allied healthcare providers make suggestions to my peers for how they could improve a patient’s care. While I often thought these were valuable recommendations, the first thing many doctors would do is adjust their posture to create a sense of superiority, followed by a quick dissertation on all the reasons why they were justified in their “decision” to not do just what had been recommended. After years of practicing medicine, maturing, and working with more doctors and patients from my seat as the medical director of a health plan, I feel I even more convinced now than ever. I now know that no one doctor can take care of all the complex needs of their growing patient panels, especially not with ever increasing administrative burdens, heightened quality performance oversight, and unprecedented scientific complexities. It takes a team, and when I look at those health plans who are achieving 4 and 5 Star performance, they have figured out how to develop a network of providers who work together as a team to improve the quality of care provided to their patients.
From my vantage point now, I believe that the integration of clinical pharmacists into this network is critically important to quality improvement efforts. One doesn’t have to search far for data to show that over a quarter of our healthcare budget is spent on pharmaceuticals. If we consider all of the positive and negative impacts of pharmaceuticals on quality and cost, it becomes very clear that highly trained clinical pharmacists are the missing quality link on many care teams. While our beloved community pharmacists do wonderful work, I am not talking about those pharmacists occupied with the dispensing of medications. Rather, I see a future where a dedicated clinical pharmacist is available to every care team to evaluate drug therapy problems, help to optimize care plans, and educate patients on the use of their medications. A quick run-through the list of MAPD plans achieving 5 Stars will highlight many integrated delivery systems who have already figured out how to build a team of care providers which includes clinical pharmacists.
I have always said that improving quality makes good business sense and I believe that the 5 Star performance system is an example of that. If you are interested in how our clinical pharmacy services model can work within your existing provider network and dramatically improve your performance, without adding additional costs, we would welcome the opportunity to meet with you.