In the words of Michael Kavouras, Vice President of Star Ratings at Aetna, “Getting to 4 stars is really, really critical”.5 Not only do the bonuses help improve medical benefits, but a high star rating creates a competitive edge for a plan and is an unparalleled tool in promoting the plan to beneficiaries.6 The score offers a way for enrollees to compare performance among plans. Past bonuses helped Aetna retain zero-premium plans in many markets and offer options such as dental and vision coverage which then help attract more enrollees.5 Plans achieving a 5-star rating can also enroll members throughout the year, while plans below 5 stars can only enroll members during the late fall annual election period (2 months). Beyond the added bonus payment, a 3 to 4-star improvement can also generate 134 percent more value to its members in extra benefits through more generous rebates.7 In 2018, the bonus pool size was $6.3 billion which was distributed to the higher-rated plans as $500 per member, per year, on top of the premium.6
Originally developed under the ACA, the MA star ratings scale measures how well plans perform in these categories:7
- Staying healthy: screenings, tests, and vaccines
- Managing chronic (long-term) conditions
- Member experience with the health plan
- Member complaints, problems getting services, and choosing to leave the plan
- Health plan customer service
Listed below are the specific Star measures related to Medication adherence that fall into the Managing chronic (long-term) conditions category.
For PDPs and MA PDs, one of the most heavily weighted Star measures is medication adherence. Medication Adherence, broadly speaking, is defined as the extent to which patients take medications as prescribed by their providers. Adherence can be measured in terms of Percent Days Covered (PDC) and the Star Rating medication adherence measures are based on what percent of enrollees have at least 80% PDC. According to the World Health Organization, medication adherence can have a more direct impact on patient outcomes than the specific treatment itself. This in combination with the fact that medication-related measures are weighted so heavily (triple weighted) in Star Ratings, small changes in adherence could dramatically affect a health plan’s star ratings, influencing recruitment and reimbursement. It’s estimated that medication adherence measures can contribute nearly 50% towards the Star Rating aggregate weighting. Health plans are therefore strongly incentivized to improve medication adherence among their members, and there is considerable growth in health plan-supported programs to target medication adherence, including the development and strengthening of pharmacy care management programs focusing on adherence and payment models with providers that incorporate medication adherence measures.
Medication non-adherence is associated with poorer health outcomes and costly, avoidable complications such as heart attack or stroke. The impact of non-adherence is especially exacerbated among patients with multiple chronic conditions – or comorbidities – like high blood pressure, high cholesterol and diabetes.8
Below are the performance thresholds associated with the Star Medication Adherence measures to specify how a small change in adherence could have a major impact on the plan’s overall star rating.