The Med Diva

An insider's guide to Medicare Part D and more

A question for Medicare: Why must a major Part D program depend on little ol’ me to save it from termination?

Medicare Part D worldIn my last two posts, I talked about how difficult it can be to convince Medicare beneficiaries to take advantage of the Medicare Medication Therapy Management program. One of the problems is that the Centers for Medicare & Medicaid Services (CMS) puts the responsibility on Part D sponsors to get members to opt into the free program. That means prescription drug plan employee peons like me have to write letters or make phone calls to persuade (in other words, beg) eligible plan members to participate in the program.

This week I am faced with a similar situation that involves convincing people to follow their doctors’ orders.  I must write a compelling letter to entice members who are not taking their medications properly to speak with a pharmacist. These members may be skipping pills, forgetting to take their medication, delaying their refills, or doing something else that is causing a gap in therapy (also called nonadherence). If members ignore this letter and don’t take their medication as directed, their Part D plan could be terminated.

Honestly, it sort of feels like the world is on my shoulders.

It’s all in the Medicare stars

To make a long story short, it all has to do with the Medicare star ratings.

CMS uses a star rating system as a guide to help beneficiaries compare the quality of private health plans in the Medicare Part D and Medicare Advantage (Part C) programs. These ratings measure everything from customer service issues such as call wait times to clinical issues such as adherence rates for members taking diabetes and hypertension medications. Based on these measurements, a plan’s overall star rating can range from 1 (poor) to 5 (excellent) stars.

Starting in 2015, CMS can cancel the contracts of Part D and Part C sponsors that fail to receive at least a 3-star (average) rating for 3 years in a row. Potential termination is a great “incentive” for Part C and Part D plans to deliver better care and value. The problem is that not all ratings are created equal: In 2012, clinical measures, such as adherence rates, were weighted three times heavier than other measures.

Many Part D plans received low star ratings in 2012 – even the plan I work for, which got a 5-star rating in 2011, dropped to 4 stars in 2012.  Many of the lower ratings were not due to poor customer service or low member satisfaction, but due to poor medication adherence rates. In other words, because many people are not following doctors’ orders and taking their medication the right way, Part D plans are getting lower star ratings. If these low medication adherence rates do not improve over the next two years, these Part D plans could be shut down by CMS.

CMS: Why is the burden on Part D plan sponsors?

Once again, I ask CMS why all the responsibility is placed on the shoulders of the Part D plan.

Although some plans do have very effective medication management tools in place—such as pharmacist outreach calls—it can be difficult and expensive for plans to ensure their members are following doctor’s orders and taking their drugs as prescribed. Plus, how do strangers at a Part D plan convince people who are not following their doctors’ orders to listen to them? If a doctor can’t make their patients take their medications as prescribed, what chance do I have?

CMS, I really hope you can give me an answer. Because right now, if I can’t convince a few thousand people to get back on track with their medications within the next few months, a large Part D program with a major health plan may soon be getting the boot from you. How wrong is that?

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One thought on “A question for Medicare: Why must a major Part D program depend on little ol’ me to save it from termination?

  1. Pingback: Medicare Buz » Blog Archive » Medicare Drug Discounts At Risk If Court Strikes Health Law

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