Comprehensive Medication Review – A Patient-Centric Effort
In 2017, the Comprehensive Medication Review (CMR) became a Medicare STAR measure. As with almost anything that is being measured and scrutinized, the CMR rate continuously and steadily increased and improved over time.
From 2016 to 2019, the average CMR rate reported by MA plans increased from 30.9% to 71.% (www.medicare.gov) attesting to the saying that “you only manage what you measure”.
CMR STAR rating thresholds are calculated each year using cluster analysis, and the thresholds for CMR completion increase in a commensurate manner. The 2019 STAR Rating thresholds for MA plans will require a CMR rate of 73% for 4 STAR status and 85% for 5 STAR status. The 2020 STAR Rating thresholds have changed subtly (see below).
While it will be more difficult to achieve 4 STAR status in 2020 (increasing from 73% to 79%), it will be a bit easier to push into the 5 STAR range (decreasing from 85% to 83%).
Barriers to Member CMR Completion
CSS Health (CSS) has found that achieving high CMR rates is primarily a patient engagement challenge. Specifically, we have identified four primary barriers to engaging plan members in a CMR:
Good contact information. Health plans have traditionally obtained a member’s contact information at the beginning of the program year and for most of the population this contact information remains stable throughout the program year. However, there is a significant portion of a plan’s population who, for a variety of reasons, will change their contact information during the program year.
Contact overload. Today everybody, in general, is more wary about outreach of any kind. Seniors, gennerally, have fallen prey to scams where they have been taken advantage of by seemingly benign outreach and are now especially wary. This wariness tends to make seniors not want to engage with callers with whom they have no previous health care relationship.
Program description. MTM and the associated CMR are an unfamiliar service. MTM has not traditionally been a part of the health care or pharmacy delivery system. Consequently, convincing Medicare members that a CMR is some thing that is different than what their prescribers and pharmacists are already doing can be a challenge.
No show rates. For years we in health care have understood the concept of the “no show” rate. Organizations such as the Institute for Health Improvement have studied no show rates in a number of environments (http://www.ihi.org/sites/search/pages/results.aspx?k=no+show+rates) in order to better understand the variables that contribute to appointment no-shows. As with any scheduled appointment, CMR appointments are subject to a a no show rate which vary by similar variables (e.g. time from scheduling to appointment)
Novel Approaches to Engaging Members
At CSS, we are constantly searching for and testing novel methods of engaging members in a CMR. Recently, the approach of engaging the member’s prescriber (vs. the member or their authorized caregiver) in a CMR was being explored. Given that the CMS regulations regarding this approach were open to interpretation, the question was brought before AMCP’s MTM Workgroup. During the AMCP Nexus 2018 meeting the workgroup finalized a letter to CMS requesting a clarification of the regulations concerning conducting a CMR with the patient’s prescriber.
In short, CMS responded that the focus of a CMR was interaction with the member. With the exception of patients who are cognitively impaired, CMRs cannot be conducted with someone other than the patients without the patients express consent. CMS was clear that patients do have the authority to request that others (prescribers, pharmacists, spouses and caregivers) participate in the completion of a CMR. This response confirmed that CMS intends for CMRs to be a patient-centric activity.
The Impact of CMRs
While CMS’s stance certainly makes CMRs more difficult to acquire, it also makes them more meaningful. Engaging members in a CMR will mean that we have to continue to engage the member on their terms and for reasons that make sense to them. Moreover, the members who qualify for a CMR are by definition the most frail and fragile members of the population. Meaning that high levels of patient engagement will require that the patient feel a “sense of relationship” with the MTM clinician. Finally, the newly developed MTM measures which place a strong focus on closing therapy gaps will require that the MTM clinician have at least one meaningful conversation with the member.
These are the key principals which we at CSS adhere to as we pursue the important work of conducting CMRs. I am happy to discuss any aspect of medication management and approaches to better patient engagement.
Best – Jim
James Notaro, RPh, PhD
Founder and Chief Clinical Officer