CSS Health has created a new, value-based adherence program for health plans designed to raise the proportion of days covered (PDC) for fragile populations with multiple co-morbidities to at least 80%. That quality metric is essential to achieve a high Star Rating from the Centers for Medicare and Medicaid Services (CMS).
“This value-based population health initiative aligns the goals of the health plan, retail pharmacist, physician and patient to not only drive adherence but also improve clinical quality and reduce the cost of care,” explains CSS Health President and Founder, James Notaro. “It’s a truly innovative combination of our proven Medical Therapy Management (MTM) and adherence coaching combined with a high-value compliance packaging solution and pharmacy network distribution system to deliver measurable results at virtually any scale.”
The program manages a complex patient population reconciling multiple medication regimens that fall within the adherence STAR measures. By capturing the reasons for non-adherence, the program goes beyond medication cost barriers to understand the root cause analysis for adherence to align organizational resources to optimize medical outcomes and care management resources to help health plans achieve key population health objectives, including:
- Improve adherence and improve efficiency with prescriber, pharmacy and payer integration
- Strengthen member engagement and support those in danger of falling below 80% PDC
- Meet triple-weighted Star adherence measures for diabetes, hypertension and cholesterol
- Reduce costs through MTM, telehealth coaching and value-priced compliance packaging
- Improve convenience and reduce waste with compliance packaging that does not require
90-day supplies for members whose prescriptions are likely to change
- Reduce hospital re-admission cycles for fragile populations with multiple co-morbidities
- Achieve high CMS Star bonuses and ratings
CSS Health estimates that the program will help its customers meet key Medicare Part C and Part D criteria for bonuses nearing $10,000 per member. Multiply that by a typical plan’s fragile population and it’s easy to see how this can translate into millions of dollars. Add in the benefits of achieving 5-star status (e.g., ability to offer year-round enrollment) and the value of this initiative is clear.
With significant results at two pilot health plans in the northeastern United States, the program is now ready for a nationwide rollout.
“We’re bringing together proven tactics and metrics in a very new way for a truly innovative approach to population health,” adds Notaro. “It brings together the best of high tech and high touch to improve clinical quality while delivering value, efficiency and rewards.”