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In early August, Medicare released its – Medicare 2019 Part C & D Star Ratings Technical Notes. The technical notes review the STAR quality measures that will be used to evaluate Medicare plans. This release has some critical information if you are managing a Medication Therapy Management Program (MTM) or drug-related quality measures. CSS Health has reviewed the technical notes and compiled a summary of what we believe to be critical issues.


Differences Between the 2018 and 2019

In 2019, a number of changes have been made to the STAR measures roster and specifications. Drug-related STAR measures which will be affected include:

New measures for 2019

  • Part C measure: C22 – Statin Therapy for Patients with Cardiovascular Disease
  • Part D measure: D14 – Statin Use in Persons with Diabetes (SUPD)


CSS Take-Away: These are both measures which should at a minimum be addressed within your MTM program, and with little incremental effort MTM can be applied to non-MTM eligible members to assure that your plan is achieving a high STAR rating

Measure Updates

Part C measure: C31 – Health Plan Quality Improvement: this measure is a composite of other Part C measures which is a function of the number of measures which improved versus the number of measures which declined. In 2019, C31 will add the following two year Part C measures to the measure calculation.

    • C19–Improving Bladder Control
    • C20–Medication Reconciliation Post-Discharge
    • C24–Getting Appointments and Care Quickly
    • C25–Customer Service
    • C28–Care Coordination

CSS Take-Away: Measures C19 and C20 lend themselves well to an MTM-like process. Like the new measure additions C19 should at a minimum be a component of your MTM program and will little incremental effort should be able to be addressed in the non-MTM eligible population.

C20 requires medication reconciliation post discharge. Addressing this measure with an MTM-like effort will require a process that runs in parallel to your MTM program (you identify members as they come out of the hospital vs. based on their utilization characteristics). The benefits of running a post-discharge medication reconciliation program within your MTM program is that your MTM clinicians are already proficient at medication reconciliation as it is a core component of MTM and many of the patients being discharged from a hospital qualify for MTM, so it is the perfect opportunity to “max pack” both a med rec and CMR into one call.

Part D measures:D10, D11 & D12 – Medication Adherence of Diabetes Medications, Hypertension (RAS antagonists), and Cholesterol (Statins):  These measures will now exclude beneficiaries with ESRD per the PQA measures specifications for Hypertension and Diabetes Medications measures and days of hospitalization will be counted in the Proportion of Days Covered (PDC) to adjust all adherence measures.

CSS Take-Away: This is generally a good thing for plans as these measure modifications will generally make it easier to achieve higher adherence rates. However, the cut points for adherence rates are also increasing (we discuss this a bit later in the blog) so these modifications may not have a tremendous impact on adherence STAR measure achievement.

Categorical Adjustment Index (CAI)

CMS has been studying the impact of socio-economic factors on STAR quality ratings. Many plans have hypothesized that members with low socioeconomic status have more difficulty accessing care and, in turn, this increases the difficulty of achieving high STAR measures in this subset of the population.   

Apparently, CMS is beginning to conclude that the plans are correct. To provide plans with higher percentages of low socio-economic status members some immediate relief they have implemented an interim adjustment called the Categorical Adjustment Index (CAI) until measure stewards can complete a comprehensive review of their measures.

The CAI is a factor that is added to or subtracted from a contract’s STAR ratings to adjust for the disparity in performance associated with a contract’s percentages of beneficiaries with Low-Income Subsidy/Dual Eligible (LIS/DE) and disability status. The value of the CAI varies by a contract’s percentage of beneficiaries with Low Income Subsidy/Dual Eligible (LIS/DE) and disability status and was developed using data collected for the 2018 Star Ratings.  The 2019 technical notes provide a comprehensive review of the calculation methodology beginning on page 15. The 2018 measures used in the 2019 CAI adjustment calculations are:

  • Breast Cancer Screening (Part C)
  • Annual Flu Vaccine (Part C)
  • Osteoporosis Management in Women who had a Fracture (Part C)
  • Diabetes Care – Blood Sugar Controlled (Part C)
  • Reducing the Risk of Falling (Part C)
  • Medication Reconciliation Post – Discharge (Part C)
  • Plan All – Cause Readmissions (Part C)
  • Medication Adherence for Hypertension (RAS antagonists)
  • MTM Program Completion Rate for CMR


CSS Take-Away: This is good news for MTM programs (and Medicare Advantage programs in general) who have higher proportions of members with low socio-economic status. The CAI adjustment would provide a boost to the plan’s CMR and other drug-related STAR measures (i.e., flu vaccine, osteoporosis screening, blood sugar control, medication reconciliation, RAS adherence).


Measures Cut Points

5 STAR cut points are generally trending upward. This is especially true for medication-related cut points (see graph below).  Hypertension adherence, cholesterol adherence, and CMR rate star measure cut points have all increased year over year, and 2019 will be no exception.  The only medication-related 5 STAR measure cut point which will dip in 2019 is diabetes adherence and this is only by a slight 1%.

CSS Health Take-Away: It will be harder than ever for plans to achieve a 5 STAR rating moving into the future. Working the same adherence and CMR improvement techniques harder will probably not be sufficient. Plans will have to engage more sophisticated approaches to achieve 5 STAR ratings.

I hope that this overview has been helpful and informative.  As always if you want to discuss don’t hesitate to give me a call or drop me a note.

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