PBMs and Star Ratings

Finally, I’m hearing more talk about PBMs and their role in Star Ratings for Medicare. It seemed like this was a subtlety at the end of last year when I raised it as a 2011 priority.

Drug Benefit News had a story about it in their March 4, 2011 edition with examples from HealthTrans and PerformRx.

In general, there are opportunities to help impact Star Ratings by:

  • Blending pharmacy and medical data
  • Helping monitor patients on long-term medications
  • Increase cholesterol screening
  • Increase use of flu shots
  • Controlling blood pressure
  • Addressing physician communication gaps
  • Improving Customer service
  • Prior authorization process
  • Churn
  • Time on hold
  • Appeal process
  • Accuracy of information provided by customer service
  • Managing complaints
  • Helping with access issues
  • Timely information about the drug plan
  • Monitoring use of drugs with a high risk
  • Making sure diabetics us hypertension drugs

Since pharmacy is the most used benefit, it can have a very direct impact on the overall satisfaction. It can drive calls. It can be complicated. It can affect perception. And, it can lead to churn.

PBMs need to be working to proactively engage consumers. They need to use data to personalize the experience. They need to use clinical data to identify gaps in care. They need to drive adherence.

I personally hope that the Star “concept” becomes a more normal set of metrics outside of Medicare for measuring success and ultimately leads to a performance-based contracting framework.

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