AH005 - Star Ratings, MTM, & CMS Translation Requirements with Jay Tran, PharmD

February 16, 2024

Capital Rx

In this episode of the Astonishing Healthcare Podcast, Capital Rx's Jay Tran, PharmD, dives into the significance of Star Ratings for health plans and Medicare payers, discussing what the ratings are based on, what drives bonus payments, as well as the role of medication therapy management (MTM) in Star Ratings and upcoming changes in the eligibility criteria. Additionally, this episode explores the importance of the CMS translation requirements for health plans serving diverse populations and provides practical tips for meeting the needs of non-English-speaking members.

Related Content

  1. Pharmacy Benefits 101: Medicare Star Ratings
  2. What You Need to Know About 2024 CMS Translation Requirements

Episode Transcript

Lightly edited for clarity.

Justin Venneri: Hello and thank you for joining us for this episode of the Astonishing Healthcare podcast. This is Justin Venneri, your host and Director of Communications at Capital Rx. I'll be discussing Star Ratings, CMS translation requirements, and maybe a little bit of MTM with my colleague Jay Tran, a pharmacist by training, working in the government space for years, and our current Senior Director for Government Services. Jay, thanks for joining me today.

Jay Tran, PharmD: Thanks for having me, Justin.

Justin Venneri: So, we worked on a Pharmacy Benefits 101 article last year on Star Ratings, and it'd be great if you could just get us going. One, take a step back [and talk] a little bit more about your background and your focus over the last handful of years. And then two, what are some of the most recent updates there? And if you want to kind of jump into and explain what Star Ratings are, that may help too, in case anybody's not familiar.

Jay Tran, PharmD: Yeah, absolutely, Justin. First and foremost, thanks for having me today. I've been in the government space ever since 2007 when I graduated from pharmacy school at the University of Illinois Chicago and just been in the managed care space, and specifically government, worked with a Medicaid fee for service program. We did prioritization reviews, criteria writing and anything the state needed. At that particular point in time, we pretty much did it for them.  

I also then, after that, transition over to a health plan: Health Care Service Corporation. It's one of the Blues (BCBS) plans. The headquarters is in Chicago, but they operate in five different states and oversaw many of the pharmacy operations, pharmacy implementation, and managed some of their clinical programs at the health plan side. I spent a few years there, then moved over to one of the big three pharmacy benefit managers (PBMs) as a clinical consultant supporting a large health plan with a focus on the Medicare line of business with formulary submissions clinical programs strategy. And here I am – Capital Rx.  

I was brought to help build out our government programs, and one of our first directives was focusing on the government needs for Capital Rx and what we need to support our health plan clients.  

Stars is extremely important to health plans and Medicare payers. First, I think the Star bonus payment is what everyone knows about health plans that can perform well on these Stars measures. They have bonus payments. It is tied to their CMS star ratings.  

So, imagine that there are several dozens of measures a health plan can be assessed on based on their quality metrics. Some of these are Medicare Part C, and these are mainly on the medical side. Think of flu shots and such that the medical payer manages. And then there are some that are specifically Medicare Part D that the PBM may be more intimate with. These are your adherence to drugs. That's the most important thing. And if we can do well in that area, in terms of some of those metrics, there's a higher rating. A higher rating means there's a potential for more revenue for that health plan they can reinvest into their organization, such as reducing premiums for Medicare beneficiaries. Or there may be some additional ad hoc services they can support that focus on very specific clinical initiatives.  

So first, it’s Stars bonus payment. The second thing that's important for health plans is that once they achieve a higher Star Rating, they get listed first during open enrollment for Medicare beneficiaries. So, for Medicare, every year members get notified, “Hey, it's that time of year, you get to re-enroll at a new plan.” What these beneficiaries do is they would go into the system, Medicare.gov, and then start looking up next year's plan to see if, well, do I want to stay with my current plan or do I want to change plans? If you're one of those plans with the higher Star Ratings, it gets listed first.  

So, imagine on a Google search you're looking something. You tend to stick [with] what's on the top few records on your page. To have a higher Star Rating, you tend to be listed first. That's really nice, and that's market potential for that particular payer.

Justin Venneri: That makes sense. I recall there were some recent updates, or I guess is it fair to categorize it as like a recalibration of some of the metrics you referred to on the adherence side and on the, I guess, satisfaction side. Can you just maybe share a handful of the things that matter most in terms of what goes into the actual star rating?

Jay Tran, PharmD: Absolutely. There's a lot of measures out there that measure performance. And CMS, every year, go through a process of identifying changes or notifying health plans of what those changes may be. Some of the big changes are technical changes that are coming up this year and moving to a few years just in terms of how they identify members within a particular measure.  

So, they just use different definitions. And these are technical changes in terms of member continuance, enrollment in the plan, and whether they stay in the denominator or not. Some of the other big items are two key outlier requirements that CMS is now applying. There's a methodology that they're using now in terms of removing some of those outlier high and low numbers on specific metrics. That change of how that is calculated does affect some of the way future Star Ratings are calculated. So that's important for health plans to assess what's going to happen with their Star Ratings for the upcoming years.  

The third big thing that I can think of that's coming up for Stars is if you look into the proposed rules or even some of the CMS final rules, they're looking at how to make Stars a health equity inclusion type of program. You reward payers for investing in these areas. So, they're going to start looking at members’ demographics in terms of calculating some of the Stars rating. Those with low socioeconomic status, like LIS (Low Income Subsidy) members, maybe based on their age or gender or disability status, they're thinking about factoring that into how Stars are calculated. So that's a big change for Stars as the government is trying to move into this space of health equity.

Justin Venneri: Got it. Okay. And just big picture: one is poor, and five stars is excellent. Right. Standard five-point scale.

Jay Tran, PharmD: You got it. Right.

[06:42] Justin Venneri: And then I guess the way I'd like to ask the question is, it seems like there are two components, more technical components, but then there's also a service aspect to it. I think the way you described it previously to me was that there are the domains, customer service, member complaints and changes, member experience with the drug plan, drug safety and accuracy. So, is it all about keeping members on their prescribed medications so adherence is high and then, basically, quote, unquote, managing their care so that their feedback is positive along the way?

Jay Tran, PharmD: Yeah, one could concisely summarize it like that, too, but it's a little bit of everything. There are those measures that focus on a patient’s experience, those CAHPS® surveys, as they are called. We don't really know how certain members are targeted and how they are communicated, but they get this survey about their experience with their health plan. So that is supposed to take that particular enrollee's experience with health plan, and that information is then scored in terms of that measure, and that's a patient-subjective measure.  

And then you have more objective measures that just clearly look at claims data, measure their adherence, and keep them on that. So yes, those are individual measures that roll up to a larger domain that could be focused on drug safety.  

Then, there are some patient experience ones, and then those are Part D, but then you have other Part C measures that looks at other type of measures. If you think about all these domains, they all have their own kind of ways their numbers are scored, and all those mathematics roll up to a bigger number that equates to a Star Rating.

Justin Venneri: Got it. Great. Thanks for that, Jay. And maybe we can touch on Medication Therapy Management (or MTM) quickly. Is that baked into the Star Rating and the sort of adherence or safety somehow? And then, I mean, it's a requirement for Part D sponsors. Are there any key updates for 2024 and what should health plans be thinking about or aware of there?

Jay Tran, PharmD: Yeah, Medication Therapy Management is one of the Stars measures that plan sponsors – they need to have this particular program. For those that are not as familiar with MTM as it's called, think of it as an annual medication review for specific Medicare enrollees. They must meet specific criteria to be eligible for this free program.  

For the member, they have to meet specific disease state criteria. They have to be on at least 7 to 10 drugs per month. And then there's an annual cost threshold calculated every year that you expect members to exceed to qualify for that program. So not everyone meets this criterion, of course, only with those three main criteria. Once they meet that, then they are required to offer that free MTM service to that member. And that is a Stars measure.  

The way that MTM works is there is a denominator -- those that qualify for MTM -- and then the numerator is those that got the MTM service. That equates to a percentage that then further correlates to a Stars rating. The big change coming for MTM is that criteria logic, what CMS has deemed as an “appropriate criterion” for a member to be eligible for MTM. They have hinted in the proposed rules and some of the final rules that they're going to change -- that they're going to try to lower the threshold criteria for eligibility.

What we expect in coming years is that there will be more members eligible for MTM. There's going to be a lower cost threshold. So, I think plan sponsors need to start thinking about how they want to plan for MTM because that means that more people will be eligible for this service, and it would impact their Star Ratings. As they plan it for future years, just figure out how to manage that additional cost for the services that they have to offer, and if they want to maintain those high Star Ratings.  

CMS hasn't fully finalized all the rules yet. They were expecting some type of update or notification in this advanced notice or CMS’s final rule coming up to tell us what they're thinking of. But for at least this year, and then moving into 2025, we do expect it to stay the same potentially, but this year would be the same. Then, next year, there are some possible changes to some of those criteria. I think once that information gets released, I think what health plans should start doing is figuring out what that means for their population group, how much more MTM members would be eligible, and how much more cost for them to deliver that service, to maintaining that Stars rating.

Justin Venneri: Thanks for that. And then one other area that's new for, well, another requirement for 2024 is the translation requirements. I just have a couple of questions for you. So, what's the significance and overall importance here? What were the changes proposed and how's it going so far?

Jay Tran, PharmD: Yeah, translation requirements are near and dear to my heart. I feel like English is the second language. First, it's hard to navigate the healthcare system. Then imagine an individual that doesn't speak English as their first language trying to navigate that. So, in the past, CMS has always recommended that health plans provide that service to these members. This is the first year, in 2024, where they codify those rules into the register as actual rules and requirements. You need to offer alternative formats and languages and also translation of materials for these particular members. I think it's CMS's approach to try to make healthcare more inclusive.  

There are some of these pockets of the population where, not having English as their primary language, they just are not knowledgeable to be able to navigate the system. What CMS is telling health plan sponsors now, and required by the rule, is that they have to offer these services. There are some caveats, of course. CMS requires this in those that are above the 5% threshold to be the rule to be in effect. It only affects specific health plans in those service areas. But I think one way to think of this is, if you're able to do the service, it's great for your membership. And here at Capital Rx, we value that member experience, and we focus on how to create a process to help our clients meet these requirements, but also if they want to optionally provide these services. So, we have various ways to set up in our system through our call centers, through our vendors, through our process to account for these particular scenarios.

Justin Venneri: That makes sense. Jay. Okay, do you have any tips or suggestions, tactical or longer term, for health plans or plan sponsors with more diverse populations that may include these members whose first language is not English to deliver the service and meet the.

Jay Tran, PharmD: Definitely. I think the health plans are having that direct relationship for their membership. They know what needs their population may [require] in terms of the translation of materials, what the primary spoken language is as they gather that data. And if they want to continue to provide good services to these particular members, there's the ability to pass down that information for PBMs, or any other downstream entities, to be able to continue that level of service for that particular member as they are taking these calls.  

And then in their call center, these members may be requesting, for which they are required to offer, translation of calls. They do have a record of some sort of data of those members and the percentage of them that are requesting an alternative language or format and volume. And with that data, if they're interested in implementing a solution downstream, work with your delegated vendors as well as their PBM in terms of providing those services, and just start looking at that aid and see if something they want to expand. I think those services that they can provide may help enrich member experience, which then further ties into an earlier conversation where we just mentioned about Stars Rating and the patients’ and members’ experience.

Justin Venneri: Makes sense. Okay, great, Jay, thanks for that overview of these new requirements and Star Ratings. My last question for you, which I'm asking everybody, given everything we've discussed today and your background, what you've seen, what's the most astonishing thing you've seen in and around the space -- that you can share, of course – and why?

Jay Tran, PharmD: As you know, I've been in this industry for some time now, from the health plan side, working with their particular infrastructure, with the data warehouses. I've been at PBMs where we've worked in legacy pharmacy adjudication systems. And the biggest bear I had in prior roles is just to be able to implement some clinical programs or initiatives with the technology that we have.  

One thing I'm amazed about here at Capital Rx is our ability to do that. There really is nothing that's stopping us from implementing any clinical programs. The ability to use data information technology and deploy it in our system is just amazing. And the way to connect these data points to get to where we want quickly and through the automation of technology has helped us facilitate some of our internal process to deliver these services for our company. JUDI® is the name of our pharmacy claims adjudication platform and I love it. It's amazing what it can do. And if you don't know about it, I say check it out and watch some of our demo videos on what JUDI can do for you.

Justin Venneri: Good stuff. Jay, thank you very much for taking the time to speak with us today. Hope you have a great rest of your day.

Jay Tran, PharmD: Thanks Justin.

Outro: Thank you for listening to Astonishing Healthcare by Capital Rx. Head over to www.cap-rx.com/insights and visit the podcast section for show notes and other relevant content. If you liked this episode, be sure to subscribe so you don't miss the next one, and definitely share the link to the show with your network if you enjoyed watching. Have a great rest of your day.

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