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Star Ratings & Performance Metrics for Pharmacies: A Primer

Medication adherence is a hot topic in the health care industry. And when it comes to pharmacies, discussions about adherence often lead to discussions about Star Ratings.

But . . . what are they? What do they mean? How are they determined? Who determines them? What results can they have for your pharmacy?

There’s a lot of information out there, and some of it can be confusing. So we took that information, brewed a strong pot of coffee, and started investigating. Here’s what we found:

CMS Star Ratings & Pharmacy Performance Explained

Let’s set one thing straight from the beginning: Pharmacies do not receive CMS Star Ratings. Star Ratings measure Medicare plan performance, not pharmacy performance. Pharmacies receive their ratings from a platform called EQuIPP, and Medicare plans use those ratings to determine which pharmacies to include in their networks.

What is EQuIPP?

EQuIPP, developed by Pharmacy Quality Solutions, is short for Electronic Quality Improvement Platform for Plans & Pharmacies. It helps prescription drug plans (PDPs) and Medicare Advantage Drug Plans (MADPs) determine which pharmacies to include in their networks. The platform provides unbiased and benchmarked performance data to both plans and pharmacies. For pharmacies, EQuIPP helps them guide quality improvement efforts. For Medicare plans, EQuIPP helps connect them to the pharmacies that meet certain standards of care.

According to the official website, EQuIPP “facilitates an environment where prescription drug plans and community pharmacies can engage in strategic relationships to address improvements in the quality of medication use.”

How Are Pharmacies Measured?

All Medicare plans are judged on three types of measures: operational measures, provider measures, and medication-use related measures. Operational measures focus on patients’ interactions with the plan itself. Provider measures focus on patients’ experiences with their care providers, particularly their physicians. And medication-use related measures focus on patients’ experiences with their prescription medication. This last measure is weighted more heavily than the other two, as it can impact up to 50 percent of a Medicare plan’s Star Rating.

EQuIPP measures pharmacies based on three different criteria: adherence, comprehensive medication review, and statin use in diabetes.

  • Adherence: A pharmacy’s adherence rating is based on proportion of days covered (PDC) for its patients. EQuIPP measures PDC for medication treating diabetes, hypertension, and cholesterol issues.
  • Comprehensive Medication Review: For this measure, EQuIPP takes the number of patients eligible for a CMR and compares it to the number that actually received a review.
  • Statin Use in Diabetes: Back in 2014, CMS determined that all patients receiving medication for diabetes should also receive a statin. This measure shows what percentage of a pharmacy’s diabetes patients are receiving a statin as recommended.

EQuIPP’s performance metrics are not only used to provide a reference point for Medicare plans. They can also influence DIR fees. Maintaining high ratings should lower the rate of DIR fees.

What Star Ratings Mean For Value-Based Care

Over the last several years, health care has seen a shift from volume-based to value-based reimbursement. Star Ratings are part of that. Plans and pharmacies are both rated based on how well they take care of their patients. The measures used to rate pharmacies are based on outcomes, not on metrics like prescription volume.

The shift to value-based care puts the focus on the patient, not the provider. Getting a good rating isn’t a matter of filling more prescriptions or seeing more patients; it’s about finding ways to make your patients’ lives better. It’s about spending more time with your patients and ensuring that they are getting the care they need. Mostly, it’s about treating your patients like people and not like orders that need to be filled.

Star Ratings and pharmacy performance metrics can be confusing. But here’s something that isn’t: As a pharmacist, your goal is to improve the health and well-being of your patients. By doing so, you’re improving their lives. Pharmacists have long based their success on patient outcomes rather than prescription volume. Thankfully, the health care industry is starting to catch up.