KP Model Highlighted in Radar on Drug Benefits Article on Medicare Prescription Drug Plan Trends


As we announced last month, for the seventh year in a row, KPMAS received the highest possible rating of 5 out of 5 stars from the Centers for Medicare & Medicaid Services for quality for 2019. And we also have the distinct honor of being the ONLY 5-star Medicare plans in the entire DC/VA/MD region. Our integrated care model and CMS rating were highlighted in the October 25 issue of Radar on Drug Benefits, which featured an article on prescription drug plan trends in relation to Medicare star ratings. Chad Friday, Executive Director of Pharmacy for KPMAS, discussed how our care model makes getting required medications more convenient and provides better care coordination and service for our members. Read the full article below.


Medicare Star Ratings for 2019 Include ‘Worrying’ PDP Trends

By Judy Packer-Tursman

CMS painted a rosy picture of quality when it unveiled Medicare star ratings on Oct. 10, saying most regions across the U.S. will have the option of Medicare Advantage (MA) and Part D plans with 4 or more stars in 2019. That’s the rating on the 5-star scale needed to qualify for a 5% federal bonus, seen as a critical competitive advantage for MA plans — though stand-alone Prescription Drug Plans (PDPs) don’t receive bonuses.

In the aggregate, the percentage of beneficiaries covered by plans qualifying for bonuses is edging slightly upward, CMS also reported. But analysts at Avalere Health tell AIS Health it’s important to examine the decline of PDPs’ performance on certain measures in this latest iteration of star ratings. They also point to the weighted enrollment shift of most PDPs into lower ratings year over year.

“At an industry level, there are two big findings. There wasn’t really that much change in star ratings, particularly for MA-PD,” says Sean Creighton, a vice president in Avalere’s policy practice. “However, there was quite a decrease in the ratings for stand-alone PDPs….I’m sure the Part D plans would love to have their scores improving instead of decreasing, but it wasn’t a good year in terms of quality improvement for Part D plans.”

Of 13 ongoing quality measures on the Part D side, PDPs’ performance fell on eight measures and increased on only three measures year over year, Creighton says. For example, he points to PDPs’ performance on medication adherence for diabetes, which dropped from 3.2 stars a year ago to 2.6 stars this year in the aggregate, according to CMS data. By contrast, MA-PDs’ collective rating on the same measure improved from 3.3 stars to 3.7 stars year over year.

Overall, MA-PDs’ performance improved on four of the Part D quality star ratings measures between 2018 and 2019, stayed the same on three measures — and dropped on six measures, though still remained above 4.0 stars on three of them, CMS data show.

Kelly Brantley, also a vice president in Avalere’s policy practice, notes that among PDPs’ eight declining measures, some of the decreases year over year are quite small.

“Where it’s more interesting” is examining medication-adherence measures for PDPs over the four-year period for which CMS provided data, “and those jump a little bit,” she says. The average star rating across PDPs on medication adherence for diabetes was 2.7 for 2016, climbed to 3.3 the following year, dipped slightly to 3.2 for 2018, and fell to 2.6 for 2019, CMS’s data show.

Meanwhile, the average star rating across PDPs on medication adherence for hypertension (renin-angiotensin system (RAS) antagonists) began higher at 3.6 four years ago, rose slightly to 3.7 the following year, then fell to 3.2 last year and 3.0 this year, CMS’s data show. That compares with MA-PDs’ collective average star rating of 3.1 on the same measure.

Average star ratings on medication adherence for cholesterol (statins) among PDPs show a similar pattern over time: increasing from 3.5 for 2016 up to 3.6 for 2017, then 3.3 a year ago and 3.1 for 2019. MA-PDs together averaged 3.2 stars on the cholesterol measure for 2019.

Thus, PDPs’ “big drop” in medication adherence year over year was for diabetes and wasn’t as dramatic a decline for hypertension and cholesterol, Brantley says.

“But it’s sort of worrying,” she says, “because these are clinical measures and really our best way of seeing how PDPs deliver care.” Looking at the general trend, cholesterol and hypertension had bigger drops over the four-year period than between 2018 and 2019, she adds, “Adherence is tricky…and sometimes a plan can do everything in its power to get people to take medications —but a plan can only do so much.”

 Yet Brantley describes medication adherence as a complex issue. In CMS’s annual report on Part D measures, “sometimes MA-PDs do consistently better, sometimes it’s even [between MA-PDs and PDPs], but it depends on the year and the measure,” Brantley says. “Adherence is tricky…and sometimes a plan can do everything in its power to get people to take medications — but a plan can only do so much,” she contends.

Brantley points out that MA-PDs “also have the medical benefit, so they have the ability to see a person soup to nuts — not just drug benefits — and they have more touchpoints and ability to intervene.” And roughly nine of 10 MA-PDs are enhanced plans, versus about half of PDPs, she says, “and that typically translates as lower-cost-sharing, which is associated to some extent with better adherence.”

The integrated care delivery model of Kaiser Permanente of the Mid-Atlantic States, which earned the full 5 stars in CMS’s 2019 Medicare star ratings, brings physicians and pharmacies together under one roof in each of the regional plan’s 30 medical centers to make getting required medications more convenient and to closely coordinate all aspects of care, says Chad Friday, executive director of pharmacy for the Kaiser Permanente region.

Members’ physicians and pharmacists have access to electronic health records to ensure they are up to date on diagnoses and care plans, he notes.

The plan initiates multiple touchpoints to make sure it is monitoring a member’s needs and being supportive and responsive, including outreach to patients through text messages and phone calls with a reminder to refill medications when due, Friday says.


Most MA-PD Members Are in 4-Star Plans

Nationwide, about 74% of MA enrollees with prescription drug coverage are projected to be in plans with 4 stars or 5 stars next year, up from 73% in 2018, based on current enrollment, CMS says. Moreover, roughly 45% of MA plans offering drug coverage will have an overall rating of four stars or higher. By contrast, about 31% of PDPs will have a rating of 4 stars or higher in 2019, CMS says, with most PDP enrollees in plans of 3.5 stars or higher.

Data weighted by enrollment show a stark divide. According to CMS’s fact sheet on 2019 Parts C and D star ratings, close to 74% of MA-PD enrollees are currently in contracts that will have 4 or more stars in 2019. By contrast, only close to 3.5% of PDP enrollees are in such contracts. Brantley describes the weighted enrollment shift for PDPs as “rather fascinating.” “In 2018, you had 16 contracts at the 4-star level and 17 at the 3.5-star level,” out of 54 total contracts,she says.

“Now you’ve got 14 [PDPs] at the 3.5-star level and 17 at the 3-star level [out of 52 total contracts], so that bolus of plans is now at 3.5 and 3 — and that general downward shift is rather dramatic.”

“In the MA-PD world, when you look at how enrollment is distributed across the star ratings, there’s not much shift,” she says, “but it’s a huge [downward]shift for PDPs.”

View CMS data at and Avalere’s ratings study at Contact Creighton at, Brantley at and Friday via Shana Selender at

Article originally published in the October 25, 2018 issue, Volume 19, Number 20, of Radar on Drug Benefits. Republished courtesy of AIS Health.

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