Keep Seniors Safe From High-Risk Meds

Aug 21, 2013
Managing high-risk medication use in the Medicare population can lead to greater health outcome and higher Star Ratings.

The Centers for Medicare & Medicaid Services (CMS) implemented its Star Ratings program to help seniors and to take some of the guesswork out of selecting a quality Medicare Advantage Plan (MAPD) and Medicare Part D Prescription Drug Plan (PDP). The Star Ratings program measures multiple dimensions important to members — from service to medication adherence.

One critical measure in the Star Ratings program is patient safety and, in particular, the use of high-risk medications (HRMs). HRMs are those that should be used with caution in patients over the age of 65 because the safety risks associated with these medications exceed their potential benefits. Medications classified as HRMs generally have a safer alternative.

A plan’s effectiveness in proactively managing the use of HRMs is weighted heavily in the plan’s CMS Star Ratings. In a recent update to, Express Scripts research highlighted the positive impacts — improved patient safety and better Star Ratings — of an effective HRM management strategy.

HRM: A High-Impact Performance Area

The Patient Safety and Accuracy of Drug Pricing category in the CMS Star Ratings program includes a specific HRM measure (in the 2013 Star Ratings, known as D14) that rates PDPs and MAPDs based on the percentage of plan members who fill prescriptions for certain HRMs when safer drug options are available.

CMS treats the HRM measure as one of the more heavily weighted clinical measures. Specifically, it’s weighted three times more than other process measures such as enrollment timeliness.

According to 2013 CMS data, the national numeric average HRM rates in 2011 were 7.8% for MAPDs and 8.8% for PDPs, which translate to an average Star Rating of 3.1 out of 5. The more plans can lower this HRM rate, the higher their Star Rating will be.

Real-Time Prior Authorization

Express Scripts’ High-Risk Medication Prior Authorization (HRMPA) program — part of our standard Medicare formulary management — helps improve patient safety by monitoring the real-time dispensing of CMS-classified HRMs. Our HRMPA program supports a plan sponsor’s prior authorization (PA) and medical exception initiatives, offers year-round, 24/7 review service, and gives physicians and pharmacists easy access to PA information.
In 2011, Express Scripts expanded the HRMPA program from its original therapy classes — skeletal muscle relaxants and first-generation (sedating) antihistamines — to also include PA and step therapy for barbiturates and benzodiazepines. Our clinical specialists continually evaluate other therapy classes for inclusion in the HRMPA.

Better Outcomes With Effective HRM Management

Evaluating more than 65 health plan contracts representing more than 2.2 million Medicare lives, the research showed that across MAPD and PDP plans, contracts without an HRMPA program had higher utilization rates of HRM prescriptions compared to contracts with the Express Scripts HRMPA, 7.4% versus 5.5%, respectively. That’s a notable difference, potentially equating to hundreds of members per plan.

The difference can also have a major impact on the heavily weighted Star Ratings metric for HRM. Looking at the 2013 Star Ratings cut points for the HRM, Express Scripts plans that had the HRMPA in place averaged 4 Stars (5.4%) for MAPDs and 5 Stars (6%) for PDPs in this specific metric. As noted above, this compares to the national average of 3.1.

Cut points for Medicare ratings

Notably, Express Scripts MAPD and PDP health plan clients — including those without our HRMPA program — overall are dispensing lower percentages of high-risk medications to Medicare beneficiaries than the national averages for their counterpart plans.

High risk medication rate comparison in medicare plans  

Multiple Express Scripts Tools for Improved Safety and Star Ratings

Programs that manage HRM use are just one way that Express Scripts helps Medicare plan sponsors improve medication safety for beneficiaries. Express Scripts’ Medication Therapy Management (MTM) programs — including our base and expanded MTM offerings — enhance overall health for members and reduce wasteful spending through targeted member and prescriber outreach and education.

Advanced solutions such as RationalMed® leverage actionable data to drive safer use of medications and evidence-based prescribing. By integrating patient medical, pharmacy and lab data, RationalMed can rapidly identify safety and health issues and effect greater changes in therapy or treatment across all disease states — and impact Star Rating measures D14 to D18.

All of these innovations help Medicare members — and plans — make better health decisions that lead to improved outcomes. By implementing programs such as HRMPA that demonstrate improved safety metrics, PDP and MAPD plan sponsors can earn higher Star Ratings and deliver upon their commitments to their members.

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