Medicare Star Clinical Programs

Discover a health plan’s experience with achieving significant improvement for multiple Medicare Star Rating measures.

Luke Cecil, Pharm.D. Vice President, Pharmacy

The Health Plan of West Virginia

Medicare Star Ratings continue to stress the importance of statin therapy for the treatment of cardiovascular disease and prevention of cardiovascular events. A specialized, pharmacist-led clinical program can effectively close gaps in care and improve Medicare Star Rating performance.

Scope of the Problem and Burden of Disease

Cardiovascular disease (CVD) is the leading cause of death in the U.S. and is responsible for one death every 33 seconds.1 Evidence-based recommendations for the prevention of CVD are heavily focused on mitigation of risk through the management of comorbidities such as hypertension, hyperlipidemia, and diabetes. While novel classes of pharmacotherapies including proprotein convertase subtilisin/ kexin type 9 (PCSK-9) inhibitors and adenosine triphosphate-citrate lyase (ACL) inhibitors have recently emerged for hypercholesterolemia management, HMG-CoA reductase inhibitors, or statins, remain at the forefront of primary and secondary prevention of CVD.

Quality performance is incentivized at the health plan level by rewarding top performing plans with bonus payments to enhance benefit offerings, a high performing icon and favorable plan placement on Medicare enrollment sites, and expanded, more flexible enrollment options.

Robust clinical evidence has spawned widespread adoption of guideline recommendations for statins as first-line intervention for high-risk populations, including those with diabetes and established cardiovascular disease. In addition to their cholesterollowering properties, statins have additional anti-atherosclerotic effects that reduce the risk of CV events including improved vascular endothelial function, stabilization of atherosclerotic plaques, and modulation of the inflammatory response.2

The American Heart Association reported that in 2016, CVD cost the U.S. $555 billion and estimates that by 2035, the costs will rise to $1.1 trillion.3 With rising prevalence and costs, it is imperative to close gaps in care for effective population health management. Clinical literature reports the number needed to treat (NNT) to prevent one CV event in patients with diabetes is as low as 37 and the NNT for secondary prevention of CV events in patients with established CVD is as low as 18.4, 5 Statins have longevity in reducing morbidity and mortality where indicated and the lowcost generic availability can provide a meaningful ROI.

The Centers for Medicare & Medicaid Services (CMS) have placed focused on statin quality measures in various capacities since 2012 via the Star Ratings program. The CMS Five-Star Quality Ratings system annually assigns a 1 through 5 Star Rating to all Medicare contracts at 0.5 Star intervals. The Star Ratings system is designed to provide Medicare enrollees with the necessary tools they need to select a high-performing Medicare plan. Quality performance is incentivized at the health plan level by rewarding top performing plans with bonus payments to enhance benefit offerings, a high performing icon and favorable plan placement on Medicare enrollment sites, and expanded, more flexible enrollment options.

The Medicare 2023 Part C & D Star Ratings include three measures directly related to statin therapy. The Part C Star Ratings, Measure C16: Statin Therapy for Patients with Cardiovascular Disease (SPC), evaluates the percentage of Medicare members with established cardiovascular disease who receive treatment with moderate-high intensity statin. Part D, D12 Statin Use in Persons with Diabetes (SUPD) annually assesses the percentage of members with diabetes who receive statin therapy. Additionally, the Part D Ratings have an adherence measure (D10) that analyzes the percentage of enrollees who remain compliant to their statin medication, defined as a proportion of days covered (PDC) ≥80%.

The objective of the CMS Star Ratings is to drive improvement in clinical outcomes at scale among the Medicare population. The important role statin therapy continues to play is reinforced by CMS with three distinct Star measures focusing on the initiation of and compliance to statin therapy for long-term clinical benefit.

Statin Use in Persons with Diabetes (SUPD)

In 2021, in an effort to improve the delivery of care provided to our enrollees, The Health Plan (THP) partnered with Magellan Rx Management (MRx) to implement a clinical program tailored to the SUPD Star measure. The SUPD measure aligns with the American Diabetes Association (ADA) recommendation for statin therapy for diabetes patients ages 40-75, regardless of baseline LDL values.6

Atherosclerotic CVD (ASCVD) is the leading cause of morbidity and mortality in patients with diabetes, and the CMS Star measure aims to reduce CV risk by maximizing adoption of the evidencebased statin recommendation. At baseline, the two Medicare contracts were performing well below the national average at 75% and 80% compliance — these rates equated to a 1- and 3-Star performance for measurement year 2020.

The program launched at the end of October 2021 generated immediate momentum in our performance. For 2021, both Medicare contracts saw treatment rate improvement and closed the gap on the national average, but only earned 2-Star performance due to rising cut points. Without the year-over-year improvement, predominantly generated in the fourth quarter of 2021, both contracts were at risk for a 1-Star finish in the SUPD measure due to changes in Star thresholds.