Improving Star Ratings Through Enhanced Formulary Data

Providing formulary data in ePrescribing systems began in 1997 with Palm Pilots being updated over phone lines, and advanced a few years later in Electronic Health Record systems (EHRs).  After the initial effort to make formulary data available, health plans have largely stagnated by not improving the quality and breadth of formulary data. Yet with the growth of ePrescribing to 86% of non-controlled substance prescriptions and increasing pressure on health plans and PBMs to improve quality while controlling costs, the time is now to enhance formulary data to help improve Medicare Five-Star Quality Ratings. By doing so, this will enhance the provider and patient experience with better information and serve to get and keep patients on the right drug.

Enhancing formulary data leads to an improved provider and patient satisfaction, plan and patient savings, and improved quality measures around medication adherence. These improvements are reflected through better Medicare Five-Star Quality Ratings. With the 2021 changes to Star Ratings, CMS increased measure weights for patient experience/complaints and access measures from 2 to 4, reflecting their commitment to empowering patients.

Enhanced formulary services  also supports the deployment of new Real-Time Pharmacy Benefit (RTPB) information.  RTPB information is expanding in availability, now estimated to be about 35%, but requires a buildout in EHRs and a web of connections before it becomes ubiquitous.  Still, during RTPB deployment, the workflow requires enhanced formulary data as the basis for suggesting lower-cost alternatives, identifying potential coverage hurdles and indicating when 90-day prescriptions can save patients money. All these data elements also help improve patient adherence by preventing therapy delays.

The value in enhanced formulary data to increase satisfaction and quality is compelling:

Widespread use of formulary data exists today. Plans generally distribute data via Surescripts, who manages the master data and identifies the appropriate formulary information for 95% of patients.  There has been considerable effort to create guidelines and certification rules for the display of formulary data in EHRs as part of the inclusion of formulary data in ePrescribing systems.  An investment by plans and PBMs in enhancing formulary data will leverage the infrastructure already in place, providing a quick return with no additional effort required by EHRs. The standard exists, and provider users are ready for the data.

Enhanced Formulary Reduces ‘Pharmacy Surprises’

Pharmacy surprises, when the patient reaches the pharmacy to find a prescription that they either cannot afford or requires prior authorization, are a source of frustration for patients that may result in abandoned prescriptions and disillusion with plans.  Getting information on drug costs and coverage restrictions in the hands of physicians while prescribing can result in improved drug selection, and a reduction of “pharmacy surprises” for patients. Reducing patient frustration should reduce member complaints, problems obtaining services, and members choosing to leave the plan.

As the federal government mounts pressure for expanding price transparency by requiring RTPB by 1/1/21 for Part D plans, patient facing apps are growing in popularity. This inserts the patient further into the drug selection process with more information than the provider may have.  The CARIN Alliance,  a non-partisan, multi-sector alliance focused on providing digital health information to consumers where, when, and how they want to achieve their goals, has been developing specifications and an implementation guide for drug cost consumer apps based on the NCPDP draft Real-time Pharmacy Benefit Check standard. Providers need the same information that patients may have access to, so enhancing formulary data is even more critical.

Enhanced formulary data with alternatives can include drug price and patient pay information, along with any restrictions such as prior authorization, and deliver it directly to providers at the time of drug selection today.  Providers can use the data in their EHR to help alleviate complaints about the drug cost and assist patients in getting needed drugs.  This improvement can impact the rating of the plan and aid in overall quality improvement.

Selecting the least expensive drug doesn’t just save patients money; a more affordable drug may be the difference in adherence to therapy.  The burden of drug cost impacts adherence. For example, increased adherence in statin use of diabetic patients  can lead to increases in the associated Star ratings, which have been proposed to increase in weight from 1.5x to 2x  (including all CAHPS and administrative measures).

Lower Cost Drug Alternatives

There are times when multiple drugs, similar in action, can be used for a condition.  A provider may have a preferred product they use routinely, but that may not match with the lowest cost drug available from the plan.  Putting the burden on providers to identify when a lower cost drug alternative is available is not necessary when enhanced formulary data can consistently provide the plan’s preferred drug alternatives.

Alternatives should be included in both formulary data, to help inform the initial drug selection by the provider, and in  RTPB to confirm the provider’s drug choice.  The advantage of having specific drug alternatives listed for the majority of drugs prescribed, helps the provider make more informed drug decisions. 

Benmedica’s SmartAlts® are designed to pinpoint drug alternative messaging opportunities and are continually updated to match changing conditions. SmartAlts cover 90% of the most commonly prescribed drugs. The patented SmartAlts service allows plans to add drug alternatives with approximate prices to guide providers to patient savings and communicate drug alternatives through enhanced formulary data and RTPB information. Selecting the best medication for a patient, including a drug the patient can afford, is central to the efforts to improve Star Ratings.

90-day Therapy

Reducing the number of refills needed in a year not only increases adherence to therapy but, in many plans, saves the patient on their copayment. This combination can have a significant impact on adherence and contribute to overall satisfaction with the plan.  Increases in adherence for drug therapies related to chronic conditions like diabetes, hypertension, and cholesterol medications can be part of a program for increasing Medicare Star Ratings.

Customized Notifications

Enhanced formulary data provided to physicians in the EHR can also contain customized information to alert physicians to specific situations.  This messaging capability exists today and is underutilized. One example to improve the information displayed for providers is found in the American Geriatrics Society’s Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults, an evolving list of drugs that should be evaluated in older patients to ensure the value outweighs the risk. Enhancing formulary data to include messaging on the Beers Criteria in the EHR workflow is a method to keep providers updated with the latest version of the list. Notifications and weblinks can also provide key information on prior authorization requirements, on biosimilars and their clinical appropriateness and use criteria to drive savings for specialty medications. 

Another key Medicare Star Measure is the use of statins in diabetes patients when indicated. While the formulary data is not patient-specific, well-chosen messages can aid in improving plan quality metrics.  

Getting Started Enhancing Formulary Data to Improve Star Ratings

The mechanism to get formulary information into the providers workflow already exists. Surescripts handles most of the nation’s formularies collecting information from plans and aggregating data. Surescripts has certified EHRs to  display formulary information. To start the process, plans need to identify formulary enhancement opportunities. Next is to prioritize the list that will have the biggest impact on Star Ratings. Execution of the plan involves establishing data enhancements that will supplement formulary data going to Surescripts. Fortunately, this does not have to happen in one pass. Enhancing formulary information is an iterative process of continuous improvement to update and strengthen information sent to providers for use in their EHR workflow.

Help is Available

For the past 8 years, Benmedica has been providing enhanced formulary data which has helped our clients achieve improved plan Star Ratings.  We have worked with plans that cover over 10 million lives and have the methodology to evaluate current activity to identify savings opportunities. “Benmedica is has invested in the tools and is passionate about improving the quality of formulary information to improve  patient and provider experience,” says Bruce Wilkinson founder of Benmedica and a leader of NCPDP’s Formulary and Benefit Task Group.

Our team leverages over 100 years of combined experience to equip plans with the information that providers can use to improve Star Ratings and decrease drug costs. Contact us today to arrange a claims-based opportunity analysis so that we can provide you with an assessment.