When health plan members switch to lower-cost medications, they keep money in their pockets. And that’s not all. As cost is also the one of the biggest barriers to taking medication as prescribed, money saved leads to greater medication adherence. And when adherence improves, a rise in star ratings often follows. It’s a cycle that health plans have the power to influence.

Health plans save when members have options

ConnectureDRX’s DatabaseRX is home to 42,000 NDCs—therapeutic interchange options offering significant cost savings over brand and generic drugs. DatabaseRX combs through claims and health plan data to pair high-cost drugs with lower-cost options. The magnitude of savings as health plan members switch to lower-cost options is significant.

Case study example: An analysis of 8.7 million prescriptions in the CMS formulary file valued at 1.2 billion dollars was put through the DatabaseRX analytics engine. We found 32% had lower cost options, a savings of more than $219 million. (Source: ConnectureDRX data)

Proactive outreach gets members to take action

Armed with the savings opportunity, health plans can develop direct-to-member outreach programs targeting members on high-cost medications. Via email, text message or direct mail, health plans can encourage members to speak to their physicians about comparable lower-cost therapeutic options.

While getting individuals to switch prescriptions can be challenging, if even a small portion of the targeted members make the switch, the savings can be substantial. Given the rising cost of medications and the current economic climate, presenting members with hundreds or potentially thousands of dollars in savings is one key to improving medication adherence and health-plan member relationships.

Case study example: 34 million people in the U.S. have diabetes. In our case study, 550,000 units of Novolog insulin at $30 per unit was prescribed. If our health plan communicated the lower-cost option and all members switched to the comparable Admelog at $13 per unit, the health plan could save $9.3 million in retail costs every year.

 Star ratings rise when the cost-adherence cycle completes

The cost of medications is one of the biggest barriers to medication adherence, if not the biggest. According to a 2019 Kaiser Family Foundation report, 1 in 4 have a hard time affording  prescription medications and 3 in 10 of those aged 50-64 have trouble paying for medications. As studies have concluded time and again, when drugs cost less, members are more apt to follow their prescribed treatments which leads to better health outcomes. Unfilled prescriptions can also lead to an increased risk of patients going to the ER.

The importance of medication adherence is even reflected in Medicare Star Ratings. Medicare Star Ratings is the five-star quality rating system (5 being the highest) the Centers for Medicare & Medicaid Services uses to measure the experience Medicare beneficiaries have with their Medicare Advantage and Part D plans. Ratings are based on member satisfaction surveys, provider feedback and overall health plan performance.

Medication-related measures influence 37.5 out of 75 star ratings points, or 50% of a health plan’s performance. One of the best ways to increase star ratings is to address medication adherence head-on.

The ability to improve star ratings can also impact the financial incentives a health plan receives. According to a 2019 AJMC article, Medicare Advantage plans that improve their star rating from 3 to 4 stars can increase revenue between 13- 17%, through increased enrollment revenue and additional Quality Bonus Payments.

MA plans with 4 and 5 stars receive an approximate $500 per member per year from CMS which, for a 10,000-member plan, can equate to $5 million, or $25 million for a 50,000-member plan. In 2020, approximately 48% of MAPDs have less than 4 stars and not yet eligible for these incentives, according to CMS.

By focusing efforts on these medication adherence measures, MAPD plans can maintain or increase their star ratings which not only translates to healthier outcomes for their members but also provides additional financial incentives to the plan as well.

DatabaseRX, combined with our repository of prescription drug costs, can be a useful tool for healthcare professionals to proactively engage members and employ interventions related to these star measures. The cycle is complete and can begin again when members save, medication adherence improves and star ratings rise.

Learn more about DatabaseRX for both Medicare and commercial products.




Medication Adherence: The Lever to Improve Medicare Advantage Star Ratings