Why Medicare Advantage Plans Must Turn Post-Discharge Care Into Drug-Driven Care Transitions


The 2022 performance year star ratings require Medicare Advantage plans to play a greater role in preventing readmissions.

Care transitions have become a major goal in improving the quality of health care and the patient experience and reducing hospital readmissions. Ineffective transfer of a patient from a health care setting (eg, patient dissatisfaction, medication non-adherence, and most importantly, unnecessary readmissions.

Almost a fifth (19.6%) of patients discharged from Medicare were readmitted within 30 days and 34.0% were readmitted within 90 days. These readmissions cost Medicare $ 17.4 billion a year. Reports indicate that up to 40% of all medication errors can be attributed to insufficient medication reconciliation during the transition of care.

In 2022, CMS announced the introduction of a new star rating measure, Transitions of Care (TRC), to promote better coordination of care across the field.

Medicare Advantage (MA) plans should take note, as this will require a greater role in preventing readmissions. Ensuring a good medication reconciliation after discharge from hospital will be a critical success factor. Patients are the most vulnerable when transferring from one clinical team to another.

Of note, more than half of the star rating system is directly related to medication management to protect patients as they interact with the complex healthcare ecosystem. Overall, MA Star Ratings’ annual Quality Bonus (QBP) payment is $ 11.6 billion in value-based reimbursement dollars available for the country’s highest quality plans each year. This works out to around $ 450 per member per year for plans that achieve 4 stars or higher on the complex star rating system.

The current Post-Discharge Medication Reconciliation (PRM) measure requires the PA to oversee medication reconciliation for individuals within 30 days of discharge in order to avoid preventable hospital readmission and to keep medication reconciled. healthier patients at home. Confounding factors, such as the nearly 100 million Americans living in “pharmacy deserts” with poor access to prescriptions, make it difficult for patients to follow medication instructions.

In addition, the current process also faces other hurdles and pain points. Several providers are often involved in a hospitalization or emergency event, leading to confusion as to who is responsible for the patient’s care plan. Poorly aligned incentives can sometimes lead stakeholders to abdicate their responsibilities. Admission, discharge, and transfer (ADT) notifications don’t always get where they’re supposed to go in a timely manner. And patients can often fall through the cracks if they don’t have a strong relationship with a proactive primary care provider with access to health information exchange tools.

These communication disruptions are set to become even less tolerable when measuring the quality of managed care, with CMS adding the TRC measure to the Star Rating program in 2022. While some of these quality measures were present in the future MRP measure, the new TRC measure is much more complex to orchestrate across the healthcare continuum.

CMS defines a ‘transition of care’ as any time a patient moves from one health care setting to another, whether from a primary care provider to a specialist, from an inpatient bed to an inpatient. skilled nursing facility, or home hospital. To get full credit for the newly designed TRC measure, plans will need to all of the following 4 objectives for patients 18 years of age and over:

  • Hospitalization notification: Documentation of receipt of the hospital admission notification no later than the day following admission
  • Receipt of discharge information: Documentation in the medical file of the reception of the discharge information at the latest the day after discharge
  • Patient engagement after discharge of the hospitalized patient: Proof of patient contact within 30 days of discharge, including office visit, telehealth visit, or home visit
  • Medication reconciliation after discharge: Medication reconciliation is performed on discharge date up to 30 days after discharge (31 days in total)

As 2022 approaches, MA’s plans only have a few months to support the new TRC process, including increased coordination of care for medication reconciliation processes. Historically, MA plans have not performed well on MRP measurements. An AdhereHealth analysis found that at least 50% of plans eligible to report on these metrics did not meet the 4-star threshold to qualify for the CMS allocated QBP pool. To succeed with the more stringent TRC measures and achieve high marks for quality care, AD plans will need to re-examine their current MRP strategies and take the lead with holistic, data-driven approaches that enable seamless care transitions.

Leverage predictive analytics to access and aggregate data in a timely manner

Neither health plans nor providers can act on medication reconciliation if they do not know a patient has experienced an event in hospital.

MA plans will need to adopt patient management tools with sophisticated predictive analytics, health information exchange capabilities, and intelligent clinical workflows that provide access to the most accurate and timely data available from all providers involved in patient care.

With the ability to aggregate and analyze clinical history, claim data, pharmacy data and ADT notifications in real time, plans can take quick action: contact the appropriate providers and patients for a conversation about medication changes.

Improved access to patient data can help PA plans complete this initial step faster, often within 48 hours, leaving less time for a drug problem to refer a patient to the emergency department.

Directly involve patients in medication reconciliation through telepharmacy

When it comes to care transitions, PA plans may be more accustomed to coordinating with providers than with patients. But integrating patients and caregivers directly into the medication reconciliation process can be very rewarding.

Pharmacist-led interventions that include patient education can help dramatically reduce readmissions, especially in high-risk patients who often have more medications to manage. With a pharmacist specially trained to work one-on-one with patients, PA plans can be sure their beneficiaries receive meaningful, personalized education and direction on how to take medications correctly.

These telepharmacy sessions can satisfy the patient engagement portion of the CRT 2022 measure as well as the medication reconciliation requirement. Telehealth engagements are also well received by patients who appreciate the convenience and lack of travel time, which can have negative implications on patient experience and CAHPS scores, helping AD plans keep their length. ahead of their performance targets.

Engage in sustained medication management with enveloping pharmacy services

Medication optimization goes beyond the immediate demands of the post-discharge period. As patients recover at home, they often need ongoing support and education on medication safety and adherence.

MA plans should consider using a hospital event as a starting point for a more in-depth conversation about medication management and the social determinants of health (SDOH) that could make self-care more difficult.

Addressing these issues and providing patients with additional resources, such as compliance packaging options to improve adherence and community services to address socio-economic issues, are key to preventing preventable hospitalizations.

It is also important to establish a comprehensive and proactive relationship with patients to enable individuals and their caregivers to become familiar with their medications so that they can defend themselves when a hospitalist or specialist makes a change.

Meeting the patient where they are at home is an essential part of preventing readmissions. Patients who live in pharmacy deserts or who do not have access to medication within a few miles of their homes benefit from mail-order prescription drug programs. In the case of underserved Americans, such as members doubly eligible for Medicare and Medicaid, a private courier pharmacy helps overcome individual barriers to SDOH that interfere with access.

By transforming medication management into an ongoing relationship, MAID plans can capitalize on their perfect positioning as custodians of medication safety. With the impending changes to the new TRC metric and the accompanying impact on star ratings, MA plans now have even more reason to take control of this critical process.

As star ratings represent over $ 10 billion in annual MA QBP, it is imperative to focus on proven and scalable methods to prevent readmissions. Leveraging a technology-driven telepharmacy approach enables healthcare teams to support better continuity of care from hospital to community, adhere to the TRC measure, avoid unnecessary healthcare costs, and, ultimately, to drive better patient outcomes.

Author Info

Jason Z. Rose, MHSA, is CEO of AdhereHealth.


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